There are emerging data revealing disparities in serious illness care for patients with advanced liver disease. Although liver disease is the 11th leading cause of death overall in adults in the United States, it is the 4th and 7th leading cause of death among American Indian/Alaska Native and Hispanic individuals, respectively.1Heron M. Deaths: leading causes for 2019.Natl Vital Stat Rep. 2021; 70: 1-114Google Scholar Despite the benefits of specialty palliative care and hospice care services in improving the quality of care for patients with serious illnesses, Black, Asian, American Indian/Alaska Native, and Hispanic adults with advanced liver disease are less likely to use these services or to die at home.2Patel A.A. Walling A.M. Ricks-Oddie J. et al.Palliative care and health care utilization for patients with end-stage liver disease at the end of life.Clin Gastroenterol Hepatol. 2017; 15: 1612-1619Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar,3Kaplan A. Fortune B. Ufere N. et al.National trends in location of death in patients with end-stage liver disease.Liver Transpl. 2021; 27: 165-176Crossref PubMed Scopus (10) Google Scholar Although there are limited data examining disparities in end-of-life care delivery for patients with advanced liver disease, socially disadvantaged patients with serious illnesses are more likely to experience invasive, costly, and potentially nonbeneficial care at end of life.4Brown C.E. Engelberg R.A. Sharma R. et al.Race/ethnicity, socioeconomic status, and healthcare intensity at the end of life.J Palliat Med. 2018; 21: 1308-1316Crossref PubMed Scopus (46) Google Scholar Serious illness communication is therefore not only an essential skillset for all clinicians providing care to patients with advanced liver disease, but also a tool to potentially advance health equity in end-of-life care in hepatology. The goal of serious illness communication is to promote patients’ prognostic understanding and elicit what matters most to them to prepare them for future decision-making in the face of uncertainty.5Jacobsen J. Bernacki R. Paladino J. Shifting to serious illness communication.JAMA. 2022; 327: 321-322Crossref PubMed Scopus (21) Google Scholar When patients do not have a full understanding of their prognosis, they may be more likely to pursue high-intensity treatments that are unlikely to sustain their lives in a way that is acceptable to them.6Weeks J.C. Cook E.F. O'Day S.J. et al.Relationship between cancer patients' predictions of prognosis and their treatment preferences.JAMA. 1998; 279: 1709-1714Crossref PubMed Scopus (998) Google Scholar Studies have shown that disparities in serious illness communication among racial and ethnic minority patients are associated with increased receipt of high-intensity care in the terminal phase of illness, contributing to health inequities in end-of-life care.4Brown C.E. Engelberg R.A. Sharma R. et al.Race/ethnicity, socioeconomic status, and healthcare intensity at the end of life.J Palliat Med. 2018; 21: 1308-1316Crossref PubMed Scopus (46) Google Scholar,6Weeks J.C. Cook E.F. O'Day S.J. et al.Relationship between cancer patients' predictions of prognosis and their treatment preferences.JAMA. 1998; 279: 1709-1714Crossref PubMed Scopus (998) Google Scholar,7Mack J.W. Paulk M.E. Viswanath K. et al.Racial disparities in the outcomes of communication on medical care received near death.Arch Intern Med. 2010; 170: 1533-1540Crossref PubMed Scopus (189) Google Scholar High-quality serious illness communication has been shown to mitigate these inequities through promoting patients’ prognostic understanding, leading to reduced emotional distress, increased satisfaction with care, and reduced receipt of costly care at end of life.8Starr L.T. O'Connor N.R. Meghani S.H. Improved serious illness communication may help mitigate racial disparities in care among Black Americans with COVID-19.J Gen Intern Med. 2021; 36: 1071-1076Crossref PubMed Scopus (10) Google Scholar To date, there have been few published approaches to serious illness communication in hepatology, particularly to promote prognostic understanding, among underrepresented populations.9Woodrell C.D. Patel A.A. Wilder J.M. et al.Cultural humility and end-of-life communication with people with advanced liver disease.Clin Liver Dis (Hoboken). 