Guidelines recommend that physicians discuss advance directives with patients with heart failure, but few report doing so, and it's not clear what impact advance directives actually have on end-of-life care. Using data from the Rochester Epidemiology Project, Dunlay and colleagues studied the prevalence and predictors of advance directive completion in community patients with heart failure. They also evaluated whether patients with an advance directive specifying limits on the aggressiveness of end-of-life care were less likely to be hospitalized, be admitted to the ICU, or receive mechanical ventilation.

A total of 608 patients were enrolled in the study; 60% had a previous diagnosis of heart failure; the rest were newly diagnosed. During follow-up (mean, 1.8 years), 164 patients died. Only 41% of patients had an advance directive at enrollment, and only 35% had one at the time of death. Most advance directives appointed a proxy decision maker, but fewer than half addressed the patient's preferences regarding the use of CPR, mechanical ventilation, artificial nutrition and hydration, or hemodialysis. Advanced age was the strongest predictor of advance directive completion, followed by malignancy and renal dysfunction.

Patients who had an advance directive specifying limits on end-of-life care were no less likely than others to be hospitalized in the last month of life, but they were less likely to receive mechanical ventilation, with a trend toward being less likely to be admitted to the ICU.-KR

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