{"paper_id":"3dceca9f-404e-4a8a-ba63-07c9006b3e4b","body_text":"Integrating Palliative Care in End-Stage Liver Disease: A Multidisciplinary Perspective on Communication, Terminology, and Educational Gaps | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Integrating Palliative Care in End-Stage Liver Disease: A Multidisciplinary Perspective on Communication, Terminology, and Educational Gaps Nivetha Saravanan, Daniel Ganger, Kenny Chen, Rachel Orbuch, Amanda Pirola, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7871200/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background End-stage liver disease (ESLD) carries a high symptom burden and mortality, yet palliative care (PC) is often introduced late. Timely, needs-based PC integration remains inconsistent and multidisciplinary perspectives poorly understood. Measures: We surveyed 55 clinicians across five specialties (transplant hepatology, transplant surgery, gastroenterology, general internal medicine, and palliative care) at a single academic institution in Chicago, IL. Domains included timing of PC referral, symptom management comfort, terminology preferences, perceived barriers, and role clarity. Intervention: A cross-sectional survey administered via REDCap evaluated attitudes toward PC integration and interdisciplinary role delineation in ESLD care. Outcomes: 89% of respondents endorsed PC for transplant-ineligible patients, though opinions varied on pre-transplant integration. Significant specialty-based differences emerged in perceived barriers, symptom management confidence and PC ownership. PC clinicians reported the highest confidence across symptom domains, while transplant providers reported discomfort with advance care planning and complex symptom management. Divergent views on use of long-term abdominal drains and role ownership highlighted variability in clinical priorities, practice pattern, and threshold for intervention. Conclusions/Lessons: Despite broad support for PC in advanced ESLD, integration remains limited by role uncertainty, training gaps, and stigma. Specialty-specific discomfort with holistic assessment and symptom management underscores the need for targeted education and co-management models. Enhanced collaboration and role clarity are critical to ensure equitable PC access across the ESLD trajectory. Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction End-stage liver disease (ESLD) represents the terminal phase of chronic liver disease characterized by progressive hepatic dysfunction, high symptom burden, and unpredictable disease trajectories. 1 While liver transplantation remains the only curative option, many patients are ineligible or face prolonged wait times due to the shortage of donor organs and strict eligibility criteria, thereby leading to significant waitlist attrition and mortality. 2 Despite the complex needs of this population, palliative care (PC), which emphasizes symptom management, psychosocial support, and advance care planning, is often introduced late in the disease course typically after curative options are exhausted. 3 Recent studies underscore that patients with ESLD receive less timely PC involvement despite experiencing symptom burdens comparable to cancer, including fatigue, pain, pruritus, anorexia, anxiety, and encephalopathy. 4 , 5 Integration of PC earlier in the course of ESLD has been associated with improved quality of life, goal-concordant care, reduced healthcare utilization. 6 Unfortunately, multilevel barriers exist including prognostic uncertainty, unfavorable social determinants of health, lack of resources, knowledge, and awareness from both patient and health care teams. While several studies have explored these barriers, 7,8 none have focused on nuanced dynamics of multispecialty clinician perspectives that influence care delivery. Existing literature largely reflects single- or dual-specialty viewpoints, offering an incomplete picture of multispecialty care barriers in ESLD. 9 , 10 This preliminary study addresses an important and currently under-explored area. It is the first to comprehensively examine multispecialty clinician perspectives, including those of transplant hepatologists, transplant surgeons, general gastroenterologists (GI), general internal medicine (GIM) clinicians, and PC clinicians in a single study. Given the complexity of ESLD management, which requires coordinated input across multiple specialties, understanding how each group perceives PC is critical for identifying communication gaps, aligning care goals, and designing scalable interventions. By offering a multidimensional view of clinician attitudes, comfort, and knowledge, this study addresses a key knowledge gap and lays the foundation for team-based strategies to improve the timing and quality of PC in ESLD. Methods Study Population Approximately 150 eligible clinicians were identified using an institution-specific internal directory. To