2022; 20: 81-85Crossref PubMed Scopus (2) Google Scholar Thus, there is a critical need to develop novel communication strategies that promote prognostic understanding among patients with advanced liver disease to advance equitable serious illness care in hepatology. In this issue of the Gastroenterology Mentoring, Education, and Training Corner, Patel et al10Patel A.A. Arnold R.M. Taddei T.H. Woodrell C.D. “Am I going to die?”: delivering serious news to patients with liver disease.Gastroenterology. 2023; 164: 177-181Abstract Full Text Full Text PDF Scopus (2) Google Scholar provide structured approaches for improving a key component of serious illness communication, delivering serious news, for patients with advanced liver disease. The piece centers on the case of a 71-year-old man (Mr D) with decompensated cirrhosis caused by fatty liver disease who recently completed his liver transplantation evaluation during an acute hospitalization for new ascites and worsening hepatic encephalopathy. After hospital discharge, he presents to his hepatologist’s clinic for follow-up, anxiously awaiting the results of the review committee’s assessment of his transplant eligibility. The committee has decided that he is not eligible because of his comorbid heart failure; the hepatologist must now communicate this to him. The authors illustrate critical strategies for delivering serious news across 4 key domains: (1) assessing patients’ illness and prognostic understanding, (2) understanding their preferences for receiving prognostic information, (3) sharing prognostic information with empathy, and (4) equipping them for the next step.5Jacobsen J. Bernacki R. Paladino J. Shifting to serious illness communication.JAMA. 2022; 327: 321-322Crossref PubMed Scopus (21) Google Scholar The case presented by Patel et al10Patel A.A. Arnold R.M. Taddei T.H. Woodrell C.D. “Am I going to die?”: delivering serious news to patients with liver disease.Gastroenterology. 2023; 164: 177-181Abstract Full Text Full Text PDF Scopus (2) Google Scholar highlights multiple deficits in serious illness communication in hepatology, particularly in conveying the life-limiting nature of advanced liver disease. In hepatology clinic, the patient shares his current understanding of his illness as follows:Mr D: Basically, I know that I have a fatty liver and that currently, it’s not working well. The team in the hospital said that my only chance is to get a transplant and that they were going to tell me after all the tests whether I’ve got a shot…. They basically told me that I’ll die if I don’t get a transplant…. I don’t understand, am I going to die?” This story, familiar to hepatologists, suggests the current state of serious illness communication is lacking. Although this patient knows he has advanced liver disease, it is only after he is declined for liver transplantation that he appreciates it might lead to his death. His first signal that he has a serious illness and a poor prognosis comes from not being listed. When patients with advanced liver disease receive information about prognosis anchored to the transplant decision, it is received too late in their illness trajectory, often as a false dichotomy of “life or death.”11Patel A.A. Ryan G.W. Tisnado D. et al.Deficits in advance care planning for patients with decompensated cirrhosis at liver transplant centers.JAMA Intern Med. 2021; 181: 652-660Crossref PubMed Scopus (21) Google Scholar, 12Kaplan A. Comisar L. Ufere N.N. et al.Understanding prognosis: discrepancy in prognosis estimates between patients with cirrhosis and their hepatologists.Clin Gastroenterol Hepatol. 2022; (Published online May 26, 2022)https://doi.org/10.1016/j.cgh.2022.04.042Abstract Full Text Full Text PDF Scopus (2) Google Scholar, 13Ufere N.N. Lai J.C. Advance care planning in liver transplant: preparing for both life and death.JAMA Intern Med. 2021; 181: 660-661Crossref PubMed Scopus (4) Google Scholar Because they hear that liver transplantation is the pathway for living, transplant candidates may be blindsided by the challenges of waiting for a liver offer, which could involve several months of progressive symptoms, frequent hospitalizations, or even dying on the waiting list in the intensive care unit (ICU). Furthermore, they may be unprepared for life after transplantation, which can involve a prolonged postoperative course and recovery.14Lieber S.R. Kim H.P. Baldelli L. et al.Early survivorship after liver transplantation: a qualitative study identifying challenges in recovery from the patient and caregiver perspective.Liver Transpl. 