Differences in End-of-Life Preferences between Congestive Heart Failure and Dementia in a Medical House Calls Program

OBJECTIVES: To compare end-of-life preferences in elderly individuals with dementia and congestive heart failure (CHF). DESIGN: Retrospective case-control study. SETTING: Geriatrician-led interdisciplinary house-call program using an electronic medical record. PARTICIPANTS: Homebound individuals who died while under the care of the house-call program from October 1996 to April 2001. MEASUREMENTS: Medical records review for demographics, functional status, advance medical planning, hospice use, and place of death. RESULTS: Of 172 patients who died in the program, 29 had CHF, 79 had dementia, 34 had both, and 30 had neither. Patients with CHF were younger (82.6 vs 87.0, P = .011) and less functionally dependent (activities of daily living score 9.1 vs 11.5, P = .001). Time from enrollment to death was not significantly different (mean ± standard deviation = 444 ± 375 days for CHF vs 325 ± 330 days for dementia, P = .113). A do-not-resuscitate (DNR) directive was given in 62% of patients with CHF and 91% with dementia (P < .001). Advance medical planning discussions were not significantly different (2.10 in CHF vs 1.65 in dementia, P = .100). More patients with CHF participated in their advance medical planning than those with dementia (86% vs 17%, P < .001). Hospice was used in 24% of CHF and 61% of dementia cases (P < .001). Finally, 45% of patients with CHF and 18% of patients with dementia died in the acute hospital (P = .006). Multivariate analysis showed that the fact that more patients with CHF were involved in their medical planning was not significant in predicting end-of-life preferences. Alternatively, Caucasian ethnicity was an independent predictor of having a documented DNR and death outside of the acute hospital. CONCLUSION: In the months before death, patients with CHF were more likely to have care plans directed at disease modification and treatment, whereas dementia patients were more likely to have care plans that focused on symptom relief and anticipation of dying. Several factors may contribute to this difference.