P0957 - Palliative Care Is Underutilized in Patients with Cirrhosis Admitted to the Intensive Care Unit Observations from a Large Academic Transplant Center

Sunday, October 22, 2023

3:30 PM – 7:00 PM PT

Location: Exhibit Hall

Has Audio

Presenting Author(s)

Jonathan Montrose, DO

Indiana University School of Medicine
Indianapolis, IN

Award: Presidential Poster Award

Jonathan Montrose, DO¹, Jessica Adams, MD², Michael Rosenheck, MD¹, Jennifer Peng, MD³, Archita Desai, MD³, Lauren Nephew, MD³, Eric Orman, MD³, Marwan Ghabril, MD³, Kavish Patidar, MD⁴, Amy Johnson, DO¹
¹Indiana University School of Medicine, Indianapolis, IN; ²IU School of Medicine, Indianapolis, IN; ³Indiana University, Indianapolis, IN; ⁴Baylor College of Medicine, Houston, TX

Introduction: In patients with cirrhosis once there are signs of clinical decompensation there is a significant decline in quality of life and life expectancy. This creates the opportunity for high quality palliative care (PC) along with goals of care (GOC) conversations and advanced care planning.

Methods: Retrospective cohort study of individuals with cirrhosis admitted to the ICU at two large referral centers. Appropriate ICD-10 codes for cirrhosis were used to screen patients with an ICU admission from 1/1/2016-12/31/2019 and confirmed through chart review. Primary outcome examined the frequency of GOC conversations and the impact on patient outcomes.

Results: Of the 1,103 patients included, only 210 (24%) received a PC consultation. The mean age, percent female and etiology of cirrhosis was similar. The PC group had a higher mean Charlson Comorbidity Index (3.5 vs 4.2, p< 0.001), CLIF-C score (10.5 vs 11.2, p=0.001), ACLF classification ≥2 (42% vs 54%, p< 0.001), and MELD-Na (24 vs 28, p< 0.001). In the PC group, 99% had a GOC conversation compared to 34% of the non-PC group (p< 0.001). The PC group had initial GOC conversation sooner with a median time of 2 days, and more often with a median of 3 conversations compared to 4 days (p< 0.001) and 2 conversations (p< 0.001) in the non-PC. Patients were able to participate 52% of the time in the PC group compared to 23% in the non-PC (p< 0.001). 75% of the PC group had a change in code status compared to 30% of the non-PC (p=0.006). Advanced directives were completed 40% of the time in the PC group compared to 4.6% in the non-PC group (p< 0.001) with greater completion rates of health care representative forms (33%), POST forms (16%) and DNR forms (15%) prior to discharge compared to the non-PC group at 8%, 1% and 2%, respectively (p< 0.001).There was no difference in initiation of dialysis or mechanical ventilation, but the PC group had greater vasopressor initiation (56%) and ICU readmissions (12%) compared to the non-PC group at 40% and 4%, respectively (p< 0.001). The PC group experienced more ICU death (38%), in-hospital non-ICU death (12%) and hospice placement (10%) compared to 35% (p=0.028), 2%, and 1%, respectively (p< 0.001). There was higher mortality at 30,90, and 180-days (p< 0.001) in the PC group.

Discussion: While PC remains underutilized, those who received a PC consultation tended to be sicker and underwent earlier and more frequent GOC conversations. Further measures to increase PC utilization in this population is warranted.

