The purpose of this study is to explore the trajectory of advanced management care in patients with heart failure over a period of 9 months, then comparing the medical treatment accepted by patients after 2 years later and compliance with the preferences of patients and their families.

this study is to observe the trajectory of the advanced care management on patients with advanced heart failure and follow the difference between the actual medical treatment accepted by patients on 2years later and the preference of the patient and their families.

the advance care management in this study is mean the patients who know about the preference of medical treatment, communication, and prognosis of illness. we also measure the sense of coherence, self-efficacy and their quality of life to compare their relationship of the advanced care management.

Inclusion Criteria:

• diagnosed with AHA stage D, or NYHA class function 4, or LVEF<=30%.
• has one or more than one symptoms such as dyspnea, lower legs edema, weakness.
• ever admission to the hospital (include emergency room or the general room)

Exclusion Criteria:

• with other end-stage diseases such cancer, dementia, COPD, ESRD...etc.
• had other physical, cognitive, or psychological condition which may influence their answer.

patient with advanced heart disease and received medical treatment now.