*Purpose: Despite benefits of palliative care referrals and early advance care planning for patients with end-stage organ disease and recipients experiencing graft failure, few patients with end-stage liver disease (ESLD), end-stage kidney disease (ESKD), or transplant recipients receive such care. We examine barriers and facilitators to advance care planning among transplant patients, especially those experiencing graft failure.

*Methods: Multicenter qualitative study, face-to-face semi structured interviews were conducted between May and August 2019, with palliative care and transplant clinicians (surgeons, palliative medicine, nurse practitioners, nurses, social workers) in 9 hospitals across the United States. Interviews were audiotaped, transcribed, and analyzed thematically; interrater reliability achieved 90%.

*Results: 30 transplant and palliative care clinicians participated. Transplant teams avoided discussing nonaggressive treatment options with patients, delayed palliative care consults, and restricted their scope to symptom management as opposed to advance care planning, leading to moral distress among palliative care clinicians consulting on transplant services. Few transplant patients received advance care planning services, even when palliative clinicians were embedded in transplant practices. Four main themes characterized clinicians’ experiences with moral distress in the context of advance care planning and palliative care for transplant recipients: 1) Conflicting systemic incentives and priorities for palliative care and transplant clinicians (quality metrics, outcomes, and reimbursement); 2) Discordant approaches to patient-centered care between palliative care and transplant clinicians; 3) Communication challenges and late notification for palliative care consultations; and 4) Different conceptions of patient autonomy, where transplant clinicians viewed transplant recipients as partly compromising their autonomy and agreeing to all measures as a condition of transplant, while palliative clinicians maintained that patients should discuss goals of care.

*Conclusions: Despite high mortality risk for patients with end-stage organ disease and recipients experiencing graft failure, few receive adequate ACP or palliative care during the last stages of life. Systemic barriers identified offer targets for interventions to improve patient-centered care throughout the transplant continuum.

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