Advance Care Planning for Patients with Cirrhosis in a Structured Inpatient/Outpatient Hepatology Program

Background: Patients with end-stage liver disease (ESLD) have high mortality, but low utilization of palliative care. A transitional care liver clinic (TCLC), bridging inpatient hepatology care to outpatient clinics, should offer the ideal setting for advance care planning (ACP). Objective: To examine ACP and related outcomes for TCLC patients who died within one year of the initial TCLC visit. Design: Retrospective chart review. Setting: Nontransplant eligible ESLD patients, seen in TCLC postdischarge from an inpatient liver unit. Measurements: Charts were reviewed for demographics, clinical data, ACP discussions, code status, location of death, and palliative care consultations. Results: Of the 58 patients who showed for the initial TCLC visit, 18 (31%) died within one year. Most patients were men (67%) with alcoholic cirrhosis (72%), Child-Pugh class C (55.5%) and median age of 56 years (37-72 years). There were no ACP discussions in any TCLC visits even after subsequent hospitalizations. Until their terminal hospitalization, 17 patients (94%) remained full code. Palliative care was consulted for 10 patients (56%). Despite late initiation, within two weeks of death for 6 of those 10 patients, palliative care consultation facilitated arrangements for out-of-hospital death: at home or inpatient hospice (70% vs. 12%, p = 0.01). Conclusions: Despite a structured program for ESLD patients, there were no ACP discussions until the terminal hospitalization. These findings support the need to integrate palliative care interventions in the management of ESLD patients, especially taking advantage of postdischarge visits.