Characteristic	Non-Palliative Care group (n=893)	Palliative Care Group (n=210)	p-value
Age (SD)	57.0 (11.3)	59.5 (12.8)	0.006
Female, n (%)	372 (41.7)	90 (42.9)	0.751
Race, n (%) Black or African American White Other	90 (10.1) 758 (84.9) 45 (5.0)	31 (14.8) 169 (80.5) 0 (4.8)	0.140
Insurance, n (%) Commercial Medicaid Medicare Other	6 (0.7) 295 (33.0) 382 (42.8) 210 (23.5)	1 (0.5) 67 (31.9) 109 (51.9) 33 (15.7)	0.045
Etiology of Cirrhosis, n (%) HCV HCV + EtOH EtOH NASH Other	137 (15.3) 87 (9.7) 290 (32.5) 197 (22.0) 182 (22.4)	43 (20.5) 19 (9.0) 56 (26.7) 46 (21.9) 46 (21.9)	0.297
Charlson Comorbidity Index (excluding liver) (SD)	3.5 (2.5)	4.2 (2.8)	< 0.001
CLIF-C score (SD)	10.5 (2.7)	11.2 (2.4)	0.001
ACLF classification, % No ACLF/ 1/ 2/ 3	31.1/11.9/16.9/25.0	16.7/12.9/24.8/29.5	< 0.001
Initial MELD-Na (SD)	24.1 (10.4)	27.8 (9.8)	< 0.001
Initial Code Status, n (%) Full Code DNR-Comprehensive DNR-Comfort Limited Code Status	860 (96.3) 18 (2.0) 1 (0.1) 14 (1.6)	186 (88.6) 18 (8.6) 0 (0.0) 4 (1.9)	< 0.001
Final Code Status, n (%) Full Code DNR-Comprehensive DNR-Comfort Limited Code status	613 (68.6) 40 (4.5) 211 (23.6) 22 (2.5)	46 (21.9) 33 (15.7) 121 (57.6) 5 (2.4)	< 0.001
Change in Code status	262 (29.3)	156 (74.2)	0.006
Change in Advance Directive	41 (4.6)	84 (40.0)	< 0.001
Advance Directives % none/at admission/at discharge	72.9/17.9/8.7	36.2/30.0/33.3	< 0.001
HCR Form % none/at admission/at discharge	76.0/16.0/7.5	51.9/27.1/21.0	< 0.001
POST Form % none/at admission/at discharge	96.8/1.2/1.1	76.7/6.2/16.2	< 0.001
DNR Form % none/at admission/at discharge	96.5/0.6/2.0	82.8/1.9/15.2	< 0.001
Health Care Utilization, n (%) Initiation of Dialysis Required Mechanical Ventilation Vasopressor use ICU Readmission during stay	125 (14.0) 343 (48.6) 355 (39.8) 36 (4.0)	36 (17.1) 110 (52.4) 117 (55.7) 26 (12.4)	0.573 0.563 < 0.001 < 0.001
Had a Goals of Care Conversation, n (%)	307 (34.4)	208 (99.0)	< 0.001
# of GOC conversations, median (IQR)	2 (2, 3)	3 (2, 4)	< 0.001
Time to GOC, median (IQR)	2 (0, 7)	4 (1, 11)	< 0.001
Trigger for GOC, n (%) Upgrade to ICU Bleed Change in Respiratory Status Need for Dialysis Hypotension/Vasopressor need Primary Team Requested Family Requested Not a Liver Transplant Candidate Other	90 (10.1) 61 (6.8) 118 (13.2) 46 (5.2) 163 (18.3) 67 (7.5) 20 (2.2) 10 (1.1) 100 (11.2)	37 (17.6) 29 (13.8) 54 (25.7) 33 (15.7) 68 (32.4) 84 (40.0) 16 (7.6) 31 (14.8) 76 (36.2)	0.002 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
Involved in GOC, n (%) Patient Only Patient & Family Family/Friend Only	13 (4.2) 59 (19.2) 233 (75.9)	17(8.2) 92 (44.2) 97 (46.6)	< 0.001
Why the Patient could not Participate, n (%) Intubated Metabolic Encephalopathy	180 (77.3) 128 (54.9)	54 (55.7) 74 (76.3)	0.076 < 0.001
Final Disposition, n (%) ICU Death In-Hospital, non-ICU Death Discharged to Hospice Discharged to SNF/Home	272 (30.5) 18 (2.0) 10 (1.1) 593(66.4)	80 (38.1) 25 (11.9) 20 (9.5) 85 (40.5)	0.028 < 0.001 < 0.001 < 0.001
Mortality at 30/90/180 days Post-Discharge (%)	34.4/41.2/47.1	57.1/61.0/63.8	< 0.001
Liver Transplant Status, n (%) Evaluated for Transplant Listed for Transplant Received Transplant	110 (12.3) 83 (9.3) 66 (7.4)	12 (5.7) 0 (0) 0(0)	0.005 < 0.001 < 0.001

Table: Table: Baseline Characteristics along with Palliative Care and Health Care Utilization between the Palliative and Non-Palliative Care groups.

Disclosures:

Jonathan Montrose indicated no relevant financial relationships.

Jessica Adams indicated no relevant financial relationships.

Michael Rosenheck indicated no relevant financial relationships.

Jennifer Peng indicated no relevant financial relationships.

Archita Desai indicated no relevant financial relationships.

Lauren Nephew indicated no relevant financial relationships.

Eric Orman: Biovie – Advisory Committee/Board Member. Salix – Consultant.

Marwan Ghabril indicated no relevant financial relationships.

Kavish Patidar indicated no relevant financial relationships.

Amy Johnson indicated no relevant financial relationships.

Jonathan Montrose, DO¹, Jessica Adams, MD², Michael Rosenheck, MD¹, Jennifer Peng, MD³, Archita Desai, MD³, Lauren Nephew, MD³, Eric Orman, MD³, Marwan Ghabril, MD³, Kavish Patidar, MD⁴, Amy Johnson, DO¹. P0957 - Palliative Care Is Underutilized in Patients with Cirrhosis Admitted to the Intensive Care Unit Observations from a Large Academic Transplant Center, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.