End-of-life in Hepatocellular Carcinoma How Palliative Care and Social Factors Impact Care and Cost

Objective: Investigate the impacts of palliative care consults, race, and socioeconomic status on the prevalence of invasive procedures in patients with hepatocellular carcinoma (HCC). Background: Palliative care, race, and socioeconomic status can all influence end-of-life care preferences, but their roles in HCC have not been adequately explored. Materials and Methods: This is a cross-sectional study of patients with HCC from 2016 to 2019 using the National Inpatient Sample. Terminal and nonterminal hospitalizations were assessed with logistical regression evaluating associations between palliative care, race, income, and procedures along with do-not-resuscitate orders and cost. Procedures included mechanical ventilation, tracheostomy, and cardiopulmonary resuscitation (CPR) among others. Results: A total of 217,060 hospitalizations in patients with HCC were included, 18.1% of which included a palliative care encounter. The mean age was 65.0 years (SD = 11.3 y), 73.9% were males and 55.5% were white. Procedures were increased in terminal hospitalizations in black [CPR adjusted odds ratio (aOR) = 2.57, P < 0.001] and Hispanic patients (tracheostomy aOR = 3.64, P = 0.018) compared with white patients. Palliative care encounters were associated with reduced procedures during terminal hospitalizations (mechanical ventilation aOR = 0.47, P < 0.001, CPR aOR = 0.24, P < 0.001), but not in nonterminal hospitalizations. No association between income and end-of-life procedures was found. Palliative care was associated with decreased mean cost in terminal ($23,608 vs $31,756, P < 0.001) and nonterminal hospitalizations ($15,786 vs $19,914, P < 0.001). Conclusions: Palliative care is associated with less aggressive end-of-life care and decreased costs in patients with HCC. Black and Hispanic race were both associated with more aggressive end-of-life care.