Palliative care for end-stage liver disease and acute on chronic liver failure: A systematic review

Table 1 Summary of data extracted from the systemically reviewed references

Ref.	Population	Study design	Structure	Results	Conclusion
Bauman et al[6], 2015	79 ESLD patients referred for LT evaluation or awaiting transplant between July 2013 and May 2014	Longitudinal, multidisciplinary, EPCI for one week pre-transplant evaluation with outpatient consultations following national guidelines. GOC discussed with patients and families until October 2014	Patients underwent EPCI with formal assessments of depression, liver-specific symptoms, psychosocial well-being, and spiritual health	Post-EPCI, there was a significant 50% reduction in symptom burden (P < 0.05) and a 43% decrease in depressive symptoms (P = 0.003). Patients with moderate to severe symptoms showed greater improvement. Assessment tools included ESAS, EPCI, and quality of life	Palliative care is underused in ESLD due to a lack of suitable distress assessment tools. EPCI effectively improves symptom burden and mood in ESLD patients awaiting transplant
Shinall et al[63], 2019	Patients with ESLD admitted to an urban, academic referral center. Total patients: 398293	RCT	Inclusion criteria involved ESLD diagnosis and expectation of potential mortality within 1 year. Patients were randomized into usual care or PC intervention groups with primary and secondary outcome assessments over 6 months	Among 293 eligible patients, 63 were enrolled in the RCT (31 in intervention, 32 in control). PC intervention showed reduced readmission risk (HR = 0.36, P = 0.017) and more days alive outside the hospital (OR = 3.97, P = 0.030) compared to control	PC demonstrated extended time before readmission and increased days alive outside hospital, highlighting its benefit for ESLD patients
Gupta et al[10], 2022	Patients admitted with decompensated alcohol-associated cirrhosis who received PC consultation	Retrospective multicenter observational study	Analysis included 78 million discharged patients (2007-2014) from national databases with ESLD diagnosis criteria including alcoholic cirrhosis or other cirrhosis with alcohol disorder and decompensation events	Out of 1,421,849 hospitalized ESLD patients, 62782 received PC. Factors like advanced age, lower income, Medicaid coverage, urban location, prolonged hospital stay, and ventilation increased odds of receiving PC. Patients treated in facilities with PC services had lower 30-day readmission rates	Increasing inpatient PC consultation for decompensated ArLD correlates with reduced 30-day readmissions, shorter hospital stays, and lower costs
Poonja et al[11], 2014	Adults with ESLD who were removed from or declined LT between January 2005 and December 2010 (n = 102)	Retrospective observational study	Primary outcome focused on DC patients referred and receiving PC Secondary outcomes included time from LT decline to death, rehospitalizations, ICU admissions, and place of death	Common reasons for LT removal or decline included noncompliance/substance abuse (26%) and severe illness/organ dysfunction (25%). Among delisted patients, 17% required renal replacement therapy, 48% had ICU admissions (median 14 days), but only 11% were referred for PC	Patients with DC declined or delisted from LT have low rates of PC referral (11%) and unclear GOC. Collaboration between LT and PC services can enhance quality of life for this patient group
Patel et al[25], 2017	Hospitalized adults with terminal DC (ESLD). Total patients: 59887	Cross-sectional observational study patient cohort	ESLD patients were identified using ICD-9 codes. Main outcomes included PC consultation rates during terminal hospitalization and total incurred costs, alongside demographic and comorbidity data	29.1% of hospitalized ESLD adults received PC with an average cost of $49167. Urban residents had higher PC rates, while African Americans, Hispanics, and Asians had lower rates (racial disparity). PC was associated with reduced procedure burden and cost savings of $8892	PC consultation during terminal hospitalization for ESLD is linked to cost reduction and lower procedure burden, despite racial disparities in PC access
