Palliative Care, Patient-Reported Measures, and Outcomes in Hospitalized Patients With Cirrhosis

Palliative Care Referral Patterns and Outcomes for Patients with End-Stage Liver Disease at an Academic Liver Transplant Center

Background: Patients with end-stage liver disease (ESLD) have complex needs and may benefit from palliative care (PC), which is often underutilized or delayed. Objectives: To characterize patients with ESLD who received inpatient PC consultation and to explore differences in characteristics between those who received PC consultation before (pre-Pall) or after (post-Pall) PC participation at weekly liver transplant (LT) Patient Selection Committee (PSC) meetings. Design: Single-center retrospective cohort study. Setting/Subjects: Hospitalized patients with ESLD who received inpatient PC consultation between February 2017 and February 2019 at an academic LT center in the United States. Measurements: PC referral reasons and timing, code status, hospice referrals, discharge location, and mortality. Results: Two hundred five patients were included. The primary reason for PC was goals of care (88.8%; n = 182). Most (86.8%; n = 178) were Full Code at hospital admission, while 81% (n = 166) were do-not-resuscitate at discharge. Nearly one quarter (22.9%; n = 47) sought life-prolonging care at discharge, while 41.5% (n = 85) were discharged with hospice, and 34.1% (n = 70) died before discharge. By the end of the study, 85.9% (n = 176) were confirmed as deceased. Median time from PC to hospice referral was 12 days [95% confidence interval [CI]: 8-23]. Median time from PC consult to death was 13 days [95% CI: 9-17] and from hospice referral to death was 7 days [95% CI: 4-13]. There were no statistically significant differences between the pre- and post-Pall groups related to PC referral patterns or outcomes. Conclusions: Most PC contacts occurred near end of life, and many led to comfort-focused care. Late referrals may be due to reliance on inpatient consults during acute illness. PC presence at PSC meetings represents an important step in collaboration with LT teams but did not lead to direct impact on PC referral patterns or outcomes.

Clinical Ethics Consultations in Cirrhosis Care

BACKGROUND

Ethics consultations may reflect the nature and frequency of conflicts in clinical care. Data regarding consultations for patients with cirrhosis, however, are limited.

AIMS

To understand the reasons and context for ethics consultations and identify areas for improvement.

METHODS

We evaluated inpatient ethics consultations from 06/2015 to 08/2023. Consults for people with severe liver, heart, and lung diseases were examined for the reasons and contextual factors for consultation. These were coded according to a qualitative conceptual content analysis by two independent reviewers. The rate of consultations was derived from the denominator of hospitalized patients with each condition over the same time.

RESULTS

During the study period, there were 38 ethics consults from 17,460 patients with liver disease (incidence 0.2%) and 96 among 48,394 patients with heart/lung disease (incidence 0.2%). The primary ethical issue was surrogate decision-making related to the lack of an identified durable power of attorney or when surrogate decision-making went against care team recommendations. These conflicts were twice as likely for patients with cirrhosis. The second most common primary ethical issues were code status and futility. Medical error, symptom management, and withdrawal of life supports were not associated with ethics consults. Legal issues were more common in patients without cirrhosis. Communication disputes with the team, intra-family disputes, and quality of life concerns were the most common contextual factors.

CONCLUSION

Ethics consultations for patients with cirrhosis occur for 0.2% of hospitalizations and are linked to deficits in advanced care planning, poor communication, and poor patient quality of life.

The Role of Palliative Care in the Management of Patients with Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver, and 85% to 90% of cases of HCC occur in patients with underlying liver disease. This makes it a complex illness to treat, because disease burden occurs not only from the cancer, but also potential decompensation of the underlying liver disease. Palliative care is multifaceted care that addresses physical, spiritual, and psychosocial needs of patients and can provide support for their caregivers. It can help in advance care planning and hospice support. Early integration of palliative care can improve patient qualify of life and patient/caregiver satisfaction.

Palliative care for end-stage liver disease and acute on chronic liver failure: A systematic review

BACKGROUND

End stage liver disease (ESLD) represents a growing health concern characterized by elevated morbidity and mortality, particularly among individual ineligible for liver transplantation. The demand for palliative care (PC) is pronounced in patients grappling with ESLD and acute on chronic liver failure (ACLF). Unfortunately, the historical underutilization of PC in ESLD patients, despite their substantial needs and those of their family caregivers, underscores the imperative of seamlessly integrating PC principles into routine healthcare practices across the entire disease spectrum.

AIM

To comprehensively investigate the evidence surrounding the benefits of incorporating PC into the comprehensive care plan for individuals confronting ESLD and/or ACLF.

METHODS

A systematic search in the Medline (PubMed) database was performed using a predetermined search command, encompassing studies published in English without any restrictions on the publication date. Subsequently, the retrieved studies were manually examined. Simple descriptive analyses were employed to summarize the results.

RESULTS

The search strategies yielded 721 references. Following the final analysis, 32 full-length references met the inclusion criteria and were consequently incorporated into the study. Meticulous data extraction from these 32 studies was undertaken, leading to the execution of a comprehensive narrative systematic review. The review found that PC provides significant benefits, reducing symptom burden, depressive symptoms, readmission rates, and hospital stays. Yet, barriers like the appeal of transplants and misconceptions about PC hinder optimal utilization. Integrating PC early, upon the diagnosis of ESLD and ACLF, regardless of transplant eligibility and availability, improves the quality of life for these patients.

