Health Care Utilization and End-of-Life Care Outcomes for Patients With Decompensated Cirrhosis Based on Transplant Candidacy

Nneka N Ufere; Jennifer L Halford; Joshua Caldwell; Min Young Jang; Sunil Bhatt; John Donlan; Janet Ho; Vicki Jackson; Raymond T Chung; Areej El-Jawahri

doi:10.1016/j.jpainsymman.2019.10.016

Health Care Utilization and End-of-Life Care Outcomes for Patients With Decompensated Cirrhosis Based on Transplant Candidacy

J Pain Symptom Manage. 2020 Mar;59(3):590-598. doi: 10.1016/j.jpainsymman.2019.10.016. Epub 2019 Oct 23.

Authors

Affiliations

¹ Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA. Electronic address: nufere@partners.org.
² Harvard Medical School, Boston, Massachusetts, USA.
³ Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
⁴ Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
⁵ Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Abstract

Context: Patients with decompensated cirrhosis have high rates of health care utilization at end of life (EOL). However, the impact of transplant candidacy on intensity of EOL care is currently unknown.

Objectives: To assess the relationship between transplant candidacy and intensity of EOL care in the last year of life in an ambulatory cohort of patients with decompensated cirrhosis.

Methods: We performed a retrospective analysis of 230 patients with decompensated cirrhosis who were evaluated for liver transplantation in a large health care system between 1/1/2010 and 12/31/2017 and died by 6/20/2018. We compared health care utilization in the last year of life and EOL care outcomes between transplant-listed (n = 133) and nonlisted (n = 97) patients. We examined predictors of palliative and hospice care utilization using multivariate logistic regression.

Results: During the last year of life, patients had a median of three hospitalizations (IQR 2-5) and spent a median of 31 days (IQR 16-49) in the hospital. In all, 80% of patients died in the hospital, with 70% dying in the intensive care unit. The majority (70.0%) received a life-sustaining procedure (mechanical ventilation, renal replacement therapy, or cardiopulmonary resuscitation) during their terminal hospitalization, which did not differ between transplant-listed and nonlisted patients (74.4% vs. 63.9%, P = 0.09). Transplant-listed patients had lower odds of receiving specialty palliative care (odds ratio 0.43, P = 0.005). Patients with hepatocellular carcinoma had higher odds of receiving hospice care (odds ratio 2.03, P = 0.049).

Conclusion: Patients with decompensated cirrhosis had intensive health care utilization during their last year of life regardless of transplant candidacy. Further work is needed to optimize their EOL care, particularly for patients who are ineligible for transplantation.

Keywords: End-stage liver disease; advance care planning; code status; hospice; liver transplantation; palliative care.

Publication types

Research Support, N.I.H., Extramural

MeSH terms

Carcinoma, Hepatocellular*
End Stage Liver Disease*
Esophageal and Gastric Varices*
Female
Gastrointestinal Hemorrhage
Hospice Care*
Humans
Liver Cirrhosis / therapy
Liver Neoplasms*
Male
Middle Aged
Patient Acceptance of Health Care
Retrospective Studies
Severity of Illness Index
Terminal Care*

Abstract

Publication types

MeSH terms

Grants and funding