Ufere et al[26], 2019	Hepatologists and gastroenterologists (396) providing care for patients with ESLD	Cross-sectional observational study patient cohort	Survey of AASLD members assessing barriers to PC and ACP delivery in ESLD patients	Most respondents (95%) cited cultural factors as a barrier to PC delivery, followed by unrealistic expectations (93%) and time constraints (91%). ACP barriers included communication issues (84%) and lack of cultural competency training (81%)	Substantial barriers hinder PC and ACP services for ESLD patients according to hepatologists and gastroenterologists. Strategies are needed to improve timely and high-quality end-of-life care for these patients
Patel et al[27], 2021	Study included 88 participants: 46 LT center physicians and 42 decompensated cirrhotic patients from 3 LT centers	Qualitative study using face-to-face semi-structured interviews	Interviews conducted with ESLD patients meeting specific criteria (consent, age 18 +, English proficiency, cirrhosis diagnosis, and specific symptoms) and clinicians (transplant hepatologists, surgeons, coordinators, social workers) exploring aspects of ACP	Study identified five themes related to ACP experiences: (1) Patients often considered values and preferences outside of clinical visits; (2) Optimism from transplant teams hindered discussions about dying; (3) Clinicians used discussions about death to encourage behavioral change; (4) Transplant teams avoided discussing nonaggressive treatment options; and (5) Surrogate decision-makers lacked preparation for end-of-life decisions	Decompensated cirrhotic patients lack adequate ACP throughout their illness trajectory, leading to overly aggressive end-of-life treatments. This highlights the need for improved ACP practices in this population
Lin et al[12], 2020	Total of 903 patients: 214 from Wang Fang Hospital and 689 from Taipei Medical University	Retrospective cohort study	Inclusion criteria: Adults (> 18 years) with CLD and specific conditions, with EMR data available within 24 hours of admission. Exclusion criteria included pregnancy, cancer, and LT history	ESLD patients were categorized into acute death (within 30 days), PC (death within 1-9 months), and survived. Overall mortality rates were 283% in the training set and 22.6% in the validation set	Machine learning monitoring systems offer a comprehensive approach to assessing ESLD patient conditions. Supervised machine-learning models demonstrate superior predictive performance compared to traditional statistical methods
Vieira da Silva et al[22], 2023	ESLD patients presenting to a university hospital and LT center from November 2019 to September 2020	Prospective observational single-center study	Study excluded patients with previous LT, isolated acute liver failure, or another terminal disease (except hepatocellular carcinoma, HCC). PC criteria screening used the NECPAL CCOMS-ICO tool to identify patients needing PC and predicting mortality. Specific PC needs were assessed using the IPOS questionnaire for symptoms and mood	Among 54 patients, 9.3% were on the LT waiting list and 14.8% were under evaluation. NECPAL CCOMS-ICO identified 42.6% needing PC. Clinicians identified functional markers and comorbidities (47.8%) as indicating PC needs. IPOS identified multiple needs, with weakness (77.8%), reduced mobility (70.3%), and pain (48.1%) being prominent	All ESLD patients, including those awaiting transplantation, demonstrated significant PC needs. This highlights the importance of addressing PC needs across all stages of ESLD care
Beck et al[28], 2016	Survey conducted among 200 LT patients	Qualitative survey study	Web-based survey evaluating attitudes of LT providers and barriers to PC for patients. Examined variables included provider attitudes toward symptom management and documentation practices	Response rate was 44% (88/200). Providers agreed that LT and PC are not mutually exclusive (86%). Most suggested PC referral when death is imminent (78%). Many providers recognized patient depression (66%), but fewer consulted PC for depression (28%). Attending physicians were identified as the main barrier to involving PC (84%)	PC in LT patients a ligns with LT goals even during listing. Barriers include confusion over referral criteria
