Association of Formal and Informal Advance Care Planning with Multidimensional Health Literacy in Patients Undergoing...

Higher critical health literacy was associated with informal advance care planning, while higher total health literacy was associated with both informal and formal advance care planning in patients receiving hemodialysis. Patients unsure about treatment preferences had lower total health literacy, and lack of opportunity was the most common barrier to advance care planning engagement. Enhancing health literacy and providing structured opportunities for advance care planning may support patient-centered decision making in dialysis care.

Although qualitative studies suggest that health literacy (HL) may influence engagement in advance care planning (ACP) among patients undergoing dialysis, this association has not been quantitatively examined. We investigated whether multidimensional HL is associated with participation in informal and formal ACP and end-of-life care preferences.

This multicenter cross-sectional study included adult patients receiving hemodialysis from six facilities in Japan. Participation in informal and formal ACP was assessed using a questionnaire, and HL was measured with the Functional, Communicative, and Critical Health Literacy scale. Associations between HL and ACP participation were analyzed using logistic regression models. We also examined patients' end-of-life care preferences in the event of serious future health deterioration.

Among 651 eligible patients, 466 were included in the analysis (median age, 71 years; 35% women). Informal ACP participation was reported by 52% of patients, whereas formal ACP participation was 5%. Higher critical HL was independently associated with informal ACP participation (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.25 to 3.00), while higher total HL was associated with formal ACP participation (OR, 4.18; 95% CI, 1.63 to 10.77). Women and diabetes were associated with informal ACP and female sex with formal ACP. Patients who reported being unsure about future treatment preferences had lower total HL and were younger (total HL: OR, 0.63; 95% CI, 0.42 to 0.95; age: OR, 0.79; 95% CI, 0.66 to 0.95). The most common reason for not engaging in ACP discussions was a lack of opportunity to discuss ACP (71/151).

Critical HL was associated with informal ACP participation, whereas total HL was associated with formal ACP among patients undergoing hemodialysis. In addition, the most frequently reported barrier to ACP engagement was a lack of opportunity for discussion, highlighting the need to both enhance HL and establish structured opportunities for ACP to support patient-centered decision making.