qualify for the study, clinicians needed to have provided direct care to adult (age 18 years or older) patients with ESLD within the last 12 months. Survey Instrument : The survey consisted of six domains: (1) clinician role and specialty, (2) timing of PC integration, (3) perceptions of PC appropriateness, (4) terminology preferences between “palliative care” and “supportive care,” (5) comfort with symptom management, and (6) perceived barriers to PC implementation. Items were adapted from a national survey conducted by Ufere et al. in 2019 and study investigators (NS, DG, JH) completed expert content analysis to refine the questionnaire to ensure its content validity. We eliminated three demographic questions to maintain confidentiality given smaller sample size. Survey Administration The survey was administered between September 2024 and January 2025. We sent participants personalized invitations through email to complete the survey using individualized links to the web-based survey through Research Electronic Data Capture (REDCap), a password protected survey tool. Participation was voluntary and uncompensated. A total of four survey reminders were sent in 1-month increments. Statistical Analysis Responses were analyzed using descriptive statistics and stratified by specialty. The Likert scale was converted into a score (1 = strongly disagree, 5 = strongly agree). Categorical variables were reported using frequencies and percentages. Due to small sample sizes and categorical nature of the variables, Fisher’s exact test was used for comparisons. We acknowledged the limitations of this approach in multi-group settings and potential for low power. Findings should be interpreted with caution. Null hypothesis was that there was no difference between clinician specialties in their belief patterns, and alternate hypothesis was that there was at least one specialty with a significantly different belief pattern. We considered a p-value < 0.05 to be statistically significant. All statistical tests were performed in R version 4.2.2. Results Cohort Demographics : A total of 55 clinicians responded (response rate: 37%). The specialty distribution of respondents closely mirrored the composition of clinicians involved in ESLD care at our institution. Clinicians were involved in caring for patients with ESLD at multiple stages of care including 73% (n = 40) pre-transplant, 49% (n = 27) referred for liver transplant, 64% (n = 35) listed for liver transplant, 58%(n = 32) post-liver transplant, 89% (n = 49) transplant ineligible. Timing of PC Utilization Most clinicians agreed PC is critical for transplant-ineligible patients (89%). Significant variation was observed in views on pre-transplant PC referral (p = 0.027). This supports existence of incongruent beliefs, particularly around the timing of PC integration during transplant evaluation among multispecialty clinicians. [Figure 1 ]. Perceived Barriers to PC Implementation Most specialties agreed widely regarding existing barriers. Meaningful differences emerged between specialties in unrealistic caregiver expectations about prognosis or survival (p = 0.005) and lack of PC expertise in managing the symptoms of patients with ESLD (p = 0.006). [Figure 2 ]. Symptom Management Confidence Comfort managing ESLD symptoms varied significantly by specialty. PC clinicians expressed near-universal confidence managing pain, dyspnea, pruritis, and psychosocial distress. Transplant hepatologists were confident managing hepatic encephalopathy and pruritis but less so with pain and dyspnea. Notably, only a minority of GI, transplant hepatologists, and transplant surgeons felt comfortable assessing goals and symptom management. GIM clinicians were more confident assessing patient needs than managing complex symptoms. Confidence in managing sexual dysfunction was low across all specialties. Additionally, perspectives differed regarding the use of long-term abdominal drains (LTADs). All transplant hepatologists typically reserved LTADs for patients receiving palliative or hospice care whereas 69% of PC clinicians endorsed broader use. This discrepancy may reflect differences in clinical priorities or thresholds for intervention, working knowledge, and practice patterns between the two specialties. [Figure 3 ]. Sense of Ownership Over Addressing PC Issues: Transplant hepatologists (p = 0.031) and GIM clinicians (p = 0.0023) felt PC clinicians were better suited to deliver PC to patients with ESLD. In contrast, GI, PC, and transplant surgery clinicians showed no statistically significant preference between PC and hepatology clinicians suggesting potential role ambiguity in who is primarily responsible for providing PC in ESLD. [Figure 4 ]. Discussion This study highlights important interprofessional differences in perceptions, comfort, and practice regarding PC integration for patients with ESLD. Our findings suggest that early PC integration remains hindered