Puentes et al[13], 2018	Hospitalized patients with hepatic cirrhosis between January 2015 and December 2016, classified using the Child–Pugh score and MELD/Na score in January 2018	Retrospective study	Child–Pugh score assessed cirrhosis prognosis using specific parameters (TB, Bil, Albumin, PT, ascites, encephalopathy). MELD/Na score predicted survival based on Na, Cr, Bil, and INR	Patients were classified into Child–Pugh Class A (17%), Class B (48.9%), and Class C (34%). MELD/Na scores ranged > 9 (2.15%), 10–19 (46.8%), 20–29 (27.7%), 30–40 (19.1%), and > 40 (4.3%). About 51.1% had MELD/Na > 20. The study showed 59.6% of patients needing PC died within 12 months	Child–Pugh and MELD/Na scores are valuable tools to identify PC needs in liver cirrhosis patients. Early identification and comprehensive care improve quality of life by addressing physical, spiritual, family, and social needs
Hudson et al[14], 2017	Study included all emergency admissions with a cirrhosis diagnosis over two distinct 90-day periods (n = 83)	Retrospective study	Patients were assessed for five criteria independently scored by clinicians: (1) Child-Pugh score C; (2) ≥ 2 admissions within last 6 months; (3) Ongoing alcohol use with ArLD; (4) Unsuitability for LT; (5) WHO Performance status 3 or 4. One-year mortality was calculated using cumulative prognostic score out of 5	Analysis of 73 admissions (79.5% male, 63% ArLD, median age 54) showed that presence of ≥ 3 poor-prognosis criteria predicted 1-year mortality with sensitivity, specificity, and positive predictive value of 72.2%, 83.8%, and 81.3%, respectively. This triggered implementation of supportive care interventions	Identifying high-risk cirrhosis patients using specific criteria allows for early implementation of supportive care alongside active management to improve outcomes
Lamba et al[21], 2011	Study included 79 LT patients and 104 ESLD patients (n = 183)	Prospective, observational pre/post study	Interdisciplinary PC model integrated into LT service and surgical intensive care unit, focusing on family support, prognosis, and patient preferences (Part I) and interdisciplinary family meetings (Part II) within 72 hours	Baseline group (LT patients) had 21 deaths, and intervention group had 31 deaths. 85% received Part I and 58% received Part II of the intervention. GOC discussions on physician rounds increased significantly during the intervention. Do not resuscitate status increased from 52% to 81%, and withdrawal of life support increased from 35% to 68	Early integration of PC alongside curative care in surgical intensive care unit can improve EOL practices without changing mortality rates in LT patients. Interdisciplinary communication interventions facilitate consensus on GOC for dying LT patients
Medici et al[15], 2008	157 ESLD patients admitted to hospice service	Observational retrospective analysis	Recorded patient details included age, gender, main diagnosis, comorbidities, length of hospice stay, and development of ESLD-specific complications during hospice stay (e.g., gastrointestinal bleeding, hepatic encephalopathy, tense ascites with dyspnea). MELD scores were computed at hospice entry and eventual LT	Most patients were male (67.5%) with a mean age of 57 years. Common ESLD causes were alcohol cirrhosis, hepatitis C virus infection, or both. HCC complicated 28% of cases. Common comorbidities included diabetes (18.2%), vasculopathy/hypertension (16.3%), kidney failure (11.3%), and chronic obstructive pulmonary disease (4.4%). A majority (78%) of patients died during the observation period	MELD scores can guide clinician recommendations for hospice care, aiming to increase duration beyond the current median of 2-3 weeks. Hospice referral for high MELD score patients is an effective strategy to enhance care for ESLD patients awaiting transplantation
Deng et al[16], 2021	233 adult cirrhosis patients evaluated for LT out patiently from July 1, 2019 to September 30, 2019	Observational retrospective analysis	Patients excluded if severe hepatic encephalopathy or non-English/Spanish speakers. Frailty assessed using liver frailty index. Symptom scores ≥ 4 triggered comprehensive assessment. ESAS score ≥ 7 indicated high symptom burden and decreased functioning. Demographic and clinical data (etiology, HCC, ascites) collected from medical records	Median age 61 years, 43% female. Frailty distribution: 22% robust, 59% pre-frail, 19% frail 38% reported ≥ 1 severe symptom (based on ESAS). Higher frailty associated with increased prevalence of pain, dyspnea, fatigue, nausea, poor appetite, drowsiness, depression, and poor well-being (all P < 0.05)	Frailty strongly linked to physical/psychological symptoms (pain, depression) and poor quality of life in cirrhosis patients. Frail cirrhosis patients may benefit from PC co-management to address symptoms and improve quality of life
