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

Abstract

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.

Central Figure

Acute heart failure (AHF) is a major cause of hospitalization among older adults both globally^1,2 and in Japan,^3,4 where the aged population is rapidly increasing. AHF is associated with high rates of readmission and mortality, and is recognized as a chronic condition with a poor prognosis.⁵

There is a growing international emphasis on supporting medical decision-making based on patients’ values and preferences. A core component of such support is the use of advance directives (ADs). ADs allow individuals to document and share their preferences for medical treatment and care in advance in case they become unable to express their wishes in the future. ADs are regarded as a key mechanism to ensure patient-centered care.⁶ Demonstrated benefits of ADs include standardization of goals-of-care discussions by healthcare providers, the integration of advance care planning (ACP), improved satisfaction among patients and families, and even cost reductions in end-of-life care.^7,8 In contrast, although policy frameworks for ACP and ADs have been developed in Japan, their clinical adoption remains limited, especially in acute care hospitals, where the documentation rate of ADs is reportedly very low.^9,10

Furthermore, little is known about the actual prevalence and characteristics of ADs among patients with AHF in Japan. Specifically, there are limited data on the proportion of patients who have completed ADs upon admission, the content of ADs and the context in which they were created, the involvement of family members or healthcare professionals in decision-making, and the relationship between patient background factors and having ADs. Cultural and systemic factors unique to Japan may also influence the timing and nature of ADs implementation.

The implementation of formal ADs remains relatively uncommon in the management of AHF in Japan. Instead, decisions regarding code status, such as resuscitation preferences or treatment limitations, are frequently made by attending physicians in real-time clinical settings, often without prior documentation of patient wishes. In many Western countries, the Physician Orders for Life-Sustaining Treatment (POLST) paradigm has been widely adopted.^11,12 POLST documents reflect a patient’s preferences regarding life-sustaining treatments, recorded as actionable medical orders signed by a physician. In Japan, however, the POLST system has not been officially implemented due to differences in legal, ethical, and healthcare frameworks. Nonetheless, a similar clinical practice exists in many Japanese hospitals. These directives, often referred to as “treatment codes,” guide in-hospital medical teams in the provision or limitation of interventions. Building on these practices, this study introduces the physician-ordered advance code (PAC) as a novel conceptual framework tailored to the Japanese inpatient context.

The aim of the present study was to retrospectively examine the PAC status among patients with AHF in Japan at the time of hospital admission. By determining the current challenges to having a PAC in place, this study seeks to inform future strategies to enhance the integration of ADs into acute care practice.

Methods

Study Design

This study was a retrospective analysis of the Kitakawachi Clinical Background and Outcome of Heart Failure (KICKOFF) registry database. The KICKOFF registry enrolled patients with AHF hospitalized between April 2015 and August 2017. The institutions participating in the KICKOFF registry were 1 cardiovascular center and 12 small- and medium-sized hospitals (<450 beds for acute care), serving as primary and secondary referral medical centers in the north of Kitakawachi (Hirakata, Neyagawa and Katano city) and in Yawata. Kitakawachi and Yawata are typical satellite communities in Japan, and are located at the eastern end of Osaka Prefecture and at the southern end of Kyoto Prefecture, respectively.¹³ The hospitals in the KICKOFF registry functioned primarily as secondary emergency medical centers, with a focus on cardiovascular emergencies in a regional setting. Unlike tertiary academic hospitals, the hospitals in the KICKOFF registry serve a more general patient population and reflect typical clinical practice environments in Japan, particularly in community-based acute care. The total population of the north of Kitakawachi and Yawata is approximately 798,000. In Hirakata city, in 2018, the proportion of people aged ≥65 years was 27.6% and the proportion of people aged ≥75 years was 20.2%. Heart failure was diagnosed by the Framingham criteria when there were at least 2 major criteria or 1 major and 2 minor criteria.¹⁴ The clinical data of all patients were collected through a review of medical records and interviews with the patients or other family members by the physicians or investigators at the participating sites. Data were collected via an internet database system and on isolated computers, and double-checked by the general office of the registry.

The study protocol followed the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the Ethics Committee of Hirakata Kohsai Hospital (Osaka, Japan; Approval no. 2021-012). A detailed study design, patient enrollment, and definitions of variables collected as part of the KICKOFF Registry are available on the University Hospital Medical Information Network (UMIN) Clinical Trials Registry (UMIN000016850). Written informed consent was obtained from all participants prior to study enrollment. Additional data not specified in the original protocol were obtained using an opt-out consent model when needed. The study protocol did not affect any of the treatments or outpatient care of patients with AHF.

