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Background: Little is known about the extent of alignment between hematopoietic stem cell transplant (HSCT) patients and their healthcare proxies with respect to advance care planning (ACP).

Aim: To determine if a structured three-step process using the letter advance directive (LAD) could (1) allow for the differences in opinion between patient–proxy dyads to surface and (2) help bridge preexisting discordance about specific treatment choices.

Design: Blinded to each other, the HSCT patient (LAD-1) and proxy (LAD-2) each completed the LAD (step 1). They unmasked, compared LAD-1 and LAD-2, and discussed their choices (step 2). They completed a final letter directive (LAD-3) by consensus (step 3).

Settings/Participants: Convenience sample of eighty dyads (patient and proxy) at a regional HSCT referral center.

Results: The mean patient–proxy concordance was 72.9% for the 12 questions in the LAD …