CONCLUSION

Despite the substantial suffering and poor prognosis associated with ESLD and ACLF, where liver transplantation stands as the only curative treatment, albeit largely inaccessible, PC services have been overtly provided too late in the course of the illness. A comprehensive understanding of PC's pivotal role in treating ESLD and ACLF is crucial for overcoming these barriers, involving healthcare providers, patients, and caregivers.

Supportive and palliative care needs in advanced non-malignant liver disease: systematic review

Advanced cirrhosis confers a significant symptom burden and has a 50% 2-year mortality rate in those with decompensated disease. There is increasing demand for supportive and palliative care (SAPC) for these patients, yet no consensus on the best model of delivery. It is necessary to identify the needs of such patients and their carers, and evaluate whether they are being met.A literature search was conducted using key words pertaining to adult patients with liver cirrhosis and their SAPC needs. Study quality was assessed and findings grouped by theme. 51 full texts were selected for inclusion, 8 qualitative studies, 33 quantitative studies, 7 systematic reviews, 2 mixed methods studies and 1 Delphi methods. Key findings were grouped into three main themes: SAPC needs, access to SAPC and models of care.Patients with cirrhosis have significant psychological and physical symptom burden with many unmet needs. These data failed to identify the best service model of care. The impact of specialist palliative care (SPC) referral was limited by small numbers and late referrals. With the majority of studies conducted in the USA, it is unclear how well these findings translate to other healthcare systems. Comparison between hepatology led services and SPC was limited by inconsistent outcome measures and prevented pooling of data sets. These data also had limited evaluation of patient-reported outcome measures. We propose the development of a core outcome set to ensure consistent and meaningful evaluation of the SAPC needs of patients with advanced non-malignant liver cirrhosis.

Health-related quality of life and frailty in liver cirrhosis

BACKGROUND AND OBJECTIVES

There is limited evidence concerning the predictive value of health-related quality of life (HRQoL) on the presence of frailty in the context of cirrhosis. We aimed to elucidate the relationship between HRQoL and multidimensional frailty and to determine which HRQoL dimension independently impacted frail phenotype in our established cohort.

METHODS

This was a prospective observational study by consecutively enrolling 355 patients with cirrhotic with decompensated signs in China. The HRQoL and frail phenotype were evaluated by the EuroQol-5D (EQ-5D) Questionnaire and Frailty Index, respectively. The relationship between EQ-5D utility index, as well as respective EQ-5D dimension, and Frailty Index was analysed according to the multiple linear regression analyses.

RESULTS

More than half of the patients (56.3%) reported problems in any dimension of the EQ-5D, suggestive of impaired HRQoL. Moreover, the proportion of patients experiencing some/extreme problems significantly increased across all five dimensions (all p<0.001) in correspondence to transition from the robust to frail phenotype. Multiple linear regression analyses demonstrated that age, ascites and hepatic encephalopathy were positively associated with Frailty Index, while EQ-5D utility index (standardised β coefficient= -0.442, p<0.001) negatively associated with Frailty Index. Notably, usual activities, self-care and mobility were the most influencing predictors associated with frailty.

CONCLUSIONS

Our results support a rapid HRQoL assessment via EQ-5D may assist in predicting multidimensional frailty, and usual activities, self-care and mobility tend to be remediable targets while taking their effect on frail phenotype into consideration among patients with cirrhosis.

Association of Palliative Care With Readmission and Resource Utilization in Patients With Ovarian Cancer: A National Perspective

OBJECTIVE

Palliative care (PC) utilization in cancer care has been shown to alleviate symptoms, increase goals of care discussions, and reduce invasive end of life measures. This study examined the association of inpatient PC consultation with readmission and hospitalization costs among patients with ovarian cancer.

METHODS

All records for women (≥18 years) hospitalized with a diagnosis of ovarian cancer were tabulated from the 2010-2020 Nationwide Readmissions Database. Multivariable logistic, Poisson, and linear regressions were used to evaluate the association of PC consultation during index hospitalization with length of stay, rates of 30-day non-elective readmission, time to readmission, as well as overall number of readmissions and hospitalization costs.

RESULTS

Of an estimated 285,487 patients included, 25,957 (9.0%) received a PC consultation, with an increase from 5.1 to 11.7% (P < 0.001) across the period. Factors associated with use of PC included: increasing age (AOR 1.03/yr, 95% CI 1.03-1.03, P < 0.001) and Elixhauser comorbidity index (AOR 1.19/point, 95% CI 1.17-1.21). PC was associated with lower risk adjusted rates of 30 day (11.63%, 95% CI 11.0-12.3 vs 20.25%, 95% CI 20.0-20.6) non-elective readmission (P < 0.001). The adjusted incident rate ratio of readmission after PC consultation was 0.41 [0.38-0.43], P < 0.001. Patients receiving PC additionally had less cost associated with their index hospital stay; -$2,407 [-$2,669.86- -$2,144.43], P < 0.001).

CONCLUSIONS

Inpatient PC consults appear to be associated with reduced medical readmissions for patients with ovarian cancer, as well as decreased hospital resource use, however disparities exist. Continued increase in access and early PC referral should be considered.