by clinical culture, unclear role delineation, and ongoing discomfort with perceived implications of PC involvement. Addressing these challenges is critical to ensuring equitable and timely access to high-quality, patient-centered care for patients with ESLD across the disease spectrum. A key finding is the disparity in primary PC skills among disciplines. GIM clinicians and PC clinicians reported high levels of comfort with symptom management and communication tasks, whereas transplant-focused clinicians expressed lower confidence. This discomfort may reflect limited formal training in primary PC competencies during subspecialty education. Comparatively, PC clinicians may have varying exposure to the complexities of liver disease trajectories, potentially contributing to transplant clinicians’ concerns about disease-specific knowledge among PC teams. These asymmetries in expertise can lead to fragmented and missed opportunities for collaboration. Structured co-management models, shared educational initiatives, and regular interdisciplinary case discussion may address these gaps and are under current study by LiverPAL trial (NCT05998330). 11 Efforts to standardize PC integration in ESLD are complicated by the clinical heterogeneity of the disease itself. 12 In our study, ESLD was operationalized as cirrhosis in the presence of at least one complication: ascites, hepatic encephalopathy, variceal hemorrhage, or jaundice. Clinicians may interpret the significance of these features differently based on disease trajectory and treatment response. For example, a patient with stable F2 varices may have minimal PC needs versus a patient with refractory ascites may prompt a more urgent consideration of supportive services. 13 These variations in disease framing likely influenced how respondents understood and answered survey items. Future studies may benefit from stratifying response by disease severity or incorporating clinical vignettes. Several study limitations must be acknowledged. The survey response rate was low, limiting generalizability even within a single academic institution. Additionally, the ambiguous survey question phrasing, as evidenced above, may have introduced interpretive challenges and reduced response reliability. Future studies should employ more rigorous survey design methodologies, including cognitive interviewing and item validation, to enhance clarity and reduce bias. Broader sampling across institutions and care settings, along with inclusion of additional stake holders such as patients, caregivers, and non-clinician team members will be essential to build a more comprehensive understanding of multidisciplinary barriers and facilitators to PC integration. This study is the first investigation to examine perspectives across diverse clinical specialties involved in the management of ESLD. Despite its exploratory nature, the findings point to broadly applicable themes and actionable strategies. Moving forward, institutions should develop structured co-management models that foster early collaboration, implement bi-directional educational curricula to strengthen both liver disease-specific and generalized PC competencies, standardize referral criteria or triggers, and enhance role clarity. Future research should expand this work to a national scale and examine how clinician perspectives translate into practice. Ultimately earlier, targeted, and more consistent integration of PC has the potential to improve quality of life and care experiences for patients across the ESLD continuum. Declarations Ethics Approval and Consent to Participate: This study was reviewed and approved by the Northwestern University Institutional Review Board (STU00221461). All participants were practicing clinicians who provided informed consent prior to participation. All study procedures were conducted in accordance with the Declaration of Helsinki and institutional ethical standards. Consent for Publication Not applicable. This manuscript does not contain any individual person’s data in any form (including individual details, images, or videos). Competing Interests The authors declare that they have no competing interests. Funding Statement None Author Contribution NS: Conceptualization, Methodology, Writing – Original Draft. DG: Conceptualization, Methodology, Writing – Review & Editing. KC: Formal Analysis. RO: Writing – Review & Editing. AP: Writing – Review and Editing. AC: Writing – Review and Editing. JH: Writing – Review and Editing. LZ: Formal Analysis. Data Availability The datasets generated and/or analyzed during the current study are not publicly available due to ethical and confidentiality restrictions related to participant privacy but are available from the corresponding author on reasonable request and with approval from the Northwestern University Institutional Review Board. References Rogal SS, Hansen L, Patel A, Ufere NN, Verma M, Woodrell CD, et al. AASLD Practice Guidance: Palliative care and symptom-based management in decompensated cirrhosis. Hepatology. 