Status of Physician-Ordered Advance Code in Patients With Acute Heart Failure.

Background: The physician ordered advance code (PAC), a treatment code used in Japanese hospitals based on the physician orders for life sustaining treatment paradigm, plays a crucial role in guiding treatment decisions for patients with acute heart failure (AHF). However, data on the clinical characteristics, decision-making processes, and outcomes associated with PAC in Japanese patients are limited. Methods and Results: We retrospectively analyzed data from 1,203 AHF patients across multiple centers in Japan. Patients were categorized based on the presence or absence of PAC orders; clinical characteristics and mortality outcomes were compared between the 2 groups. Patients with PAC orders were significantly older, more often female, and had lower activities of daily living scores. Cognitive impairment was markedly more prevalent in the PAC than non-PAC group. PAC decisions were primarily communicated to family members rather than to patients themselves, with only 7.3% of patients directly informed. The median time from admission to final PAC order was 2 days, with 74.1% finalized within 5 days. PAC orders frequently permitted intravenous therapies, but limited resuscitative measures in only 15% of patients. In-hospital and 2-year mortality rates were substantially higher in the PAC than non-PAC group. Conclusions: PAC designation reflected poor clinical status and was linked to significantly worse mortality outcome. Enhancing shared decision-making and aligning PAC with patient values are essential steps to optimize care for this vulnerable population.