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

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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.


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).


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.


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.

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Advance care planning


Confidence interval




Designated power of attorney


End-stage liver disease


Hepatitis B virus


Hepatitis C virus


Interquartile range


Model for end-stage liver disease-sodium


Nonalcoholic steatohepatitis


Provider Orders for Life-Sustaining Treatment


Standard deviation


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This study was funded by K23AG048337 (Lai) and R01AG059183 (Lai). This funding agency played no role in the analysis of the data or preparation of this manuscript.

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CWW and JCL contributed to study concept and design. CWW and AL participated in data collection; all authors contributed to data analysis and interpretation. CWW, RLS, and JCL contributed to the drafting of the manuscript; all authors contributed to critical revision of the manuscript and approved the final version.

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Correspondence to Jennifer C. Lai.

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The authors of this manuscript have no conflicts of interest to disclose as described by Digestive Diseases and Sciences.

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Wang, C.W., Lebsack, A., Sudore, R.L. et al. Low Rates of Advance Care Planning (ACP) Discussions Despite Readiness to Engage in ACP Among Liver Transplant Candidates. Dig Dis Sci 66, 1446–1451 (2021).

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