Too Little, Too Late – Palliation and End Stage Liver Disease

Background: End‐stage liver disease (ESLD) is a leading cause of mortality worldwide. Fewer than 60% of patients with decompensated cirrhosis survive after two years, with patients often experiencing distressing symptoms impairing quality of life. Early advanced care planning and timely palliative care referral using accepted criteria such as the Supportive and Palliative Care Indicators Tool (SPICT) can improve quality of life and the end of life experience, but frequently is not routine for patients with ESLD. We aimed to determine palliative care referral rates and patterns for patients admitted with decompensated ESLD, and to identify the factors associated with referral. Methods: This was a retrospective, single‐ centre study undertaken at a metropolitan tertiary referral hospital. Patients admitted between 1st June 2016 to 31st January 2019 with a Child‐Pugh (CP) score of B or C, and a Model for End‐Stage Liver Disease (MELD) score ≥15 were included. We assessed eligibility for referral to palliative care for each admission using the SPICT criteria. We assessed survival and compared those referred and not referred to palliative care, adjusting for lag‐time to referral (Kaplan‐Meier analysis). Results: 116 admissions met SPICT eligibility criteria for referral. Of these, 63 (54%) had a MELD score ≥20. The median age at admission was 59 years (IQR 52‐66), with 76% male. Only a fifth of eligible patients (25/116) were referred to palliative care. Patients with CP C cirrhosis were more likely to be referred (27% or 22/81) compared with those with CP B cirrhosis (8.6% or 3/35, p = 0.02), however, referral rates did not correlate with the MELD score (15% or 8/53 for MELD 15‐19 and 27% or 17/63 for MELD ≥20, p = 0.12). Only 13% (7/52) of patients were referred in their index admission. Patients with non‐alcoholic steatohepatitis were more likely to be referred (47%, 10/21), compared to those with viral hepatitis (19%, 3/16) and alcoholic liver disease (16%, 12/76, p = 0.03). Significantly more patients with hepatocellular carcinoma were referred to palliative care (63%, or 10/16), compared to those without (15% or 15/100, p = 0.0001). Gastroenterologists were more likely to refer than general physicians, however referral rates remained low for gastroenterologists at 23% (21/89 gastroenterology patients referred, compared to 13% or 3/24 of eligible patients under general physicians). The median survival (from referral) for those referred to palliative care was 20 days, versus 148 days for those not referred. Conclusion: Despite benefits from timely referral, less than half of palliative‐eligible ESLD patients were referred. Referral appears reserved for those facing imminent death ‐ surviving just under three weeks post‐referral, yet mortality in non‐referred patients remained high (148‐day median). Clinicians may fail to recognise the high mortality of ESLD and miss opportunities to improve end of life care with palliative care referral. Disclosures: Matthew Mickenbecker – Mater Hospital Brisbane: Employment The following people have nothing to disclose: Hayley Chen, Alexander Johnston, Andrew Palmer, Mazhar M. Haque, Paul J Clark Disclosure information not available at the time of publication: Nicholas Rigby, Timothy O'Sullivan, Marianne Mortimore, Aidan Woodward