2022;76(3):819–53. Fricker ZP, Serper M, Current, Knowledge. Barriers to Implementation, and Future Directions in Palliative Care for End-Stage Liver Disease. Liver Transpl. 2019;25(5):787–96. Chen H, Johnston A, Palmer A, Mickenbecker M, O'Sullivan T, Clark P. Too little, too late: Palliation and end-stage liver disease. J Gastroenterol Hepatol. 2021;36(8):2303–6. Akhras A, Nabi S, Santana K, et al. Evaluating the Impact of Early Palliative Care Consultation on 30-Day and 90-Day Readmissions Among Patients With Decompensated Cirrhosis: A National Perspective. J Clin Gastroenterol Published online August. 2025;20. 10.1097/MCG.0000000000002235 . Shehadah A, Yu Naing L, Bapaye J, et al. Early palliative care referral may improve end-of-life care in end-stage liver disease patients: A retrospective analysis from a non-transplant center. Am J Med Sci. 2024;367(1):35–40. 10.1016/j.amjms.2023.10.006 . Mafi VIP, Soldera J. Palliative care for end-stage liver disease and acute on chronic liver failure: A systematic review. World J Methodol. 2024;14(4):95904. 10.5662/wjm.v14.i4.95904 . Published 2024 Dec 20. Kanagalingam G, Allen J, Chin GH, Lee HM. Palliative care & chronic liver disease: barriers to care, health disparities & the role of health literacy. Ann Palliat Med. 2025;14(4):353–68. 10.21037/apm-25-15 . Hasjim BJ, Harris A, Balbale SN, et al. Social Disadvantage and Disparities in Chronic Liver Disease: A Systematic Review. Am J Gastroenterol. 2024;120(7):1548–66. 10.14309/ajg.0000000000003171 . Published 2024 Oct 30. Ufere NN, Donlan J, Waldman L, Patel A, Dienstag JL, Friedman LS, et al. Physicians' Perspectives on Palliative Care for Patients With End-Stage Liver Disease: A National Survey Study. Liver Transpl. 2019;25(6):859–69. Oliveira HM, Ramos JP, Rego F, Nunes R. Palliative care and end stage liver disease: A survey study comparing perspectives of hepatology and palliative care physicians and clinical scenarios that could require palliative care intervention. Clin Res Hepatol Gastroenterol. 2024;48(7):102416. 10.1016/j.clinre.2024.102416 . Massachusetts General Hospital. LiverPAL: A Trial of Inpatient Palliative Care for Patients With Advanced Liver Disease ; NCT05998330. ClinicalTrials.gov. https://clinicaltrials.gov/study/NCT05998330 . Published August 18, 2023. Accessed [September 16, 2025]. Mafi VIP, Soldera J. Palliative care for end-stage liver disease and acute on chronic liver failure: A systematic review. World J Methodol. 2024;14(4):95904. 10.5662/wjm.v14.i4.95904 . Published 2024 Dec 20. Kusztos V. ACLF: A Tipping Point in Chronic Liver Disease. Liver Fellow Network, AASLD. April 14, 2025. Accessed September 16, 2025. https://www.aasld.org/liver-fellow-network/core-series/back-basics/aclf-tipping-point-chronic-liver-disease Additional Declarations No competing interests reported. Supplementary Files SaravananSupplementalSurvey.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 10 Nov, 2025 Reviews received at journal 07 Nov, 2025 Reviews received at journal 03 Nov, 2025 Reviewers agreed at journal 30 Oct, 2025 Reviewers agreed at journal 29 Oct, 2025 Reviewers agreed at journal 29 Oct, 2025 Reviewers invited by journal 29 Oct, 2025 Editor invited by journal 21 Oct, 2025 Editor assigned by journal 17 Oct, 2025 Submission checks completed at journal 17 Oct, 2025 First submitted to journal 15 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-7871200\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":541937328,\"identity\":\"82358e9a-2d4c-4ad9-9add-996cf94f24a9\",\"order_by\":0,\"name\":\"Nivetha 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16:37:24\",\"extension\":\"png\",\"order_by\":11,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":48154,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Onlinefloatimage4.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7871200/v1/0cb0752ad92167da1fc55330.png\"},{\"id\":95662051,\"identity\":\"24e92fd7-1689-4d9b-aeab-863ad2d820af\",\"added_by\":\"auto\",\"created_at\":\"2025-11-11 16:37:06\",\"extension\":\"xml\",\"order_by\":12,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":48537,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"77dc3025e7ff484f8688911822131cfe1structuring.xml\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7871200/v1/970d31b6089df6ea30235633.xml\"},{\"id\":95662353,\"identity\":\"029c1d84-8ce1-4cb9-b443-0ac0bd112b47\",\"added_by\":\"auto\",\"created_at\":\"2025-11-11 16:37:26\",\"extension\":\"html\",\"order_by\":13,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":57803,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"earlyproof.html\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7871200/v1/0f8c307d6c01d70ca2fbe373.html\"},{\"id\":95661883,\"identity\":\"301aa9d8-80b6-4f4c-99de-63b79048cf54\",\"added_by\":\"auto\",\"created_at\":\"2025-11-11 