Current status and characteristics of advance directives in Japanese patients with acute heart failure

Abstract Background The need and importance of enhanced advance care planning (ACP) and end-of-life (EOL) discussions with terminal cancer patients have been recognized in clinical guidelines for palliative care. ACP is also recommended in heart failure (HF) management, and the importance of advance discussions concerning future care preferences is well recognized for patients with HF. Cultural differences between Asia and Western countries, including the ways individuals interact with religion, their families, and their ways of thinking, may influence these discussions. Data on the current status of advance directives (AD), including do-not-attempt-resuscitation (DNAR) orders, in Japanese patients with HF remains scarce. Purpose This study aimed to identify the current status and clinical characteristics of AD in Japanese patients with acute HF and clarify the details of AD. Methods Data on AD were retrospectively collected from a multicenter cohort study (KICKOFF Registry) enrolling 1,253 patients with acute HF, with a median age of 80 years. As of December 2024, we evaluated 1,203 patients for details of AD and compared the clinical characteristics and outcomes between patients with and without AD. Results AD was implemented in 495 (41.1%) patients. Patients who had AD were significantly older than those without AD (mean age: 82.8 vs. 74.7 years). Patients with AD had significantly lower activity of daily living, were more likely to be certified for long-term care insurance, and had a higher incidence of cognitive impairment compared to those without AD. There was no difference in the rate of first hospitalization for HF. However, the length of hospital stay was significantly longer for patients with AD than for those without (median days: 26 vs. 18). The last AD since the admission was obtained within 3 days of admission in 58.4% of cases and within 5 days in 74.1% of cases. Changes or reconfirmations of AD during hospitalization were made in 21.0% of cases. Mortality rates at 6 months, 1 year, and 2 years were significantly higher in discharged patients with AD compared to those without (6 months: 19.3% vs. 4.6%; 1 year: 30.9% vs. 10.1%; 2 years: 45.5% vs. 16.5%). AD was implemented directly with only 7.3% of patients, with 27.1% involving their partner and 87.3% involving other family members. Details of AD included preferences for chest compressions (14.1%), tracheal intubation (13.1%), non-invasive positive pressure ventilation (42.0%), intravenous inotropes (57.2%), and intravenous therapy (98.6%). Conclusion This large and unique study reports the current state of AD in Japan and Asia. Greater efforts should be made to implement AD, ACP, and EOL discussions directly with patients who have sufficient cognitive function to understand their care preferences.