Original Study - Brief Report| Volume 22, ISSUE 2, P349.e29-349.e34, February 2021

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Instability in Preference for Place of Death Among Patients With Symptoms of Advanced Heart Failure



      Patient preference for place of death is an important component of advance care planning (ACP). If patients’ preference for place of death changes over time, this questions the value of their documented preference. We aimed to assess the extent and correlates of change in preference for place of death over time among patients with symptoms of advanced heart failure.


      We conducted a secondary analysis of data from a randomized controlled trial of a formal ACP program vs usual care.

      Setting and Participants

      We interviewed 282 patients aged 21 years old and above with heart failure and New York Heart Association Classification III and IV symptoms in Singapore. Analytic sample included 200 patients interviewed at least twice.


      We assessed factors associated with patients’ preference for place of death (home/institution/no preference) and change in their preference for place of death from previous time point (change toward home death/toward an institutional death/toward no preference/no change). These included patient demographics, quality of life (Kansas City Cardiomyopathy Questionnaire), and prognostic understanding.


      In our study, 66% of patients with heart failure changed their preference for place of death at least once during the study period with no consistent pattern of change. Correct prognostic understanding at the time of survey reduced the relative risk of change in preference for place of death to home (relative risk ratio 0.49, 95% confidence interval 0.32, 0.76), whereas a higher quality of life score was associated with a lower relative risk of patients changing their preferred place of death to an institution (relative risk ratio 0.99, 95% confidence interval 0.97, 1.00) relative to no change in preference.

      Conclusions and Implications

      We provide evidence of instability in patients with heart failure preference for place of death, which suggests that ACP documents should be regularly re-evaluated.


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        • Gomes B.
        • Calanzani N.
        • Gysels M.
        • et al.
        Heterogeneity and changes in preferences for dying at home: A systematic review.
        BMC Palliative Care. 2013; 12: 7
        • Brinkman-Stoppelenburg A.
        • Rietjens J.A.
        • Van der Heide A.
        The effects of advance care planning on end-of-life care: a systematic review.
        Palliat Med. 2014; 28: 1000-1025
        • Abel J.
        • Pring A.
        • Rich A.
        • et al.
        The impact of advance care planning of place of death, a hospice retrospective cohort study.
        BMJ Support Palliat Care. 2013; 3: 168-173
        • Chadwick S.
        • Miller B.
        • Russell S.
        The impact on the place of death through advance care planning documentation in heart failure and end stage respiratory disease patients.
        BMJ Support Palliat Care. 2011; 1: 69
        • Sudore R.L.
        • Fried T.R.
        Redefining the "planning" in advance care planning: preparing for end-of-life decision making.
        Ann Intern Med. 2010; 153: 256-261
        • Wright A.A.
        • Keating N.L.
        • Balboni T.A.
        • et al.
        Place of death: Correlations with quality of life of patients with cancer and predictors of bereaved caregivers' mental health.
        J Clin Oncol. 2010; 28: 4457-4464
        • Skorstengaard M.H.
        • Jensen A.B.
        • Andreassen P.
        • et al.
        Advance care planning and place of death, hospitalisation and actual place of death in lung, heart and cancer disease: A randomised controlled trial.
        BMJ Support Palliat Care. 2019; (bmjspcare-2018-001677)
        • Tang S.T.
        • Liu T.-W.
        • Chow J.-M.
        • et al.
        Associations between accurate prognostic understanding and end-of-life care preferences and its correlates among Taiwanese terminally ill cancer patients surveyed in 2011–2012.
        Psychooncology. 2014; 23: 780-787
        • Malhotra C.
        • Hu M.
        • Malhotra R.
        • et al.
        Instability in end-of-life care preference among heart failure patients: Secondary analysis of a randomized controlled trial in Singapore.
        J Gen Intern Med. 2020; 35: 2010-2016
        • Malhotra C.
        • Sim D.K.L.
        • Jaufeerally F.
        • et al.
        Impact of advance care planning on the care of patients with heart failure: study protocol for a randomized controlled trial.
        Trials. 2016; 17: 285
        • Malhotra C.
        • Sim D.
        • Jaufeerally F.R.
        • et al.
        Impact of a formal advance care planning program on end-of-life care for patients with heart failure: Results from a randomized controlled trial.
        J Card. 2020; 26: 594-598
        • Green C.P.
        • Porter C.B.
        • Bresnahan D.R.
        • et al.
        Development and evaluation of the Kansas City Cardiomyopathy Questionnaire: A new health status measure for heart failure.
        J Am Coll Cardiol. 2000; 35: 1245-1255
        • Janssen D.J.A.
        • Spruit M.A.
        • Schols J.M.G.A.
        • et al.
        Dynamic preferences for site of death among patients with advanced chronic obstructive pulmonary disease, chronic heart failure, or chronic renal failure.
        J Pain Sympt Manage. 2013; 46: 826-836
        • Agar M.
        • Currow D.
        • Shelby-James T.
        • et al.
        Preference for place of care and place of death in palliative care: Are these different questions?.
        Palliat Med. 2008; 22: 787
        • Iecovich E.
        • Carmel S.
        • Bachner Y.G.
        Where they want to die: correlates of elderly persons' preferences for death site.
        Soc Work Public Health. 2009; 24: 527-542