This mixed-methods systematic review searched six databases from inception through 10 September 2026, identified 182 records and included 20 reports representing 18 unique studies; 18 reports entered thematic synthesis. The authors organised findings into three relational domains, nine themes and 25 subthemes spanning clinician–patient, family–patient and socio-cultural/institutional relationships. Conversations were often initiated only with severe deterioration or crisis, while transplant contexts tended to prioritise prognosis and transplant information over life goals and care preferences. This heterogeneous synthesis does not show that relational-nudging strategies improve goal-concordant care.
Key findings
- From 182 records, the review included 20 reports representing 18 unique studies; 18 reports contributed to thematic synthesis, so report and study counts should not be conflated.
- The synthesis produced three relational domains, nine themes and 25 subthemes: clinician–patient, family–patient and socio-cultural/institutional.
- ACP conversations were often delayed until deterioration or crisis instead of functioning as a continuing process before emergency decisions.
- Communication in transplant pathways frequently prioritised prognosis and transplant information over exploration of goals, values and care preferences.
- Families or surrogate decision-makers could remain underprepared. The authors interpreted possible facilitators as initiating, framing and environmental relational nudges, but these strategies were not tested for effect.
Why this matters globally
End-stage liver disease has an uncertain course intertwined with transplant decisions, making ACP a relational and system problem rather than merely a directive form. The three-level framework can generate testable approaches to clinician training, family preparation and conversation timing. Before global guidance, cultural fit and effects on goal-concordant care, family distress, service use and equity need prospective evaluation.
Thai researcher contribution
Yaowarat Matchim and Zhichao Jin are affiliated with the Faculty of Nursing, Thammasat University and collaborated with researchers in China and South Korea. This links Thai nursing scholarship to an international synthesis of end-of-life care and creates a basis for testing whether the identified relational processes fit Asian family and service structures.
Limitations to consider
Primary screening by one reviewer with only subset checking by a second raises the chance of missed or inconsistently selected studies. Included studies varied in method, population, country and transplant setting, so themes reveal patterns but not comparable prevalence or effect sizes. Relational nudging is a post-synthesis interpretation, not a randomised intervention, and has not been shown to improve goal-concordant care. The accessible publisher copy is an accepted/early version that may receive textual or production changes before the final version of record.