Relational processes in advance care planning among patients with end-stage liver disease: a mixed-methods systematic review

Advance care planning (ACP) is particularly important for patients with end-stage liver disease (ESLD) because of the disease's unpredictable trajectory, substantial symptom burden, and fluctuating decision-making capacity. However, evidence on the relational processes associated with ACP engagement in this population remains fragmented. This review aimed to identify, appraise, and synthesise evidence on relational processes associated with ACP engagement among patients with ESLD and to develop an empirically informed relational framework using Wright's concept of relational nudging as an interpretive lens. A mixed-methods systematic review was conducted. PubMed, Scopus, Web of Science, CINAHL, Embase, and PsycINFO were searched from database inception to 10 September 2026. One reviewer screened titles, abstracts, and full-text articles, with a second reviewer independently checking a subset of records. Methodological quality was assessed using the QualSyst tool. A convergent integrated approach was used to synthesise qualitative and quantitative evidence. The review was prospectively registered in PROSPERO (CRD420261390589). A total of 182 records were identified, and 20 reports representing 18 unique studies met the inclusion criteria. Of the 20 reports, 18 contributed findings to the thematic synthesis. Thematic synthesis generated three relational domains comprising nine themes and 25 sub-themes. These domains included clinician–patient relational processes, family–patient relational processes, and the socio-cultural and institutional relational context. Across these domains, ACP discussions frequently occurred late, communication in transplant settings often focused on prognosis and transplant-related information rather than patients' goals and preferences, and surrogates were not always prepared for future decision-making. These relational patterns were subsequently interpreted through Wright's concept of relational nudging and conceptualised as initiating, framing, and environmental relational nudges. ACP engagement among patients with ESLD occurs within relational processes involving clinicians, patients, families, and healthcare organisations rather than solely as an individual decision-making behaviour. This review proposes an empirically informed relational framework for understanding ACP engagement in ESLD. Further research is needed to examine this proposed framework in other populations and care settings.