2022; 28: 422-436Crossref PubMed Scopus (6) Google Scholar Alternatively, patients declined for liver transplantation may only see their impending death. Transplant teams typically do not discuss alternative treatment options with patients, such as continuing to pursue best supportive hepatology care.11Patel A.A. Ryan G.W. Tisnado D. et al.Deficits in advance care planning for patients with decompensated cirrhosis at liver transplant centers.JAMA Intern Med. 2021; 181: 652-660Crossref PubMed Scopus (21) Google Scholar In turn, patients who are not listed for liver transplantation may feel unprepared to receive serious news, as was the case for Mr D. This failure to promote prognostic understanding earlier in the illness trajectory may result in the pursuit of high-intensity treatment even in the setting of poor prognosis, contributing to inequities in end-of-life care for patients with advanced liver disease. More than 50% of patients with advanced liver disease receive dialysis, mechanical ventilation, and/or cardiopulmonary resuscitation during their terminal hospitalizations.2Patel A.A. Walling A.M. Ricks-Oddie J. et al.Palliative care and health care utilization for patients with end-stage liver disease at the end of life.Clin Gastroenterol Hepatol. 2017; 15: 1612-1619Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar,15Ufere N.N. Halford J.L. Caldwell J. et al.Health care utilization and end-of-life care outcomes for patients with decompensated cirrhosis based on transplant candidacy.J Pain Symptom Manage. 2020; 59: 590-598Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Black, Asian, and American Indian/Alaska Native patients with advanced liver disease are significantly more likely to die in the inpatient setting than White patients and thus may disproportionately receive these invasive procedures at end of life.3Kaplan A. Fortune B. Ufere N. et al.National trends in location of death in patients with end-stage liver disease.Liver Transpl. 2021; 27: 165-176Crossref PubMed Scopus (10) Google Scholar The receipt of high-intensity care in the terminal phase of illness may feel overly burdensome, nonbeneficial, and inconsistent with how patients would want to spend their last days.6Weeks J.C. Cook E.F. O'Day S.J. et al.Relationship between cancer patients' predictions of prognosis and their treatment preferences.JAMA. 1998; 279: 1709-1714Crossref PubMed Scopus (998) Google Scholar Given current racial and ethnic inequities in end-of-life care in advanced liver disease, we need a new strategy to communicate prognosis that pushes beyond the binary framework implicit in transplant candidacy decisions. Transplant listing is not a definitive pathway to complete cure and a life without liver transplantation is not certain impending death; patients face a range of possible outcomes in their future. To date, traditional predictors, Model for End Stage Liver Disease-Sodium scores, are used to inform patients about their prognosis in advanced liver disease care. However, data on survival do not show the range of uncertainty in outcomes, nor do they help patients imagine what it would be like to experience waitlist time, to die on the waitlist, or even consider life without undergoing liver transplantation. Most importantly, a strategy is needed to communicate prognosis with cultural humility that respects patients’ core values, beliefs, and preferences for communication, receiving health information, and medical decision-making. Approaching these conversations with cultural paternalism or stereotyping can lead to patient and family emotional distress, medical mistrust, and goal-discordant care, worsening health inequities.16Cain C.L. Surbone A. Elk R. et al.Culture and palliative care: preferences, communication, meaning, and mutual decision making.J Pain Symptom Manage. 2018; 55: 1408-1419Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar The referral for liver transplantation evaluation should be identified as a critical moment for clinicians to communicate prognosis and prepare patients for life with advanced liver disease. From this point, patients face a life that is filled with uncertainty, requires difficult decisions, and requires contextual understanding of their overall health trajectory. Thus, a better way is needed to express the life-limiting nature of their disease, describe the range of uncertainty surrounding liver transplantation, how treatments impact length and quality of life, and understand their feelings about interventions that are highly invasive and often feel burdensome. Most importantly, a way to cultivate their “double awareness” is needed.17Colosimo K. Nissim R. Pos A.E. et al.Double awareness” in psychotherapy for patients living with advanced cancer.J Psychother Integr. 