Changing Preferences for Survival After Hospitalization With Advanced Heart Failure

Objectives This study was designed to analyze how patient preferences for survival versus quality of life change after hospitalization with advanced heart failure (HF). Background Although patient-centered care is a priority, little is known about preferences to trade length of life for quality among hospitalized patients with advanced HF, and it is not known how those preferences change after hospitalization. Methods The time trade-off utility, symptom scores, and 6-minute walk were measured at hospitalization and again in 287 patients during 6 months after therapy to relieve congestion in the ESCAPE trial. Results Willingness to trade was bimodal. At baseline, the median trade for better quality was 3 months survival time, with modest relation to symptom severity. Preference for survival time was stable for most patients, but increase after discharge occurred in 98/145(68%) patients initially willing to trade survival time, and was more common with symptom improvement, and after therapy guided by pulmonary artery catheters (p=0.034). Adjusting days alive out of hospital for patients’ survival preference reduced overall days by 24%, with largest reduction in patients dying early after discharge (p=0.0015). Conclusions Preferences remain in favor of survival for many patients despite advanced HF symptoms, but increase further after hospitalization. The bi-modal distribution and stability of patient preference limit utility as a trial endpoint, but support its relevance in design of care for an individual patient.