Jung et al[72], 2020	101 patients with liver disease, including HCC and cirrhosis, who completed POLST at general tertiary hospitals in Seoul from February 4, 2018, to August 31, 2018	Retrospective descriptive survey analyzing decision-making practices and outcomes of life-sustaining treatment in ESLD patients with POLST	Case report form based on POLST and EMR, including patient characteristics, POLST details, life-sustaining treatment regimen, treatment outcomes, and withdrawals	63 patients (62.4%) completed their own POLST; 3 patients withdrew (2 for LT, 1 for chemotherapy). Majority were male (81.2%) with an average age of 61.8 years	Emphasizes the importance of considering LT for ESLD patients before deciding on life-sustaining treatment. Supports patient self-determination and highlights the need for effective guidelines in this context
Kathpalia et al[17], 2016	The study included 683 adult cirrhotic patients listed for LT at a large United States center from 2013 to 2014	Descriptive retrospective study	The study included adult cirrhotic patients newly listed for LT who either died before transplant or were too ill for transplant. Patients with certain exclusion criteria were not included. Patient demographics, disease etiology, MELD score, education level, Child-Pugh Score, presence of HCC, and insurance type were recorded from EMR	Among the 683 Listed patients, 16% (107) either died (62 patients) or were removed due to clinical decompensation (45 patients) before receiving a LT. The median age was 58 years, and most patients were male (66%), Caucasian (53%), and had Child C cirrhosis (61%) or hepatocellular carcinoma (52%)	PC services are underutilized in older, non-white patients with cirrhosis awaiting LT. Early integration of PC into transplant decision-making is recommended
Adejumo et al[69], 2020	The study included 67480 hospitalized patients with ESLD	Retrospective longitudinal analysis of ESLD patients hospitalized from January 2010 to January 2014	The study used a database with a 90-day follow-up after discharge, matching patients who received PC to those who did not (1:1) using propensity scores	Among the ESLD hospitalizations, 5.3% (3485) received PC, showing an annual increase from 3.6% to 6.7%. Average 30- and 90-day readmission rates were 362% and 54.6%, respectively. PC was associated with a lower risk of 30- and 90-day readmission	PC was linked to reduced readmission rates, potentially lessening the burden on healthcare resources and improving cost savings during subsequent readmissions
Low et al[68], 2017	The study involved 66 individuals with cirrhosis who died between April 2010 and September 2011, and 22 liver health professionals who participated in focus groups or interviews	This study used mixed methods, including retrospective case note review, qualitative focus groups, individual interviews, and qualitative focus group discussions	Researchers selected 30 out of the 66 deceased individuals with cirrhosis for data collection from their records in the 12 months before death. Additionally, semi-structured interviews and focus groups were conducted with health professionals involved in care	The study highlighted high rates of hospital admissions and symptom burden among participants with cirrhosis. Clinicians demonstrated reluctance to discuss prognosis or future care preferences due to lacking skills and confidence, resulting in delayed provision of PC	People with cirrhosis experience unpredictable disease trajectories marked by frequent hospitalizations and worsening symptoms nearing death. The study recommends implementing clinical tools to identify irreversible deterioration and fostering collaboration between liver services and PC to enhance care quality