Patient Data and Outcomes

The KICKOFF registry enrolled 1,253 patients hospitalized with AHF. PAC was defined as a records documented by physicians in a patient’s medical record as an advance code. This definition applies regardless of whether the patient had been directly informed about the decision-making process. It also encompasses instances where the treatment policy was discussed and determined in consultation with a patient’s partner or family members. As of February 2025, after excluding the medical records of 50 patients that remained unreviewed, the study population consisted of 1,203 patients for whom PAC data in hospital were available. We compared baseline characteristics between patients with and without PAC orders in hospital.

Detailed definitions of comorbidities have been reported previously.¹⁵ In the present study, we divided patients into 4 activities of daily living (ADL) groups both before admission and at discharge: independent outdoor walking; independent indoor walking; indoor walking with assistance; or abasia. Detailed in-hospital PAC data included the number of patients with a PAC order, the number of days from admission to the last PAC order, changes to the last PAC order after hospitalization, and the medical procedures allowed in the PAC order (e.g., chest compressions, intubation, mechanical ventilation, electrical defibrillation, non-invasive positive pressure ventilation [NPPV], hemodialysis, catecholamines [drip in vein], and other intravenous therapy).

The outcome measure was the incidence of all-cause death during the 2-year follow-up period. Clinical follow-up was performed at 6 months, 1 year, and 2 years after discharge. Follow-up data were collected primarily by a review of hospital records, with additional follow-up information obtained via telephone or mail contact with the patients or their relatives.

Statistical Analysis

We compared clinical baseline characteristics and status between the patients with and without PAC orders. Continuous variables are presented as the mean±SD or as the median with interquartile range; categorical variables are presented as numbers and percentages. Chi-squared tests were used to compare categorical variables; Student’s t-tests were used to compare continuous variables.

Statistical analyses were performed using JMP version 18 (SAS Institute, Cary, NC, USA).

Results

Baseline Clinical Characteristics

Table 1 summarizes the clinical characteristics of patients with and without PAC orders. Compared with the non-PAC group, patients in the PAC group were more likely to be female, older, and had a lower body mass index. There was no significant difference in the proportion of previous hospitalizations for heart failure between the 2 groups. The prevalence of cognitive impairment was markedly higher in the PAC than non-PAC group (55.2% vs. 21.6%, respectively). In addition, patients with PAC orders had lower serum total protein, albumin, and hemoglobin levels, a lower estimated glomerular filtration rate, and higher B-type natriuretic peptide levels than those without. Left ventricular ejection fraction did not differ significantly between the 2 groups.

Table 1.

Baseline Clinical Characteristics in Patients With and Without Physician-Ordered Advance Code

	PAC	Non-PAC	P value
No. patients	495 (41.2)	708 (58.8)
Male sex	228 (46.1)	390 (55.1)	<0.01
Age (years)	82.8±10.1	74.7±11.3	<0.01
BMI (kg/m2)	20.6±4.2	22.5±4.0	<0.01
SBP (mmHg)	141.9±35.2	143.8±32.6	0.35
DBP (mmHg)	80.5±22.9	83.9±22.9	0.01
Heart rate (beats/min)	93.8±28.1	91.9±30.7	0.26
Previous hospitalization for HF	176 (35.6)	239 (33.8)	0.52
PAC before hospitalization	52 (10.5)	–
Comorbidities
Hypertension	317 (64.0)	475 (67.1)	0.27
Coronary artery disease	165 (33.3)	194 (27.4)	0.03
Valvular disease	133 (26.9)	207 (29.2)	0.37
Diabetes	143 (28.9)	254 (35.9)	0.01
Dyslipidemia	145 (29.3)	286 (40.4)	<0.01
Atrial fibrillation	201 (40.6)	300 (42.4)	0.54
Chronic kidney disease	288 (58.2)	371 (52.4)	0.05
COPD	93 (18.8)	87 (12.3)	<0.01
Device implantation	36 (7.3)	58 (8.2)	0.56
Cognitive dysfunction	273 (55.2)	153 (21.6)	<0.01
Active malignancy	38 (7.7)	25 (3.5)	<0.01
Blood test
Total protein (mg/dL)	6.2 [5.7–6.8]	6.7 [6.2–7.1]	<0.01
Albumin (mg/dL)	3.0 [2.6–3.4]	3.5 [3.2–3.8]	<0.01
Hemoglobin (g/dL)	10.8 [9.6–11.9]	12.1 [10.8–13.8]	<0.01
Creatinine (mg/dL)	1.16 [0.81–1.85]	1.04 [0.83–1.43]	<0.01
eGFR (mL/min/1.73 m2)	40.4 [23.8–58.7]	47.1 [33.6–62.2]	<0.01
BNP (pg/dL)	322 [157–718]	191 [83–520]	<0.01
HbA1c (JDS) (%)	6.1 [5.7–6.8]	6.2 [5.8–6.8]	0.23
Echocardiography
LV end-diastolic diameter (mm)	46.0±8.8	49.2±9.5	<0.01
LV end-systolic diameter (mm)	33.4±10.2	36.4±11.3	<0.01
LVEF (%)	52.5±17.0	51.6±17.8	0.36