16:36:58\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":1180017,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eTiming of PC Integration in the Management of ESLD\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis figure displays clinician-reported preferences for when PC should be introduced across various stages of ESLD. The responses are stratified by specialty. Cell shading reflects the gradation of responses with darker shades indicating higher frequency of response rate. This visual ‘heat map’ is intended to aid rapid pattern recognition. All numeric values are also shown for clarity. For analysis of responses related to timing of PC integration, Fisher's exact test was applied individually at each disease stage to assess whether perceptions of PC timing different significantly across clinical specialties. Specifically, four separate 2x4 contingency tables were constructed – one for each disease stage (i.e. new diagnosis, pre-transplant evaluation, actively listed, transplant ineligible) – to evaluate differences in response distributions among specialties. The table pictured condenses the results of four 2x4 tables into one grand table. The last column, \\\"all clinicians\\\" column was not used in outcome analysis.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7871200/v1/8eed413f38177181c341fd37.png\"},{\"id\":95661740,\"identity\":\"1b5339d1-cb18-45fe-b4dc-3e32c26b32ee\",\"added_by\":\"auto\",\"created_at\":\"2025-11-11 16:36:48\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":1763863,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eClinician-Perceived Barriers to the Integration of Palliative Care in ESLD\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis figure summarizes the key barriers identified by clinicians regarding the integration of PC into ESLD management. Results are stratified by specialty to elucidate differing perspectives and systemic challenges faced by various disciplines. Cell shading reflects the gradation of responses with darker shades indicating higher frequency of response rate. This visual ‘heat map’ is intended to aid rapid pattern recognition. All numeric values are also shown for clarity.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7871200/v1/a6dd8d475d580bc130fc0103.png\"},{\"id\":95662127,\"identity\":\"0950ff39-32ab-48ec-be47-5acd110afeb8\",\"added_by\":\"auto\",\"created_at\":\"2025-11-11 16:37:12\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":1341888,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eClinician-Reported Comfort and Knowledge in Delivering PC for Patients with ESLD\\u003c/strong\\u003e\\u003cbr\\u003e\\nPresented here are clinicians’ self-assessments of their comfort and knowledge in managing symptom management and advanced care planning for ESLD patients. The data are categorized by specialty, providing a comparative view of perceived clinical preparedness. Cell shading reflects the gradation of responses with darker shades indicating higher frequency of response rate. This visual ‘heat map’ is intended to aid rapid pattern recognition. All numeric values are also shown for clarity.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7871200/v1/60479399b4e5553f3b7bc0c3.png\"},{\"id\":95662126,\"identity\":\"d35cc317-b5cf-4f74-9deb-a61e8a6ef4f9\",\"added_by\":\"auto\",\"created_at\":\"2025-11-11 16:37:12\",\"extension\":\"png\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":615249,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eClinician Perspectives on Ownership of Palliative Care Delivery in ESLD\\u003c/strong\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003eThis figure explores clinician opinions regarding which specialty is best suited to deliver PC to patients with ESLD, either PC clinicians or hepatologists. Responses are categorized by specialty group\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image4.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7871200/v1/cf2b5becee6f6c9636cfe1b0.png\"},{\"id\":95663628,\"identity\":\"3a09e1d8-090c-414f-8757-4dbd47fd71c3\",\"added_by\":\"auto\",\"created_at\":\"2025-11-11 16:39:11\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":5902607,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7871200/v1/5ef5493f-3ab9-4042-8295-129d49ba39d2.pdf\"},{\"id\":95662290,\"identity\":\"b5912cfe-67d8-4c27-b7ca-a8462d305969\",\"added_by\":\"auto\",\"created_at\":\"2025-11-11 16:37:20\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":69051,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SaravananSupplementalSurvey.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7871200/v1/a7ff7ef616966beb6c3adf61.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Integrating Palliative Care in End-Stage Liver Disease: A Multidisciplinary Perspective on Communication, Terminology, and Educational Gaps\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eEnd-stage liver disease (ESLD) represents the terminal phase of chronic liver disease characterized by progressive hepatic dysfunction, high symptom burden, and unpredictable disease trajectories.