Walling et al[58], 2015	The study compared 49 hospitalized veterans to 61 pre-quality improvement project veterans	This was a comparative study that retrospectively evaluated PC consultation rates among care management recipients compared to a prospective cohort of LT identified using the same ICD-9 codes and screening criteria over a one-year period	Veterans with cirrhosis were identified using specific ICD-9 codes and screened for ESLD based on medical records at a VA hospital. A care coordinator followed veterans from hospitalization through April 2013, encouraging LT evaluation consults for those with a MELD ≥ 14 and PC consults for those with a MELD ≥ 20 or inoperable HCC	During the intervention period, hospitalized veterans were more likely to be considered for LT (77.6% vs 31.1%, P < 0.001) and to receive PC consultation, though the latter finding did not reach statistical significance (62.5% vs 47.1%, P = 0.38)	Active case finding increased consideration for LT without reducing PC consultation rates
Donlan et al[29], 2021	The study involved ESLD patients and their informal caregivers	This was a qualitative study involving semi-structured interviews with 15 ESLD patients and 14 informal caregivers	Interviews were conducted by a team including a gastroenterologist, study coordinator, psychologist, and oncologist, aiming to explore participants' perceptions of PC and when it should be introduced to ESLD patients	Transplant-listed patients were concerned that PC referral might impact their chance of receiving a LT. Most participants felt that ESLD patients should learn about PC soon after diagnosis	Study participants often equated PC with hospice care initially. However, after receiving education on PC, nearly all participants, including transplant-eligible and ineligible patients, supported the early introduction of PC in ESLD care
Shinall et al[9], 2022	The study included 24 participants from 11 institutions across the United States and Canada who participated in three focus groups	The study involved qualitative analysis of transcripts from provider focus groups followed by a community engagement studio with patients and caregivers	Three Zoom focus groups were conducted with hepatologists and PC specialists using open-ended questions. Qualitative data coding and analysis were performed following COREQ guidelines by the Vanderbilt University Qualitative Research Core, led by a PhD-level psychologist	The focus groups identified elements of specialist PC beneficial for LT patients. They also highlighted barriers to integrating PC, such as role boundaries, differences in clinical cultures, limited time and staff, and competing goals and priorities	Hepatologists, PC specialists, patients, and caregivers identified key barriers in LT patient care that specialist PC could address, including role boundaries, clinical culture differences, limited resources (time and staff), and conflicting priorities
Tombazzi et al[62], 2022	The study included all patients discussed in the LTC at an academic medical center in the United States between August 2018 and May 2020, totaling 769 patients	This was a retrospective descriptive study followed by cohort analysis	Out of 135 patients declined for LT, 37 (27%) received a referral to PC. Data collected included baseline demographics, MELD score, decompensation events, and reasons for transplant ineligibility. Primary outcome was PC referral, and secondary outcomes included survival from LTC decision, time from LTC decision to PC referral, and code status at PC referral	Among 769 patients discussed at LTC, 135 were declined for transplantation, and 37 (27%) received a PC referral. Patients with higher MELD scores (21-30 and > 30) had significantly higher odds of PC referral compared to those with MELD score < 20	Only a minority (27%) of patients declined or delisted for LT were referred to PC. MELD score and degree of decompensation were important factors associated with PC referral. Further exploration of this data is needed to inform future studies and establish criteria and timing for PC referral
Holden et al[73], 2020	The study included 397 patients with DC admitted to Indiana University Hospital in 2012	Retrospective cohort study	Patients were identified using EMR and confirmed for cirrhosis through manual chart review. Exclusions were patients under 18 years and those with prior LT. Primary outcome: Referral to PC. Secondary outcomes included hospitalization duration, medical interventions, code status limitations, LT, and mortality	Among 397 patients, 61 (15.4%) were referred to PC, 71 (17.9%) to hospice, and 99 (24.9%) to PC and/or hospice. Within one year, 50.4% of patients died. Referrals to PC and hospice were predominantly late, with 68.5% and 62.7% respectively	PC and hospice services are underutilized for patients with DC, with most referrals occurring late. Referral to PC was associated with increased comorbidity, while hospice referral was associated with greater comorbidities according to multivariable logistic regression
