BACKGROUND: Research suggests that patients' end‐of‐life (EOL) care is determined primarily by the medical resources available, and not by patient preferences. The authors examined whether patients' desire for life‐extending therapy was associated with their EOL care. METHODS: Coping with Cancer is a multisite, prospective, longitudinal study of patients with advanced cancer. Three hundred one patients were interviewed at baseline and followed until death, a median of 4.5 months later. Multivariate analyses examined the influence of patients' preferences and treatment site on whether patients received intensive care or hospice services in the final week of life. RESULTS: Eighty‐three of 301 patients (27.6%) with advanced cancer wanted life‐extending therapy at baseline. Patients who understood that their disease was terminal or who reported having EOL discussions with their physicians were less likely to want life‐extending care compared with others (23.4% vs 42.6% and 20.7% vs 44.4%, respectively; P ≤ .003). Patients who were treated at Yale Cancer Center received more intensive care (odds ratio OR, 3.14; 95% confidence interval CI, 1.16‐8.47) and less hospice services (OR, 0.52; 95% CI, 0.29‐0.92) compared with patients who were treated at Parkland Hospital. However, in multivariate analyses that controlled for confounding influences, patients who preferred life‐extending care were more likely to receive intensive care (adjusted OR AOR, 2.91; 95% CI, 1.09‐7.72) and were less likely to receive hospice services (AOR, 0.45; 95% CI, 0.26‐0.78). Treatment site was not identified as a significant predictor of EOL care. CONCLUSIONS: The treatment preferences of patients with advanced cancer may play a more important role in determining the intensity of medical care received at the EOL than previously recognized. Future research is needed to determine the mechanisms by which patients' preferences for care and treatment site interact to influence EOL care. Cancer 2010. © 2010 American Cancer Society. Research suggests that patients' end‐of‐life care is determined primarily by the medical resources available and not by patient preferences. In this multisite, prospective, longitudinal cohort study, the authors observed that patients with advanced cancer who wanted life‐extending care were 3 times more likely to receive cardiopulmonary resuscitation and/or mechanical ventilation and to die in an intensive care unit, independent of treatment site.