\\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u003c/sup\\u003e While liver transplantation remains the only curative option, many patients are ineligible or face prolonged wait times due to the shortage of donor organs and strict eligibility criteria, thereby leading to significant waitlist attrition and mortality.\\u003csup\\u003e\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e\\u003c/sup\\u003e Despite the complex needs of this population, palliative care (PC), which emphasizes symptom management, psychosocial support, and advance care planning, is often introduced late in the disease course typically after curative options are exhausted.\\u003csup\\u003e\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eRecent studies underscore that patients with ESLD receive less timely PC involvement despite experiencing symptom burdens comparable to cancer, including fatigue, pain, pruritus, anorexia, anxiety, and encephalopathy.\\u003csup\\u003e\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u003c/sup\\u003e Integration of PC earlier in the course of ESLD has been associated with improved quality of life, goal-concordant care, reduced healthcare utilization.\\u003csup\\u003e\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e\\u003c/sup\\u003e Unfortunately, multilevel barriers exist including prognostic uncertainty, unfavorable social determinants of health, lack of resources, knowledge, and awareness from both patient and health care teams. While several studies have explored these barriers,\\u003csup\\u003e7,8\\u003c/sup\\u003e none have focused on nuanced dynamics of multispecialty clinician perspectives that influence care delivery. Existing literature largely reflects single- or dual-specialty viewpoints, offering an incomplete picture of multispecialty care barriers in ESLD.\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eThis preliminary study addresses an important and currently under-explored area. It is the first to comprehensively examine multispecialty clinician perspectives, including those of transplant hepatologists, transplant surgeons, general gastroenterologists (GI), general internal medicine (GIM) clinicians, and PC clinicians in a single study. Given the complexity of ESLD management, which requires coordinated input across multiple specialties, understanding how each group perceives PC is critical for identifying communication gaps, aligning care goals, and designing scalable interventions. By offering a multidimensional view of clinician attitudes, comfort, and knowledge, this study addresses a key knowledge gap and lays the foundation for team-based strategies to improve the timing and quality of PC in ESLD.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eStudy Population\\u003c/strong\\u003e\\u003cp\\u003eApproximately 150 eligible clinicians were identified using an institution-specific internal directory. To qualify for the study, clinicians needed to have provided direct care to adult (age 18 years or older) patients with ESLD within the last 12 months.\\u003c/p\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eSurvey Instrument\\u003c/b\\u003e: The survey consisted of six domains: (1) clinician role and specialty, (2) timing of PC integration, (3) perceptions of PC appropriateness, (4) terminology preferences between \\u0026ldquo;palliative care\\u0026rdquo; and \\u0026ldquo;supportive care,\\u0026rdquo; (5) comfort with symptom management, and (6) perceived barriers to PC implementation. Items were adapted from a national survey conducted by Ufere et al. in 2019 and study investigators (NS, DG, JH) completed expert content analysis to refine the questionnaire to ensure its content validity. We eliminated three demographic questions to maintain confidentiality given smaller sample size.\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eSurvey Administration\\u003c/strong\\u003e\\u003cp\\u003eThe survey was administered between September 2024 and January 2025. We sent participants personalized invitations through email to complete the survey using individualized links to the web-based survey through Research Electronic Data Capture (REDCap), a password protected survey tool. Participation was voluntary and uncompensated. A total of four survey reminders were sent in 1-month increments.