Peng et al[65], 2020	The study included all adult patients with ESLD who died during hospitalization from 2010 to 2013 in Taiwan (n = 14,247)	Retrospective cohort study using the National Health Institute Research Database, adhering to STROBE guidelines	The study focused on ESLD patients aged 18 and older who died during hospitalization. Primary outcome was ICU admission during terminal hospitalizations. Secondary outcomes were cardiopulmonary resuscitation (CPR) and mechanical ventilation during terminal hospitalizations	Among ESLD patients, 60.8% had comorbid HCC. Patients without HCC were less likely to receive PC before terminal hospitalization compared to those with HCC. Those without HCC had higher rates of ICU admission, CPR, and mechanical ventilation during terminal hospitalization	Patients with ESLD not comorbid with HCC require more attention regarding PC needs and decision-making for intensive care utilization. Prior PC was associated with reduced probability of ICU admission
Patel et al[23], 2020	The study included 167 veterans newly diagnosed with ESLD in 2012 at the Greater Los Angeles Healthcare System using the VA Corporate Data Warehouse	Prospective cohort study	Veterans were selected using ICD-9 codes for cirrhosis and liver decompensation. Different sampling techniques were applied to identify patients with ESLD using ICD-9 codes and chart abstraction	Among the identified patients, 62 met ESLD criteria after chart abstraction. The majority were male (98%), with a mean age at diagnosis of 61 years, and 74% were White. The quality indicator pass rate was 68%. Patients who received PC consultations were more likely to receive information care planning quality indicator	The study highlights inadequate quality of PC in veterans with ESLD. Patients who received specialty PC consultations and those affected by homelessness, drug, and alcohol abuse received better care. Combination of ICD-9 codes can effectively identify patients with ESLD
Orman et al[24], 2022	The study included 679 adults (age ≥ 18) with cirrhosis admitted to Indiana University Hospital between June 2014 and July 2019 who received PC	Prospective cohort study	Patients were followed from admission through 90 days post-discharge to assess outcomes. PC consults were considered EOL care for patients with imminent in-hospital death Primary outcome was unplanned 30-day readmission. Secondary outcomes included hospital length of stay, intensive care utilization, inpatient costs, discharge medications, and 90-day post-discharge mortality and costs	Among 679 patients, 74 received PC, typically later in their hospitalization. Patients receiving PC had higher Charlson comorbidity index and greater impairments in activities of daily living, social activity, and quality of interactions	PC is underutilized and often initiated late in patients with severe liver disease and functional impairment. PC may reduce healthcare utilization and increase completion of advanced directives. RCTs are needed to further evaluate PC for this population
Thandassery et al[18], 2022	The study compared patients with COVID-19 and cirrhosis (Group A, n = 1969) vs those with COVID-19 alone (Group B, n = 169257)	The study retrospectively analyzed a global multicenter database to assess mortality risk and PC referrals in patients with COVID-19 and cirrhosis	Data from 50 healthcare organizations worldwide were analyzed using a federated cloud-based network (TriNetX). Patients aged 18 to 90 years with COVID-19 were identified between January 20, 2020, and November 16, 2020	Group A (COVID-19 and cirrhosis) had a higher mortality rate (8.9%) compared to Group B (COVID-19 alone, 5.6%). The hazard ratio (95%CI) for mortality with cirrhosis was 1.59 (1.26–1.99) (P = 0.01). PC referrals were more frequent in Group A (4.1%) compared to Group B (2.0%). The hazard ratio (95%CI) for PC referrals with cirrhosis was 2.02 (1.39–2.94) (P = 0.01)	Hospitalized patients with COVID-19 and cirrhosis are at high risk of mortality and should be considered for PC referrals