2018; 28: 125Crossref Scopus (33) Google Scholar The unique challenge of advanced liver disease care is to support patients in their desire to prolong life, with the pursuit of such treatments as transplantation, while also being prepared for the possibility of death, with engagement in high-quality end-of-life care. The Best Case/Worst (BC/WC) communication tool, first developed to facilitate communication between surgeons and older adults facing acute surgical conditions and now adapted for patients with advanced liver disease, provides a structured framework to enhance prognostic understanding and cultivate double awareness in the face of multiple uncertain outcomes.18Kruser J.M. Nabozny M.J. Steffens N.M. et al.Best case/worst case": qualitative evaluation of a novel communication tool for difficult in-the-moment surgical decisions.J Am Geriatr Soc. 2015; 63: 1805-1811Crossref PubMed Scopus (89) Google Scholar BC/WC uses scenario planning through the use of a handwritten graphic aid and narrative storytelling to prepare patients and families for the range of plausible outcomes in the “best case,” “worst case,” and “most likely” scenarios.19Wack P. Scenarios: uncharted waters ahead.Harv Bus Rev. September, 1985; Google Scholar BC/WC allows clinicians to acknowledge uncertainty and deliver prognostic information without using medical jargon or traditional prognostic metrics.18Kruser J.M. Nabozny M.J. Steffens N.M. et al.Best case/worst case": qualitative evaluation of a novel communication tool for difficult in-the-moment surgical decisions.J Am Geriatr Soc. 2015; 63: 1805-1811Crossref PubMed Scopus (89) Google Scholar By framing the conversation as “this is what we are hoping for” (best case scenario) and “this is what we are worried about” (worst case scenario), clinicians can engage patients in discussion to assess their prognostic understanding and elicit their hopes and fears based on the possible futures described.20Lakin J.R. Jacobsen J. Softening our approach to discussing prognosis.JAMA Intern Med. 2019; 179: 5-6Crossref PubMed Scopus (17) Google Scholar What would it have looked like if the BC/WC tool had been used to promote prognostic understanding with cultural humility for Mr D before referring him to the transplant team for evaluation? The clinician would open this conversation by first eliciting Mr D’s communication preferences. For example, if Mr D’s primary language is not English, offering the use of a trained medical interpreter during the visit is of critical importance. Patients with limited English proficiency have been found to have inadequate prognostic understanding and experience worse quality end-of-life care when professional interpreters are not used during serious illness conversations.21Silva M.D. Genoff M. Zaballa A. et al.Interpreting at the end of life: a systematic review of the impact of interpreters on the delivery of palliative care services to cancer patients with limited English proficiency.J Pain Symptom Manage. 2016; 51: 569-580Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar Having a premeeting with the interpreter to brief them about the content and terminology that will be addressed during the conversation is an important best practice.21Silva M.D. Genoff M. Zaballa A. et al.Interpreting at the end of life: a systematic review of the impact of interpreters on the delivery of palliative care services to cancer patients with limited English proficiency.J Pain Symptom Manage. 2016; 51: 569-580Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar Using such questions as, “Some people like to know all the details, whereas others prefer an overview or have their family hear the information first and then share with them. What is your preference?” and “Who should participate in discussions about your care?” can help the clinician to identify Mr D’s informational and decision-making preferences.9Woodrell C.D. Patel A.A. Wilder J.M. et al.Cultural humility and end-of-life communication with people with advanced liver disease.Clin Liver Dis (Hoboken). 