A LiverPal Perspective: Palliative Care Pearls for the Care of Hospitalized Patients with Advanced Liver Disease

Key Message: A LiverPal team with three years of subspecialty experience provides five consensus-based pearls highlighting how the unpredictability of advanced liver disease pushes providers beyond the boundaries of usual palliative care practice. Critical opportunities exist in managing uncertainty, stigma, symptoms, end-of-life, and the journey to, through, and after a life-saving transplant.

Abstract: Advanced liver disease (AdvLD) is a life-limiting illness marked by immense symptom burden, significant psychological distress, high healthcare utilization, and poor-quality end-of-life (EOL) care (1). Caring for hospitalized patients with AdvLD is nuanced, involving high levels of prognostic uncertainty and complex transplant decision-making. Because the prevalence of AdvLD is rising, inpatient palliative care teams will likely face growing frequency of consultations for this population. Therefore, palliative care providers must better understand the unpredictable trajectory of AdvLD to deliver care that addresses the complex, evolving needs of patients and their caregivers.

LiverPal, a randomized controlled trial initiated in 2023, investigates early integration of specialty-aligned palliative care versus usual care for hospitalized patients with AdvLD. Study clinicians have encountered clinical features and patterns not typically considered in usual palliative care consults. In this session, a panel of palliative care clinicians and a hepatologist will distill consensus-based topics into five practical pearls aimed to enhance interdisciplinary team practice in caring for this population: 1) operationalizing prognostic humility for the management of dynamic uncertainty to support patients, families, and clinical teams; 2) understanding how stigma surrounding AdvLD and substance use can shape patient and family experiences, communication preferences, and care decisions (2), and the importance of stigma-informed serious illness communication; 3) symptom optimization requires robust understanding of AdvLD pathophysiology and using a multidisciplinary approach combining pharmacological and non-pharmacologic options; 4) EOL care in AdvLD requires providers to challenge existing assumptions and embrace unconventional approaches; and 5) exploring the role of palliative care in transplant survivorship, including supporting patients as they cope with the ambiguity between gratitude in receiving a life-saving liver and survivor’s guilt (3).

These important dimensions of AdvLD care reinforce the need for a collaborative, interdisciplinary team approach among palliative care, hepatology, and transplant surgery with the goal to deliver whole-person care.

References: 1) Rogal SS, Hansen L, Patel A, et al. AASLD Practice Guidance: Palliative care and symptom-based management in decompensated cirrhosis. Hepatology. 2022;76(3):819-853.

2) Schomerus G, Leonhard A, Manthey J, et al. The stigma of alcohol-related liver disease and its impact on healthcare. J Hepatol. 2022;77(2):516-524.

3) Lai JC, Ufere NN, Bucuvalas JC. Liver Transplant Survivorship. Liver Transpl. 2020;26(8):1030-1033.