Palliative Care and Hospice Referrals in Patients with Decompensated Cirrhosis: What Factors Are Important?

Abstract

<b><i>Background:</i></b> Palliative care (PC) and hospice care are underutilized for patients with end-stage liver disease, but factors associated with these patterns of utilization are not well understood. <b><i>Objective:</i></b> We examined patient-level factors associated with both PC and hospice referrals in patients with decompensated cirrhosis (DC). <b><i>Design:</i></b> Retrospective cohort study. <b><i>Setting/Subjects:</i></b> Patients with DC hospitalized at a single tertiary center and followed for one year. <b><i>Measurements:</i></b> We assessed PC and hospice referrals during follow-up and examined patient-level factors associated with the receipt of PC and/or hospice, as well as associated clinical outcomes. We also examined late referrals (within one week of death). <b><i>Results:</i></b> Of 397 patients, 61 (15.4%) were referred to PC, 71 (17.9%) were referred to hospice, and 99 (24.9%) were referred to PC and/or hospice. Two hundred patients (50.4%) died during the one-year follow-up. In multivariable logistic regression, referral to PC was associated with increased comorbidity burden, ascites, increased MELD (Model for End-Stage Liver Disease)-Na score, lack of listing for liver transplant, and unmarried status. Hospice referral was associated with increased comorbidities, portal vein thrombosis, and hepatocellular carcinoma. PC referrals were late in 68.5% of cases, and hospice referrals were late in 62.7%. Late PC referrals were associated with younger age and married status. Late hospice referrals were associated with younger age and recent alcohol use. <b><i>Conclusions:</i></b> PC and hospice is underutilized in patients with DC, and most referrals are late. Patient-level factors associated with these referrals differ between PC and hospice.