Low Rates of Advance Care Planning (ACP) Discussions Despite Readiness to Engage in ACP Among Liver Transplant Candidates

• Published in: Digestive diseases and sciences 2021-05, Vol.66 (5), p.1446-1451
• Main Authors: Wang, Connie W., Lebsack, Adrienne, Sudore, Rebecca L., Lai, Jennifer C.
• Format: Article
• Language: English
• Subjects: Advance Care Planning; Advance Directives; Aged; Analysis; Ascites; Biochemistry; Confidence; Decision making; Documentation; End Stage Liver Disease - diagnosis; End Stage Liver Disease - mortality; End Stage Liver Disease - surgery; Female; Gastroenterology; Health Knowledge, Attitudes, Practice; Hepatitis; Hepatology; Humans; Hypertension; Liver; Liver diseases; Liver Transplantation - adverse effects; Liver Transplantation - mortality; Liver transplants; Male; Medical prognosis; Medical records; Medicine; Medicine & Public Health; Middle Aged; Oncology; Original Article; Palliative treatment; Patient Acceptance of Health Care; Patients; Planning; Proxy; Quality of life; Retrospective Studies; Self Report; Terminal Care; Transplant Recipients - psychology; Transplant Surgery; Transplantation
• ISSN: 0163-2116; 1573-2568
• DOI: 10.1007/s10620-020-06369-1

Background Patients with end-stage liver disease awaiting liver transplantation (LT) are seriously ill and experience fluctuating periods of clinical decompensation. Discussion of a patient’s advance care planning (ACP) wishes early in their dynamic disease course is critical to providing value-aligned care while awaiting LT. We aimed to evaluate current ACP documentation and assess readiness to engage in ACP in this population. Methods We conducted a retrospective study of adults undergoing LT evaluation from January 2017 to June 2017 and assessed characteristics associated with documentation using logistic regression. We then administered a survey to LT candidates from March 2018 to May 2018 to determine self-reported readiness to engage in ACP (range 1 = not at all ready to 5 = very ready). Results Among 170 LT candidates, median (interquartile range) age was 58 (53–65), 65% were men, MELDNa was 15 (11–21), and Child–Pugh A/B/C were 33/38/29%. Nine percent reported completing ACP prior to LT evaluation, but 0% had legal ACP forms or end-of-life wishes documented in the medical record. A durable power of attorney (DPOA) was discussed with 10%. In univariable analysis, white race (OR 4.16, p  = 0.03) and female sex (OR 3.06, p  = 0.04) were associated with ACP documentation, but Child–Pugh score and MELDNa were not. Of the 41 LT candidates who completed the ACP survey, 93% were ready to appoint a DPOA and 85% were ready to discuss end-of-life care. Conclusion There is a paucity of ACP documentation and identification of DPOA among LT candidates, despite patients reporting readiness to complete ACP and appoint a DPOA. These results reveal an opportunity for tools to facilitate discussions around ACP between clinicians, patients, and their caregivers.