A 70-year-old man with a history of cirrhosis, ascites, and hepatic encephalopathy was admitted for abdominal pain and shortness of breath. He had been recently hospitalized for the same symptoms. This admission was for a liver transplant evaluation. Several days after admission, he developed acute hepatic encephalopathy, secondary to Streptococcus mitis bacteremia. Advance care planning had not yet occurred.
Over the next several days, his encephalopathy gradually improved with antibiotics and lactulose treatment, and the possibility of liver transplant was again discussed with the patient and his wife. At that time, the couple raised questions regarding the risks and benefits of such an invasive procedure. Understanding he was at high risk for mortality, surgical complications, and poor quality of life, the patient and his wife struggled to process through the next steps.