2022; 20: 81-85Crossref PubMed Scopus (2) Google Scholar Asking these questions may uncover important aspects of a his cultural identity, such as whether he has an individual versus family-oriented approach to receiving medical information including serious news and the potential role of his faith community in his medical decision-making. Once the clinician has a richer understanding of Mr D’s communication, informational, and decision-making preferences, he or she can then set the stage for the use of the BC/WC tool. For the BC/WC graphic aid, vertical bars are used to represent different treatment pathways. One graphic aid can be used to consider the range of outcomes for evaluation and listing for liver transplantation (Figure 1A). A second graphic aid can be used to imagine best supportive hepatology care (Figure 1B). In both figures, a star represents the best case scenario, a box represents the worst case scenario, and an oval represents the most likely outcome. The clinician then uses scenario planning (ie, rich narratives to generate a story) for each star, box, and oval to incorporate patient-specific prognostic and health information. The clinician might open this discussion by saying "Let’s talk about what it might look like to wait for a liver transplantation” and use the scenarios to help Mr D imagine getting a liver with a straightforward recovery, and other possible experiences, such as getting sicker or even dying while waiting for a liver offer (Table 1). Because Mr D is frail, his clinician might place the “most likely scenario” lower on the line because he has a higher risk of having a prolonged posttransplant length of stay, including time in the ICU, and may be less likely to be discharged home after his transplant hospitalization.22Lai J.C. Shui A.M. Duarte-Rojo A. et al.Frailty, mortality, and health care utilization after liver transplantation: from the Multicenter Functional Assessment in Liver Transplantation (FrAILT) Study.Hepatology. 2022; 75: 1471-1479Crossref PubMed Scopus (7) Google ScholarTable 1Example Best Case/Worst Case Narratives for Liver Transplant Listing and Best Supportive Hepatology CareLet’s talk about what it might look like to wait for a liver transplantation. If we decide to move forward with the liver transplantation evaluation, you will have an initial visit with several people at the transplant center to review your personal and medical history. After that visit, you will undergo a very thorough evaluation that will include laboratory tests, imaging, and potentially even procedures. This evaluation may take several months to complete. At the end of your evaluation, the transplant team will meet together to decide if a transplant is the right choice for you. If you qualify, you will be added to the liver transplantation waiting list.In the best case scenario, you wait a few months for a liver transplant. If we are lucky, your liver disease doesn’t get much worse, and you stay out of the hospital. An appropriate liver comes for you and you have a major operation, which takes 6–10 hours and requires a few days in the ICU afterward. If everything continues to go well, and there are no complications, you spend another week in the hospital and can go home, taking new medicines every day, for the rest of your life. You will need to come back for frequent clinic visits with the transplant team for the first few months. If things go well, about 2–3 months after surgery you will feel fully recovered, and probably much better than you do now. Over time there will be some bumps in the road, such as infections or rejection where you have to come into the hospital for treatment, but if things go well we would hope you live for several years after transplant. This is what we are hoping for.20Lakin J.R. Jacobsen J. Softening our approach to discussing prognosis.JAMA Intern Med. 2019; 179: 5-6Crossref PubMed Scopus (17) Google ScholarIn the worst case scenario, you are on the waiting list but your health gets worse, your liver function gets worse, and you spend a lot of time in the ICU and in the hospital. These illnesses take a lot out of you, your body weakens, and you reach a point when you are really “too sick for transplant,” meaning even with a transplant, we would not be able to extend your life, and you die from complications of your liver disease or heart failure. This is what we are worried about.20Lakin J.R. Jacobsen J. Softening our approach to discussing prognosis.JAMA Intern Med. 2019; 179: 5-6Crossref PubMed Scopus (17) Google ScholarWhat is most likely? You get progressively sick and weak from your liver disease and heart failure, needing to come to the hospital and the ICU while you are waiting for a liver, over many months. Then you have the operation for liver transplant. Because of your age, your heart failure, and frailty, you will likely spend days in the ICU and probably a few weeks in the hospital.22Lai J.C. Shui A.M. Duarte-Rojo A. et al.Frailty, mortality, and health care utilization after liver transplantation: from the Multicenter Functional Assessment in Liver Transplantation (FrAILT) Study.Hepatology. 