Advance Directive Completion Among Community-Dwelling Adults with Decompensated Cirrhosis

Advance care planning (ACP) is recommended as part of usual care for patients with cirrhosis, but it is uncommonly performed. Little data exist to assess baseline rates of ACP that can be targeted for intervention development and quality improvement initiatives. Therefore, we evaluated advance directive completion among adults with decompensated cirrhosis across three large academic centers serving racially and ethnically diverse populations and described patient factors associated with completion.

We conducted a secondary analysis of the UC Health Care Planning Study. All patients were identified using a validated, electronic health record algorithm. Our primary outcome was completion of an advance healthcare directive or physician order for life-sustaining treatment. We compared demographics and advance directive completion between patients with decompensated cirrhosis and other advanced chronic illnesses. Bivariate analysis and multivariable logistic regression were performed to assess demographic factors associated with advance directive completion rates.

Of 8707 patients with advanced chronic illnesses, 539 (6%) had decompensated cirrhosis. Patients with decompensated cirrhosis were much less likely to have an advance directive compared to patients with other advanced conditions (22% vs. 34%, p < 0.001). In multivariable analysis, older age (odds ratio [OR]: 1.03 per year, 95% confidence interval [CI]: 1.01-1.05) and Hispanic race/ethnicity (OR: 0.42, 95% CI 0.21-0.84) were significantly associated with advance directive completion.

Advance directive completion is low among adults with decompensated cirrhosis. Tailored programs are needed to improve advance directive completion among younger and Hispanic patients with decompensated cirrhosis.