The aim of this research was to describe knowledge and attitudes regarding advance directives (ADs) in patients with advanced heart failure and identify factors influencing such knowledge and attitudes. We conducted a cross-sectional survey in 75 patients with advanced heart failure at a cardiovascular outpatient clinic and an in-patient ward. Data were collected by a validated measure of knowledge and attitudes regarding ADs. We compared knowledge and attitudes regarding ADs across patient age, sex, socioeconomic status, care received, and disease status using both univariate and stepwise regression models. Only four of the 75 participants (5.3%) had signed ADs. As a result of stepwise regression analysis, positive attitudes toward ADs were higher in those who were not religious (β = 3.10; 95% confidence interval [CI], 0.26-5.95), and patients who had a poorer left ventricular ejection fraction had more positive attitudes (β = 7.03; 95% CI, 3.32-10.73) toward ADs. Knowledge of ADs was higher in subjects with college level education (β = 0.82; 95% CI, 0.13-1.50) and in subjects with heart failure for greater than 1 year of duration (β = 2.04; 95% CI, 0.59-3.50). The use of ADs is low in patients with advanced heart failure, despite evidence regarding its benefits.