2022; 75: 1471-1479Crossref PubMed Scopus (7) Google Scholar You need to go to a rehabilitation or nursing facility because it will take several months to get strong enough to go home.22Lai J.C. Shui A.M. Duarte-Rojo A. et al.Frailty, mortality, and health care utilization after liver transplantation: from the Multicenter Functional Assessment in Liver Transplantation (FrAILT) Study.Hepatology. 2022; 75: 1471-1479Crossref PubMed Scopus (7) Google Scholar As you recover you will probably need to come back to the hospital within the first few months after your transplant.22Lai J.C. Shui A.M. Duarte-Rojo A. et al.Frailty, mortality, and health care utilization after liver transplantation: from the Multicenter Functional Assessment in Liver Transplantation (FrAILT) Study.Hepatology. 2022; 75: 1471-1479Crossref PubMed Scopus (7) Google Scholar It will take several months to get used to taking new immunosuppressant medications, which might make you feel lousy.14Lieber S.R. Kim H.P. Baldelli L. et al.Early survivorship after liver transplantation: a qualitative study identifying challenges in recovery from the patient and caregiver perspective.Liver Transpl. 2022; 28: 422-436Crossref PubMed Scopus (6) Google Scholar With time we think you will achieve a “new normal,” which means in some ways you will feel better, and in other ways you will feel weaker. At some point your heart failure will get worse, but we hope after this long recovery you would be able to live for a few years after your liver transplantation.Would you like to talk about what it might look like if you don’t get listed?23Singh S. Cortez D. Maynard D. et al.Characterizing the nature of scan results discussions: insights into why patients misunderstand their prognosis.J Oncol Pract. 2017; 13: e231-e239Crossref PubMed Scopus (36) Google Scholar If we decide not to move forward with a liver transplantation, or if you are not able to be placed on the transplantation waiting list because of your other medical issues, our goal would be to continue to focus on how you can live for as long and as well as possible outside of the hospital to maximize high-quality home time. We would continue to aggressively manage your physical and psychological symptoms with a central focus on optimizing your quality of life.In the best case scenario, you would have regular clinic visits for close monitoring and your ascites, hepatic encephalopathy, and heart failure would be well-controlled on medical therapy. You would be able to enjoy your time at home with your family without experiencing any unplanned hospitalizations because of your liver disease or your heart failure. During this time your health would decline slowly and you would be able to live for 1–2 years.26D'Amico G. Garcia-Tsao G. Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies.J Hepatol. 2006; 44: 217-231Abstract Full Text Full Text PDF PubMed Scopus (1985) Google Scholar This is what we are hoping for.20Lakin J.R. Jacobsen J. Softening our approach to discussing prognosis.JAMA Intern Med. 2019; 179: 5-6Crossref PubMed Scopus (17) Google ScholarIn the worst case scenario, you would rapidly develop new or worsening complications of your liver disease and/or heart failure that would be difficult to manage at home, resulting in frequent hospitalizations. Your quality of life would decline rapidly, and your time may be as short as a few months before passing away. This is what we are worried about.20Lakin J.R. Jacobsen J. Softening our approach to discussing prognosis.JAMA Intern Med. 2019; 179: 5-6Crossref PubMed Scopus (17) Google ScholarWhat is most likely? With regular clinic visits we will achieve good control of your symptoms and you will have some good days at home. Because of your age, heart failure, and how frail you are, I worry that you are likely to experience episodes where your ascites, hepatic encephalopathy, or heart failure get acutely worse, resulting in a few, hopefully short, hospital stays. Your ascites will likely progress over the next few months and may become difficult to manage with just diuretics. At that point, managing your ascites may require serial abdominal paracenteses or placement of an abdominal drain and you would live for a few months before passing away from your liver disease.What do you think about all of this? What is important to you