Palliative Care Utilization and Advance Care Planning in End-Stage Liver Disease: A Quality Improvement Project

Problem: Patients with end-stage liver disease (ESLD) have high mortality, symptom burden, and healthcare utilization. Palliative care and advance care planning support patients' healthcare goals, improve quality of life, and decrease healthcare costs; however, utilization of these services are often infrequent. In this project, data were collected and analyzed from a single academic medical center regarding palliative care utilization and advance care planning that provides evidence to stakeholders supporting the need for practice change and quality improvement for patients with ESLD at this institution. Methods: A retrospective review of electronic health records (EHR) was performed to examine patients with ESLD with at least one inpatient admission to the study hospital. Data were collected on patients beginning at their index admission on or after October 1, 2015, until their death date or December 31, 2017. Two presentations were delivered to the hospital palliative care team, both pre-and post-data collection, to disseminate findings and recommendations. Results: Of the 530 patients identified, 32.6% died during the study period with 68.8% dying as inpatients at the study hospital. Only 15.5% received a palliative care consult, and 37.5% had advance directives charted in EHR. Almost 66% had at least one ICU admission, and about 18% were deferred, ineligible, removed, or inactive from the liver transplant list. These findings were presented to the palliative care team, who expressed support for a future quality improvement project. Conclusion: The findings reveal that inpatient mortality and healthcare utilization are high, and palliative care utilization and advance care planning are underutilized for patients with ESLD at this institution. The evidence collected, analyzed, and presented proved to be an impetus for future practice change.