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

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.

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.

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.