Unless indicated otherwise, data are given as the mean±SD, median [interquartile range], or n (%). BMI, body mass index; BNP, B-type natriuretic peptide; COPD, chronic obstructive pulmonary disease; DBP, diastolic blood pressure; eGFR, estimated glomerular filtration rate; HF, heart failure; JDS, Japan Diabetes Society; LV, left ventricular; LVEF, left ventricular ejection fraction; PAC, physician-ordered advance code; SBP, systolic blood pressure.

Table 2 presents clinical status and treatments in patients with and without PAC orders. Prior to admission, patients in the PAC group were significantly less likely to be living alone and more likely to reside in a hospital or an institution for the elderly. ADL scores were significantly lower in the PAC than non-PAC group both before admission and at discharge. The rate of long-term care insurance certification was significantly higher among patients in the PAC than non-PAC group. During hospitalization, rates of cardiac care unit admission, intubation, NPPV, intravenous diuretics, and continuous catecholamine infusion therapy were significantly higher rates in the PAC than non-PAC group. In-hospital mortality was also significantly higher in the PAC than non-PAC group (26.5% vs. 0.6%, respectively).

Table 2.

Clinical Status and Treatment in Patients With and Without Physician-Ordered Advance Code

	PAC	Non-PAC	P value
No. patients	495 (41.2)	708 (58.8)
Living situation before admission			<0.01
Alone	101 (20.4)	237 (33.5)
Only with partner	78 (15.8)	142 (20.1)
With son or daughter	190 (38.4)	286 (40.4)
Hospital or institution for the aged	126 (22.5)	43 (6.1)
ADL before admission			<0.01
Independent outdoor walking	166 (33.5)	539 (76.1)
Independent indoor walking	182 (36.8)	122 (17.2)
Indoor walking with assistance	74 (14.9)	232 (4.5)
Abasia	73 (14.8)	15 (2.1)
ADL at discharge			<0.01
Independent outdoor walking	108 (21.8)	506 (71.5)
Independent indoor walking	108 (21.8)	130 (18.4)
Indoor walking with assistance	72 (14.6)	46 (6.5)
Abasia	207 (41.8)	26 (3.7)
Long-term care insurance certification	313 (63.2)	206 (29.1)	<0.01
Acute treatment
Admission to the CCU	284 (57.4)	259 (36.6)	<0.01
Intubation	40 (8.1)	20 (2.8)	<0.01
NPPV	96 (19.4)	56 (7.9)	<0.01
Diuretics (i.v.)	427 (86.3)	519 (73.3)	<0.01
Catecholamine (d.i.v.)	160 (32.3)	127 (17.9)	<0.01
Length of hospital stay (days)	26 [16–42]	18 [13–26]	<0.01
Discharged	231 (46.7)	646 (91.2)	<0.01
NYHA functional class at discharge			<0.01
I	67 (13.5)	431 (60.9)
II	110 (22.2)	167 (23.6)
III	125 (25.3)	83 (11.7)
IV	62 (12.5)	23 (3.2)
In-hospital death	131 (26.5)	4 (0.6)	<0.01

Unless indicated otherwise, data are given as the median [interquartile range] or n (%). ADL, activities of daily living; CCU, cardiac care unit; d.i.v., drip in vein; i.v., intravenous; NPPV, non-invasive positive pressure ventilation; NYHA, New York Heart Association; PAC, physician-ordered advance code.

In the PAC group, 87.3% of PAC-related discussions were with family members other than the patient’s partner, 27.1% were with the patient’s partner, and only 7.3% were with the patient (Figure 1). The mean interval from hospital admission to the final PAC acquisition was 7.1 days (median 2 days; Figure 2). Notably, 74.1% of patients had their final PAC obtained within 5 days of admission. During the hospitalization period, PAC orders were changed or reconfirmed in 20% of patients. Regarding the contents of the PAC orders, approximately 15% of patients were designated to receive cardiopulmonary resuscitation measures, including chest compression, intubation, mechanical ventilation, and electrical defibrillation (Figure 3). The PAC orders included documentation of NPPV for 42.0% of patients, continuous catecholamine infusion for 57.2%, and intravenous treatment in nearly all patients.

Figure 1.

Distribution of individuals informed about physician-ordered advance code (PAC). Most PAC decisions were communicated to family members other than the patient’s partner, with only 7.3% of PAC orders directly discussed with the patient.

