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



      Studies of palliative care (PC) in hospitalized patients with cirrhosis have been retrospective, with limited evaluation of patient-reported measures and outcomes.


      To examine the relationship between PC, patient-reported measures (quality of life and functional status), and outcomes.


      We performed a prospective cohort study of patients with cirrhosis hospitalized from 2014 to 2019. We recorded PC consultation details, quality of life (chronic liver disease questionnaire), and functional status (functional status questionnaire). Patients were followed for 90 days to assess readmissions, costs, and mortality.


      Seventy-four of 679 patients saw PC, often later in the hospitalization (median hospital day 8; IQR 4–16). Those who saw PC had greater Charlson comorbidity index (mean 6.8 vs. 5.9), MELD (mean 25 vs. 20), and prior 30-day admission (47% vs. 35%). Compared to those who did not see PC, PC patients had greater impairments in intermediate activities of daily living (83% vs. 72%), social activity (72% vs. 59%), quality of interactions (49% vs. 36%), abdominal symptoms (mean score 3.1 vs. 3.6), activity (mean 3.3 vs. 3.6), and overall quality of life (mean 3.6 vs. 3.8). PC was associated with fewer transfusions and upper endoscopies and with greater completion of advanced directives. After multivariable adjustment, PC was not associated with intensive care, 30-day readmissions, 90-day costs, or mortality.


      PC occurs infrequently and late in those with more severe liver disease and functional impairment. PC may be associated with reduction in utilization and greater completion of advanced directives. Randomized trials are needed to evaluate PC for this population.

