Abstract

Background: Clinician inexperience with advanced care planning (ACP) is a barrier to patient-centered care for adults with decompensated cirrhosis (DC) at liver transplant centers. Because transplant nurse coordinators are well-versed in DC prognoses and often develop marked therapeutic relationships with patients, these health care team members may be uniquely poised to promote ACP in the DC population. Our aim was to pilot test an ACP educational program for transplant nurse coordinators.

Methods: An ACP expert familiar with the liver transplant population (N.W.) conducted a 1-hour educational seminar, attended by liver transplant nurse coordinators (n=8). Subject matter included the importance of ACP in the DC population as well as practical requirements for completing and documenting advanced directives (AD) at our medical center. Following the seminar, transplant coordinators were encouraged to bring up AD completion during intake appointments with pre-liver transplant patients. Three follow-up check-in meetings occurred at various intervals to help address barriers to workflow incorporation. Documentation of ACP conversations and AD completion rates in the 12 weeks before and after the intervention were compared using paired t-tests. A post- intervention survey was conducted to assess nurse coordinator engagement and perceptions on feasibility, applicability, and appropriateness of the intervention.

Results: Prior to the intervention, 10 of 108 patients (9.3%) had any ACP documentation and 5 (4.6%) had a completed AD. After the intervention, 5 of 107 (4.7%) had any ACP documentation and 5 (4.7%) patients completed an AD, demonstrating no significant differences pre- and post- intervention (Δ ACP documentation: p = 0.187, Δ AD completion: p = 0.998). The most cited barrier by the transplant nurse coordinators was other responsibilities taking precedence (N=3), as well as a perception that transplant social workers are better suited to perform this task (N=5, open-ended responses). Regarding nurse coordinator engagement, acceptability scores received the highest mean scores of 4.0 out of 5.0 (SD 0.82), followed by feasibility (3.5, SD 0.65) and applicability (3.42, SD 0.57).

Conclusion: This project demonstrates that an education intervention for health care providers alone may not be sufficient in improving ACP amongst patients with DC, and further work to reduce other ACP barriers such as operational constraints may be required.