now?18Kruser J.M. Nabozny M.J. Steffens N.M. et al.Best case/worst case": qualitative evaluation of a novel communication tool for difficult in-the-moment surgical decisions.J Am Geriatr Soc. 2015; 63: 1805-1811Crossref PubMed Scopus (89) Google Scholar Open table in a new tab Not all patients are ready to face difficult news, so the clinician should then ask “Would you like to talk about what it might look like if you don’t get listed?” as an opportunity to provide a similar framework for best supportive hepatology care (Table 1).23Singh S. Cortez D. Maynard D. et al.Characterizing the nature of scan results discussions: insights into why patients misunderstand their prognosis.J Oncol Pract. 2017; 13: e231-e239Crossref PubMed Scopus (36) Google Scholar Rather than asking the patient what they want after presenting these scenarios, the clinician can elicit Mr D’s priorities and needs by instead asking such questions as, “What do you think about all of this?,” “What is important to you now?,” and “What are your biggest sources of strength?.”9Woodrell C.D. Patel A.A. Wilder J.M. et al.Cultural humility and end-of-life communication with people with advanced liver disease.Clin Liver Dis (Hoboken). 2022; 20: 81-85Crossref PubMed Scopus (2) Google Scholar,18Kruser J.M. Nabozny M.J. Steffens N.M. et al.Best case/worst case": qualitative evaluation of a novel communication tool for difficult in-the-moment surgical decisions.J Am Geriatr Soc. 2015; 63: 1805-1811Crossref PubMed Scopus (89) Google Scholar These questions may uncover additional important aspects of Mr D’s cultural identity, family supports, faith and spiritual needs, and social determinants of health, prompting engagement with religious figures or trusted members from his community, chaplaincy, specialty palliative care, social work, and more. Through this conversation, Mr D would have been better informed of his illness and prognosis, what he might expect if liver transplantation is not an option, and what life could look like moving forward. Additionally, by learning more about Mr D’s priorities, his clinician can use this information to guide future treatment decisions that are aligned with Mr D’s goals. A copy of the BC/WC tool can be given to Mr D and another copy placed in his medical record. How might communication tools, such as BC/WC, help advance health equity in hepatology and transplant care? There is evidence that decision support tools and narrative communication improve prognostic awareness and understanding of complex health information among minority, limited English proficiency, and low health literacy patients.24Moran M.B. Frank L.B. Chatterjee J.S. et al.A pilot test of the acceptability and efficacy of narrative and non-narrative health education materials in a low health literacy population.J Commun Healthc. 2016; 9: 40-48Crossref PubMed Scopus (39) Google Scholar,25Durand M.A. Carpenter L. Dolan H. et al.Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis.PLoS One. 2014; 9e94670Crossref Scopus (291) Google Scholar By providing a structured approach that allows patients to imagine the range of possible futures living with advanced liver disease, the BC/WC tool may empower them through promoting prognostic understanding and reducing default or even biased decision making by clinicians. Through promoting prognostic understanding, the BC/WC tool can help patients with advanced liver disease receive care that is aligned with their values throughout the course of their illness, including at end of life. The illness experience of patients with advanced liver disease and their families is defined by uncertainty. There is a need to improve their prognostic understanding and support them as they experience major changes in their health status, especially among racial and ethnic minorities that experience disparities in serious illness care. For effective serious illness care in hepatology, clinicians must push beyond probabilistic descriptors of survival and use communication frameworks that allow patients and families to envision the range of plausible futures they may face, and create space for discussion that reveals patients’ priorities relative to their diverse backgrounds and belief systems. Future clinical and research work should examine how communication tools, such as BC/WC, can be used to promote prognostic understanding among patients with advanced liver disease and their families, align future treatment decisions with their unique priorities, and advance health equity in serious illness care.