Hepatologists effectively deliver palliative care to patients with liver disease

Advanced liver disease (ALD) occurs when significant scarring causes the liver to lose function. Patients with ALD often have serious health challenges but have limited access to palliative care that could improve their quality of life. A new multicenter trial led by Manisha Verma, MD, and Victor Navarro, MD, at Jefferson Einstein Philadelphia Hospital demonstrates a new approach that could potentially transform access to palliative care for patients with ALD and address a major care gap.

In the PAL LIVER trial, a large cluster-randomized study conducted across 19 U.S. centers, researchers evaluated whether hepatologists trained in primary palliative care could match the effectiveness of palliative care specialists in delivering quality-of-life benefits to patients with ALD, including those with decompensated cirrhosis and liver cancer. With 935 patients enrolled, this is one of the largest trials to date in liver disease palliative care.

Palliative care was provided to patients (559 caregivers are also included in the study) over four monthly visits by either a palliative care specialist utilizing a standard checklist or by a hepatologist trained to deliver palliative care using the same standardized checklist. The study findings, published in JAMA Internal Medicine, found that quality of life improved significantly in both groups over three months, with care delivered by hepatologists matching that of palliative specialists in improving quality of life. Symptom burden improved similarly in both groups, and short-term mortality was also comparable between groups.

These results challenge traditional care models. We've demonstrated that non-specialists can effectively deliver structured palliative care with the appropriate training."

Dr. Manisha Verma, associate chair and director of research, Department of Medicine, Jefferson Einstein Philadelphia Hospital and first author of the study

The approach could be a timely, scalable solution in the face of a growing workforce shortage in palliative care. "By embedding palliative care within hepatology clinics, this would allow earlier and more widespread access for patients who might otherwise not receive it," adds Dr. Verma

Furthermore, patients reported higher satisfaction with hepatologist-delivered care. This suggests patients may value receiving palliative care from clinicians already managing their liver disease, with improved continuity and coordination in their care. With patient outcomes and engagement at the forefront of this trial, this study was funded by the Patient Centered Outcomes Research Institute (PCORI). The team developed a patient and caregiver research advisory board with participants from multiple centers, who contributed to the study throughout.

"At the time the grant was awarded, this was one of the largest grants funded by PCORI for palliative care research," says senior author Dr. Navarro, chief clinical officer for the central region of Jefferson Health. "Our patient-centered trial has the ability to significantly transform the patient experience for those suffering with ALD."

The researchers plan to scale the integration of palliative care into routine hepatology practice, by developing standardized training for providers and comprehensive patient education. The team also hopes to leverage artificial intelligence-driven approaches to enhance the adoption and dissemination of the model.

Dr. Verma and Dr. Navarro, both faculty at Sidney Kimmel Medical College, also reiterate that this integrated model could also be extended to other advanced chronic diseases, including chronic heart, kidney and lung disease. With a rapidly aging population and therefore an increased burden of serious illnesses, more than 13.7 million people in the U.S. could benefit from palliative care. The PAL LIVER trial lays the foundation to meet these growing needs.