Brown et al[76], 2016	The study included a cohort of ESLD patients (n = 22311)	This was a retrospective cohort study that identified hospitalized ESLD and HF patients between 2007 and 2011	The study analyzed endpoints during index hospitalization, including mortality, discharge to hospice, and length of stay. Post-discharge endpoints included all-cause mortality, rehospitalization, hospice enrollment, and days alive and out of hospital. Follow-up occurred at one and three years after discharge, comparing with a reference cohort of decompensated HF patients	One year after discharge, ESLD patients had 209 days alive and out of hospital compared to 252 days alive and out of hospital for decompensated HF patients. Inpatient mortality for ESLD was 13.5%, with all-cause mortality at 64.9%, higher than HF rates. ESLD patients had a rehospitalization rate of 59.1%, slightly lower than HF patients	The study demonstrates substantial morbidity and mortality rates associated with end-of-life care in ESLD. There is a critical need for alternative approaches to manage the care of ESLD patients
Whitsett et al[30], 2022	The study surveyed all United States transplant hepatology fellows enrolled in accredited fellowship programs during the 2020–2021 academic year	This was a qualitative study conducted using a national survey	The survey assessed the frequency of PC provision and fellows' comfort levels with physical and psychological symptom management, psychosocial care, communication skills, ACP, and end-of-life care	Out of 56 transplant hepatology fellows, 45 responded to the survey (79%), including 50% females (n = 22). Most fellows (67%, n = 29) trained at centers performing over 100 transplants per year. Additionally, 69% (n = 31) had a PC or hospice care rotation during residency, and 42% (n = 19) received education in PC during their transplant hepatology fellowship	The survey revealed gaps in PC experience and education during transplant hepatology fellowship, highlighting a lack of comfort in managing psychological distress and ACP. There is a desire among fellows to improve skills, particularly in symptom management
Ufere et al[20], 2020	The study included patients with DC evaluated for LT between January 1, 2010, and December 31, 2017 (n = 230)	It was a retrospective analysis of all adults (age ≥ 18 years) evaluated for LT across a network of nine acute care hospitals	The study compared healthcare utilization in the last year of life and EOL care outcomes between transplant-listed (n = 133) and non-listed (n = 97) patients. Predictors of PC and hospice care utilization were examined using multivariate logistic regression	The majority of patients (80%) died in the hospital, with 70% of them in the ICU. About 70.0% received a life-sustaining procedure during their terminal hospitalization, which did not differ between transplant-listed and non-listed patients. Transplant-listed patients had lower odds of receiving specialty PC, while patients with HCC had higher odds of receiving hospice care	Patients with DC, regardless of transplant candidacy, exhibit high rates of healthcare utilization with low utilization of palliative and hospice care. They spend most of their last 90 days of life in the hospital, where they often eventually die

ESLD: End stage liver disease; EPCI: Early palliative care intervention; GOC: Goals of care; ESAS: Edmonton symptom assessment symptom; RCT: Randomized controlled trial; PC: Palliative care; LT: Liver transplantation; AASLD: American Association for the Study of Liver Diseases; ACP: Advance care plan; CLD: Chronic liver disease; EMR: Electronic medical records; HCC: Hepatocellular carcinoma; NECPAL CCOMS tool: Strategy of identifying patients who require in palliative care in general health service; IPOS: Integrated palliative care outcome scale; INR: International normalized ratio; ArLD: Alcohol-related liver disease; EOL: End of life; POLST: Physician Orders for Life-Sustaining Treatment; LTC: Liver transplantation committee; DC: Decompensated cirrhosis; COVID-19: Coronavirus disease 2019; HR: Hazard ratio; OR: Odds ratio; ICU: Intensive care unit; HF: Heart failure; ICD-9: International Classification of Diseases, Ninth Revision; CPR: Cardiopulmonary resuscitation.