title: Advance directives among hospitalized patients with heart failure.
abstract: OBJECTIVE
  The purpose of this study was to assess the frequency and correlates of documented advance directives (ADs) among patients hospitalized for heart failure (HF).
  
  
  BACKGROUND
  Discussing ADs with patients with HF is critical for identifying treatment goals consistent with patients' values and preferences and for facilitating health care team communication.
  
  
  METHODS
  We retrospectively identified electronic medical records of adult patients admitted to 2 large tertiary care hospitals with either the primary or secondary discharge diagnosis of HF from September 2008 to August 2013 to assess the presence of ADs in electronic medical records. We performed analyses including HF as either the primary or secondary admission diagnosis and HF as the primary admission diagnosis only. Multivariable models were constructed to investigate independent predictors of documented ADs.
  
  
  RESULTS
  Data included 44,768 admissions from 24,291 individual patients over 5 years. Mean age of patients at admission was 64.8 ± 15.9 years; 47.9% of these patients were female, 51.8% were black. The median length of stay for all admissions was 5 (3 to 10) days; 12.7% of patients had documented ADs. Older age, female sex, white race, higher socioeconomic status, higher risk for adverse in-hospital outcomes, length of stay ≥5 days, hospice discharge, palliative care consultation, and a do-not-resuscitate order were all associated with a significantly higher chance of having documented ADs. A significant increase in ADs over time was noted, but more than 80% of patients did not have ADs in medical records at the end of the study period.
  
  
  CONCLUSIONS
  In a diverse population of hospitalized patients with HF, most did not have a documented AD in the medical records. Although several factors were associated with a higher probability, major opportunities exist for all subgroups of patients with HF to improve documentation of ADs.
authors.affiliation: Cardiology Division, Stony Brook University, Stony Brook, New York. Electronic address: javed.butler@stonybrookmedicine.edu.
authors.forename: Javed
authors.initials: J
authors.lastname: Butler
authors.affiliation: Emory Cardiovascular Clinical Research Institute, Emory University, Atlanta, Georgia.
authors.forename: Zachary
authors.initials: Z
authors.lastname: Binney
authors.affiliation: Emory Palliative Care Center, Emory University, Atlanta, Georgia.
authors.forename: Andreas
authors.initials: A
authors.lastname: Kalogeropoulos
authors.affiliation: Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.
authors.forename: Melissa
authors.initials: M
authors.lastname: Owen
authors.affiliation: Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Clevenger
authors.affiliation: Emory Cardiovascular Clinical Research Institute, Emory University, Atlanta, Georgia.
authors.forename: Debbie
authors.initials: D
authors.lastname: Gunter
authors.affiliation: Cardiology Division, Stony Brook University, Stony Brook, New York.
authors.forename: Vasiliki
authors.initials: V
authors.lastname: Georgiopoulou
authors.affiliation: Emory Cardiovascular Clinical Research Institute, Emory University, Atlanta, Georgia; Atlanta Veterans Administration Medical Center, Department of Veterans Affairs, Atlanta, Georgia.
authors.forename: Tammie
authors.initials: T
authors.lastname: Quest
mesh_terms: D016223:Advance Directives / Q000706:statistics & numerical data*; D000367:Age Factors; D000368:Aged; D003376:Counseling; D005260:Female; D005845:Georgia / Q000453:epidemiology; D006333:Heart Failure / Q000453:epidemiology*; D006738:Hospices; D006760:Hospitalization; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010166:Palliative Care; D010351:Patient Discharge; D016414:Resuscitation Orders; D012189:Retrospective Studies; D012737:Sex Factors; D012923:Social Class; D044465:White People
keywords: advance directives; heart failure; palliative care