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        • D'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: 217-231
        • Peng JK
        • Hepgul N
        • Higginson IJ
        • Gao W.
        Symptom prevalence and quality of life of patients with end-stage liver disease: a systematic review and meta-analysis.
        Palliat Med. 2019; 33: 24-36
        • Low J
        • Davis S
        • Vickerstaff V
        • et al.
        Advanced chronic liver disease in the last year of life: a mixed methods study to understand how care in a specialist liver unit could be improved.
        BMJ Open. 2017; 7e016887
        • Hudson B
        • Round J
        • Georgeson B
        • et al.
        Cirrhosis with ascites in the last year of life: a nationwide analysis of factors shaping costs, health-care use, and place of death in England.
        Lancet Gastroenterol Hepatol. 2018; 3: 95-103
        • Orman ES
        • Ghabril MS
        • Desai AP
        • et al.
        Patient-reported outcome measures modestly enhance prediction of readmission in patients with cirrhosis.
        Clin Gastroenterol Hepatol. 2021; (PMID 34311111)
        • Elsayem A
        • Swint K
        • Fisch MJ
        • et al.
        Palliative care inpatient service in a comprehensive cancer center: clinical and financial outcomes.
        J Clin Oncol. 2004; 22: 2008-2014
        • Bischoff K
        • O'Riordan DL
        • Marks AK
        • Sudore R
        • Pantilat SZ.
        Care planning for inpatients referred for palliative care consultation.
        JAMA Intern. Med. 2018; 178: 48-54
        • Holden JH
        • Shamseddeen H
        • Johnson AW
        • et al.
        Palliative care and hospice referrals in patients with decompensated cirrhosis: what factors are important?.
        J Palliat Med. 2020; 23: 1066-1075
        • Poonja Z
        • Brisebois A
        • van Zanten S V
        • Tandon P
        • Meeberg G
        • Karvellas CJ
        Patients with cirrhosis and denied liver transplants rarely receive adequate palliative care or appropriate management.
        Clin Gastroenterol Hepatol. 2014; 12: 692-698
        • Kelly SG
        • Campbell TC
        • Hillman L
        • Said A
        • Lucey MR
        • Agarwal PD.
        The utilization of palliative care services in patients with cirrhosis who have been denied liver transplantation: a single center retrospective review.
        Ann Hepatol. 2017; 16: 395-401
        • Kathpalia P
        • Smith A
        • Lai JC.
        Underutilization of palliative care services in the liver transplant population.
        World J Transplant. 2016; 6: 594-598
        • Ufere NN
        • Halford JL
        • 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: 590-598
        • Rush B
        • Walley KR
        • Celi LA
        • Rajoriya N
        • Brahmania M.
        Palliative care access for hospitalized patients with end-stage liver disease across the United States.
        Hepatology. 2017; 66: 1585-1591
        • Patel AA
        • Walling AM
        • Ricks-Oddie J
        • FP May
        • Saab S
        • Wenger N.
        Palliative care and health care utilization for patients with end-stage liver disease at the end of life.
        Clin Gastroenterol Hepatol. 2017; 15 (e4): 1612-1619
        • Highet G
        • Crawford D
        • Murray SA
        • Boyd K.
        Development and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT): a mixed-methods study.
        BMJ Support Palliat Care. 2014; 4: 285-290
        • Hudson BE
        • Ameneshoa K
        • Gopfert A
        • et al.
        Integration of palliative and supportive care in the management of advanced liver disease: development and evaluation of a prognostic screening tool and supportive care intervention.
        Frontline Gastroenterol. 2017; 8: 45-52
        • Verma M
        • Kosinski AS
        • Volk ML
        • et al.
        Introducing palliative care within the treatment of end-stage liver disease: the study protocol of a cluster randomized controlled trial.
        J Palliat Med. 2019; 22: 34-43
        • Baumann AJ
        • Wheeler DS
        • James M
        • Turner R
        • Siegel A
        • Navarro VJ.
        Benefit of early palliative care intervention in end-stage liver disease patients awaiting liver transplantation.
        J Pain Symptom Manage. 2015; 50 (e2): 882-886
        • Ufere NN
        • O'Riordan DL
        • Bischoff KE
        • et al.
        Outcomes of palliative care consultations for hospitalized patients with liver disease.
        J Pain Symptom Manage. 2019; 58: 766-773
        • Patidar KR
        • Shamseddeen H
        • Xu C
        • et al.
        Hospital-acquired versus community-acquired acute kidney injury in patients with cirrhosis: a prospective study.
        Am J Gastroenterol. 2020; 115: 1505-1512
        • McDonald CJ
        • Overhage JM
        • Barnes M
        • et al.
        The Indiana network for patient care: a working local health information infrastructure.
        Health Aff. 2005; 24: 1214-1220
        • Yuen JK
        • Reid MC
        • Fetters MD.
        Hospital do-not-resuscitate orders: why they have failed and how to fix them.
        J Gen Intern Med. 2011; 26: 791-797
        • Myers RP
        • Quan H
        • Hubbard JN
        • Shaheen AAM
        • Kaplan GG.
        Predicting in-hospital mortality in patients with cirrhosis: results differ across risk adjustment methods.
        Hepatology. 2009; 49: 568-577
        • Pugh RN
        • Murray-Lyon IM
        • Dawson JL
        • Pietroni MC
        • Williams R.
        Transection of the oesophagus for bleeding oesophageal varices.
        Br J Surg. 1973; 60: 646-649
        • Kamath PS
        • Wiesner RH
        • Malinchoc M
        • et al.
        A model to predict survival in patients with end-stage liver disease.
        Hepatology. 2001; 33: 464-470
        • Jette AM
        • Davies AR
        • Cleary PD
        • et al.
        The Functional Status Questionnaire: reliability and validity when used in primary care.
        J Gen Intern Med. 1986; 1: 143-149
        • Cleary PD
        • Jette AM.
        Reliability and validity of the Functional Status Questionnaire.
        Qual Life Res. 2000; 9: 747-753
        • Younossi ZM
        • Guyatt G
        • Kiwi M
        • Boparai N
        • King D.
        Development of a disease specific questionnaire to measure health related quality of life in patients with chronic liver disease.
        Gut. 1999; 45: 295-300
        • Younossi ZM
        • Boparai N
        • Price LL
        • Kiwi ML
        • McCormick M
        • Guyatt G.
        Health-related quality of life in chronic liver disease: the impact of type and severity of disease.
        Am J Gastroenterol. 2001; 96: 2199-2205
        • Kamal AH
        • Bull JH
        • Swetz KM
        • Wolf SP
        • Shanafelt TD
        • Myers ER.
        Future of the palliative care workforce: preview to an impending crisis.
        Am J Med. 2017; 130: 113-114
        • Low J
        • Carroll C
        • Wilson J
        • et al.
        Do screening tools assess palliative care needs and 12-month mortality in patients admitted to hepatology in-patient wards?.
        Frontline Gastroenterol. 2021;
        • Orman ES
        • Ghabril M
        • Emmett TW
        • Chalasani N.
        Hospital readmissions in patients with cirrhosis: a systematic review.
        J Hosp Med. 2018; 13: 490-495
        • Wigg AJ
        • McCormick R
        • Wundke R
        • Woodman RJ.
        Efficacy of a chronic disease management model for patients with chronic liver failure.
        Clin Gastroenterol Hepatol. 2013; 11 (e4): 850-858
        • Shinall MC
        • Karlekar M
        • Martin S
        • et al.
        COMPASS: a pilot trial of an early palliative care intervention for patients with end-stage liver disease.
        J Pain Symptom Manage. 2019; 58 (e3): 614-622
        • Ufere NN
        • Brahmania M
        • Sey M
        • et al.
        Outcomes of in-hospital cardiopulmonary resuscitation for patients with end-stage liver disease.
        Liver Int. 2019; 39: 1256-1262
        • Oud L.
        In-hospital cardiopulmonary resuscitation of patients with cirrhosis: a population-based analysis.
        PLoS One. 2019; 14: 1-14
        • Stotts MJ
        • Hung KW
        • Benson A
        • Biggins SW
        Rate and predictors of successful cardiopulmonary resuscitation in end-stage liver disease.
        Dig Dis Sci. 2014; 59: 1983-1986
        • Brown CL
        • Hammill BG
        • Qualls LG
        • Curtis LH
        • Muir AJ.
        Significant morbidity and mortality among hospitalized end-stage liver disease patients in medicare.
        J Pain Symptom Manage. 2016; 52 (e1): 412-419