P4659 - Late and Encephalopathic: Timing and Circumstances of Primary and Specialty Palliative Care in Patients With End Stage Liver Disease

Dina Zaret, MD¹, Anita Mahadevan, MD¹, Kemeberly Charles, MD¹, Smruti Rath, MD¹, Thomas Schiano, MD², Christopher Woodrell, MD^1
1Icahn School of Medicine at Mount Sinai, New York, NY; ²Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY

Introduction: Early receipt of palliative care (PC) improves quality of life, reduces costs, and extends survival, but is delivered inconsistently to patients with end stage liver disease (ESLD). AASLD and AGA guidance advise early PC delivered by primary hepatology and specialty PC teams. However, we know little of how the timing of that care varies for people with ESLD. This study aims to describe the timing and nature of palliative care received by a cohort of persons with ESLD at a single transplant center who had either died or been referred to hospice.

Methods: We identified 110 of 698 total patients admitted 7/1/2020 – 11/8/2022 to the pre-transplant liver service or with an ICD10 code for liver cancer or alcohol-associated hepatitis (AAH) who are deceased or were referred to hospice, and had a “sick” admission where they would be eligible for early PC. This was defined as an admission at any time where they had decompensated liver disease, severe AH (MELD ≥21), an ICU stay, or a terminal admission. The EMR provided demographic data. Manual chart review was used to determine etiology of liver disease, comorbidities, physical exam, and lab data at select time points.

Results: 74 patients in our sample were decompensated at the time of sick admission, 30 had an ICU admission, 8 had severe AH, and for 25 their sick encounter was a terminal admission. 34% of patients had physical exam signs of PSE on admission. Most patients had ALD (27%), HCV (28%), HCC (28%), MASH (15%) or CCA (16%). 23 patients received an LT after their sick admission; 2 had prior LTs. Of the 49 patients with a primary ACP note from the time of their sick admission or beyond, 17 (35%) had their first note within 1 week of death or discharge to hospice; of the 84 patients with a specialty PC note, 38 (45%) did. Of those with a primary ACP note, 63% had signs of PSE at the time of first note; of the patients who had a specialty PC note, 56% did. 69 patients had an in-hospital death and 49 patients received hospice services, mostly (32) in a palliative care unit.

Discussion: Our study shows that while the majority of a diverse sample of patients with ESLD have either primary or specialty PC discussions, they are happening when patients often have signs of PSE and frequently are close to the end of life. We found a high proportion of inpatient deaths and low home hospice utilization. The next step of our project, a content analysis of the notes, will help us understand the drivers of these phenomena.


Disclosures:


Dina Zaret, MD¹, Anita Mahadevan, MD¹, Kemeberly Charles, MD¹, Smruti Rath, MD¹, Thomas Schiano, MD², Christopher Woodrell, MD¹. P4659 - Late and Encephalopathic: Timing and Circumstances of Primary and Specialty Palliative Care in Patients With End Stage Liver Disease, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.