Figure 2.

Timing of final physician-ordered advance code (PAC) orders after hospital admission. The figure shows the time from hospital admission to the final PAC order. The median interval was 2 days (interquartile range 1–6 days), the mean (±SD) interval was 7.1±13.5 days, and 74.1% of patients had their final PAC order within 5 days of admission.

Figure 3.

Contents of physician-ordered advance code (PAC) orders among hospitalized patients showing the proportion of patients for whom chest compressions, intubation, mechanical ventilation, and defibrillation were prescribed. Intravenous treatments, non-invasive positive pressure ventilation (NPPV), and catecholamine infusions were also frequently included. d.i.v., drip in vein.

Among patients who survived to discharge, the mortality rate of those with a PAC order was approximately 3-fold higher up to 2 years after discharge compared with patients without a PAC order (Figure 4).

Figure 4.

Two-year mortality in patients with and without physician-ordered advance code (PAC) orders. The mortality rate over a 2-year period after discharge was nearly 3-fold higher among patients with than without PAC orders.

Discussion

This study provides important insights into the current status of PAC orders in elderly patients hospitalized with AHF in Japan, and has identified several key challenges. Patients with a PAC order were generally older, more likely to be female, and had higher rates of cognitive impairment and poor nutritional status than those without a PAC order. Furthermore, patients with a PAC order had significantly lower ADL scores at both admission and discharge, and were more likely to be residing in hospitals or institutions for the elderly prior to admission. These characteristics are consistent with known prognostic factors in AHF, suggesting that the PAC was often implemented in those patients with overall vulnerability and frailty.

Of particular note is the fact that the decision-making process for the PAC rarely involved direct discussions with the patient; only 7.3% of cases included explanations to the patient themselves. Instead, decisions were predominantly made in consultation with family members other than the patient’s partner. This finding underscores the challenges in promoting shared decision-making and patient autonomy in the aging Japanese population. The low involvement of patients in their own care planning highlights a critical gap in current practice, indicating the need for improved decision-making support that prioritizes patient preferences and values.

In contrast, Western countries have widely implemented ACP frameworks that emphasize patient autonomy and shared decision-making. Studies from the US and Europe have shown that ACP can lead to more patient-centered care and improved end-of-life outcomes.^6,16 A previous study reported that many elderly Americans needed decision-making near the end of life at a time when most lacked the capacity to make decisions.¹⁷ In these settings, structured discussions and documentation of patients’ wishes are integrated into clinical practice, ensuring that treatment decisions align more closely with the individual preferences of the patients. However, in East Asian countries, family-centered decision-making remains a dominant cultural norm, often limiting direct patient involvement.^18–21 Our findings are consistent with these regional cultural practices, highlighting a significant gap in patient autonomy within the context of AHF care in Japan. In order to bridge this gap, it is clinically important to integrate validated prognostic tools into routine practice to guide discussions around ACP and the implementation of the PAC.^22–24 Moreover, comprehensive assessment of cognitive function, frailty, and self-management capacity plays a pivotal role in the care of patients with AHF^25–27 because these factors critically influence prognosis, treatment adherence, and the appropriateness of care goals.

This study has several important limitations. First, it was a retrospective study, which may limit the generalizability of the findings. However, our study had a relatively large sample size of over 1,000 patients with a relatively high prevalence of documented PAC orders. Nonetheless, further research in other regions and healthcare systems is warranted to validate the generalizability of these findings. Second, the process of PAC determination was not standardized, and the degree of patient and family involvement in decision-making was based on available medical records, potentially underestimating patient-centered discussions. Third, we were unable to evaluate whether the implementation of PAC orders aligned with patient values and preferences, because direct patient interviews were not conducted. Fourth, data on potential confounding factors, including socioeconomic status, were not systematically collected or adjusted for.

Conclusions

In elderly AHF patients, PAC designation reflected poor clinical status and was linked to significantly worse mortality outcome. Enhancing shared decision-making and aligning PAC orders with patient values are essential steps to optimize care for this vulnerable population.

Acknowledgment

The authors extend their sincere appreciation to all the institutions participating in the registry and the clinical research coordinators.

Sources of Funding

This research was supported by research funding from Nakajima Steel Pipe Company Limited, the Osaka Heart Club (Osaka, Japan), and Osaka Yakugyou club (Osaka, Japan).

Disclosures

All authors have no relationships relevant to the contents of this paper to disclose.

IRB Information

The study protocol followed the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the Ethics Committee of Hirakata Kohsai Hospital (Osaka, Japan; Approval no. 2021-012) and the ethics committees of all participating hospitals.

Data Availability

The deidentified participant data will not be shared.

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