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The therapeutic options available to individuals with advanced heart failure (HF) are limited; recent guidelines have introduced the concept of palliative care for these patients.To review the characteristics of patients with acute decompensated HF who are referred to hospice care.This was a retrospective analysis of data from the ADHERE (Acute Decompensated Heart failurE national REgistry) database. Patients included in the registry are aged 18 years or older and hospitalized in an academic, community, or tertiary facility in the US with a primary diagnosis of HF. For the purposes of the registry, HF is defined as "new onset or decompensation of chronic HF, with symptoms severe enough to warrant hospitalization". Each patient record in the registry concludes with information on patient discharge, transfer, or in-hospital death; follow-up data are, therefore, not available.The demographic and clinical characteristics and the medical treatment of patients referred to hospice care were assessed and compared with those of patients who received alternative care following hospital discharge.Between 1 October 2001 and 31 December 2005, there were 182,898 hospitalizations (307 hospitals) for acute decompensated HF recorded in the ADHERE database, of which just 1.6% concluded with hospice referral. By comparison, following discharge from hospital, 62.1% of patients returned home with self-care, 14.8% returned home with additional care, and 17.6% were referred to another acute-care facility. Over the study period there was a nonsignificant trend towards a temporal increase in the median rate of hospice referral, from 0.8% in 2001-2002 to 1.3% in 2004-2005 (P = 0.008). Patients referred to hospice care were significantly older (mean age 80.2 years), and significantly more likely to have been hospitalized with HF during the 6 months before the index admission than were patients who received alternative care after discharge (P<0.001 for both comparisons). Generally, left ventricular ejection fraction was lowest among patients referred to a hospice (mean 33.4%). Among the initial symptoms of HF reported in the database (fatigue, edema, and dyspnea), fatigue was far more common among hospice patients than among those with other discharge destinations (P<0.0001). In addition, the authors noted that patients referred to a hospice were less likely to undergo dialysis or cardiac catheterization (P<0.001 for both) or to receive evidence-based therapies (e.g. angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, and β-blockers) than were other patients. The hospitals most likely to refer patients to hospice care were nonacademic facilities (P<0.001 for comparison with academic hospitals) and those in the top quartile of compliance with Joint Commission on Accreditation of Health Care Organizations quality indicators for HF (P<0.001 for comparison with hospitals in lower quartiles).The proportion of patients with acute decompensated HF referred to hospice care remains low, but there seems to be a trend towards increasing use of these facilities over time.