BACKGROUND: Guidelines recommend hospice care as a treatment option for end-stage heart failure (HF) patients. Little is known regarding utilization of hospice care in a contemporary cohort of patients hospitalized with HF and how this may vary by estimated mortality risk. METHODS: We analyzed HF patients ≥65 years (n = 58,330) from 214 hospitals participating in the Get With the Guidelines-HF program. Univariate analysis comparing patients discharged to hospice versus other patients was performed. Hospice utilization was evaluated for deciles of estimated 90-day mortality risk using a validated model. Multivariate analysis using admission patient and hospital characteristics was also performed to determine factors associated with hospice discharge. RESULTS: There were 1,442 patients discharged to hospice, and rates of referral varied widely by hospital (interquartile range 0-3.7%) as shown in the univariate analysis. Patients discharged to hospice were significantly older and more often white, had lower left ventricular ejection fraction, higher B-type natriuretic peptide, and lower systolic blood pressure on admission. Utilization rates for each decile of 90-day estimated mortality risk ranged from 0.3% to 8.6%. Multivariable analysis found that factors associated with hospice utilization included increased age, low systolic blood pressure on admission, and increased blood urea nitrogen. CONCLUSIONS: Hospice utilization remains low among HF patients, even those with the highest predicted risk of death.