Advance directives (ADs) are legal instruments that enable individuals to express their healthcare preferences in anticipation of a future loss of decision-making capacity. These directives are particularly important in the context of chronic conditions such as heart failure (HF), a disease marked by progressive functional decline and unpredictable medical crises. ADs help safeguard patient autonomy by ensuring that care aligns with personal values and preferences, especially at the end of life. This systematic review and meta-analysis was conducted in accordance with PRISMA guidelines to examine the preferences of patients with heart failure regarding life-sustaining treatments and end-of-life decision-making. A comprehensive literature search was performed across PubMed, Scopus, and Web of Science databases, covering publications up to March 2024. Search terms included "advance directive," "advance care planning," "heart failure," and "end-of-life decision-making." Studies were included if they were original, peer-reviewed, full-text articles focusing on HF patients aged 18 and older. Non-peer-reviewed works and inaccessible full texts were excluded. A total of 25 eligible studies were identified and appraised using the NIH quality assessment tool. Extracted data included demographic characteristics, preferences for treatment, surrogate decision-making, and educational interventions. Findings from the reviewed literature reveal consistently low levels of awareness and completion of ADs among HF patients. Completion rates varied significantly across studies, reflecting potential cultural and systemic influences. Preferences for surrogate decision-makers overwhelmingly favored family members over healthcare professionals. A notable finding from Jawahri et al. (2016) indicated that patients who received video-based education were significantly less inclined to choose cardiopulmonary resuscitation (CPR) or mechanical ventilation compared to those receiving only verbal information. Additional qualitative insights, such as those from Formiga et al. (2004), showed that patients prioritized maintaining dignity, independence, and meaningful relationships over merely extending life. These patterns highlight the necessity of aligning care with patients’ broader goals and values. Across the 25 studies included, a total of 4,091 heart failure patients were analyzed, with a mean age of 68.22 years. Meta-analytic findings demonstrated diverse preferences regarding life-sustaining interventions: approximately 53.73% of patients favored such treatments, while 45.37% declined CPR. These statistics underscore a substantial variability in end-of-life preferences, further reinforcing the need for individualized care planning. In conclusion, patients with heart failure display heterogeneous preferences concerning end-of-life care, shaped by cultural context, personal values, and the type of information provided. Despite the established importance of ADs, significant deficits in awareness, understanding, and documentation persist. These findings point to a critical need for tailored educational interventions, improved provider-patient communication, and culturally sensitive approaches to advance care planning. Future research should focus on designing and integrating standardized AD facilitation tools into routine clinical practice to support truly patient-centered care.
