S1072 Integrating Palliative Care in Liver Clinic: It Is Not About Less Aggressive Care

Abstract

INTRODUCTION: Goals of care are not adequately addressed in patients with severe liver disease. We analyzed the rates of advance directive (AD) and code status completion in patients receiving palliative care (PC) consultation during liver clinic visits. METHODS: This is a retrospective study of patients with decompensated cirrhosis and/or advanced hepatocellular carcinoma (HCC) who had PC consultation. We collected demographics, clinical/laboratory data, and outcomes including AD/code status completion. Associations between categorical predictors and AD/code status completion were analyzed using Pearson’s chi-square test or Fisher’s exact test. Associations between quantitative predictors and AD/code status completion were analyzed using Student’s t-test or the Wilcoxon rank sum test. McNemar’s test was used to assess differences in AD/code status completion before and after PC consult. RESULTS: We identified 61 patients (characteristics described in Table 1). At the PC consult, 79% patients chose full code and 21% Do-Not-Resuscitate (DNR) vs 6.5% DNR prior to PC consult (P = 0.0027), with no differences related to demographics, cirrhosis etiology/decompensations, MELDNa or HCC (Table 1). HCC was inversely associated with switching to a less aggressive code status (Table 2). Only 33% of patients had AD prior to PC consult vs 82% after PC consult (P < 0.0001). Ascites was associated with AD completion, but HCC was inversely associated with AD completion. Patients were followed until death or for at least one year post PC consult. During the first year from PC consult, there were on average 4.9 PC visits/patient, and 10 patients (16%) died. Average time of follow up was 713.4 days, with subsequent changes in the code status. Last documented code status was 70% full code, 20% DNR/Do-Not-Intubate/Do-Not-Treat, 10% DNR but allow other treatments. Higher MELDNa was associated with choosing DNR (P = 0.001, Table 2). CONCLUSION: Integrating palliative care in liver clinic successfully increased the completion of AD and clarification of code status. Among several variables studied, only MELDNa was associated with DNR, and ascites with higher rates of AD completion. Interestingly, our patients with HCC were less likely to complete AD or downgrade their code status. Only a minority of patients (16%) switched to a less aggressive code status after discussions with PC, showing that the focus of PC is documenting patients’ wishes, not “getting the DNR”.Table 1Table 2