\\u003c/p\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eStatistical Analysis\\u003c/strong\\u003e\\u003cp\\u003eResponses were analyzed using descriptive statistics and stratified by specialty. The Likert scale was converted into a score (1\\u0026thinsp;=\\u0026thinsp;strongly disagree, 5\\u0026thinsp;=\\u0026thinsp;strongly agree). Categorical variables were reported using frequencies and percentages. Due to small sample sizes and categorical nature of the variables, Fisher\\u0026rsquo;s exact test was used for comparisons. We acknowledged the limitations of this approach in multi-group settings and potential for low power. Findings should be interpreted with caution. Null hypothesis was that there was no difference between clinician specialties in their belief patterns, and alternate hypothesis was that there was at least one specialty with a significantly different belief pattern. We considered a p-value\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05 to be statistically significant. All statistical tests were performed in R version 4.2.2.\\u003c/p\\u003e\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eCohort Demographics\\u003c/strong\\u003e: A total of 55 clinicians responded (response rate: 37%). The specialty distribution of respondents closely mirrored the composition of clinicians involved in ESLD care at our institution. Clinicians were involved in caring for patients with ESLD at multiple stages of care including 73% (n\\u0026thinsp;=\\u0026thinsp;40) pre-transplant, 49% (n\\u0026thinsp;=\\u0026thinsp;27) referred for liver transplant, 64% (n\\u0026thinsp;=\\u0026thinsp;35) listed for liver transplant, 58%(n\\u0026thinsp;=\\u0026thinsp;32) post-liver transplant, 89% (n\\u0026thinsp;=\\u0026thinsp;49) transplant ineligible.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTiming of PC Utilization\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eMost clinicians agreed PC is critical for transplant-ineligible patients (89%). Significant variation was observed in views on pre-transplant PC referral (p\\u0026thinsp;=\\u0026thinsp;0.027). This supports existence of incongruent beliefs, particularly around the timing of PC integration during transplant evaluation among multispecialty clinicians. [Figure \\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e].\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePerceived Barriers to PC Implementation\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eMost specialties agreed widely regarding existing barriers. Meaningful differences emerged between specialties in unrealistic caregiver expectations about prognosis or survival (p\\u0026thinsp;=\\u0026thinsp;0.005) and lack of PC expertise in managing the symptoms of patients with ESLD (p\\u0026thinsp;=\\u0026thinsp;0.006). [Figure \\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e].\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSymptom Management Confidence\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eComfort managing ESLD symptoms varied significantly by specialty. PC clinicians expressed near-universal confidence managing pain, dyspnea, pruritis, and psychosocial distress. Transplant hepatologists were confident managing hepatic encephalopathy and pruritis but less so with pain and dyspnea. Notably, only a minority of GI, transplant hepatologists, and transplant surgeons felt comfortable assessing goals and symptom management. GIM clinicians were more confident assessing patient needs than managing complex symptoms. Confidence in managing sexual dysfunction was low across all specialties. Additionally, perspectives differed regarding the use of long-term abdominal drains (LTADs). All transplant hepatologists typically reserved LTADs for patients receiving palliative or hospice care whereas 69% of PC clinicians endorsed broader use. This discrepancy may reflect differences in clinical priorities or thresholds for intervention, working knowledge, and practice patterns between the two specialties. [Figure \\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e].\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch3\\u003eSense of Ownership Over Addressing PC Issues:\\u003c/h3\\u003e\\n\\u003cp\\u003eTransplant hepatologists (p\\u0026thinsp;=\\u0026thinsp;0.031) and GIM clinicians (p\\u0026thinsp;=\\u0026thinsp;0.0023) felt PC clinicians were better suited to deliver PC to patients with ESLD. In contrast, GI, PC, and transplant surgery clinicians showed no statistically significant preference between PC and hepatology clinicians suggesting potential role ambiguity in who is primarily responsible for providing PC in ESLD. [Figure \\u003cspan class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e].\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study highlights important interprofessional differences in perceptions, comfort, and practice regarding PC integration for patients with ESLD. Our findings suggest that early PC integration remains hindered by clinical culture, unclear role delineation, and ongoing discomfort with perceived implications of PC involvement. Addressing these challenges is critical to ensuring equitable and timely access to high-quality, patient-centered care for patients with ESLD across the disease spectrum.\\u003c/p\\u003e\\u003cp\\u003eA key finding is the disparity in primary PC skills among disciplines. GIM clinicians and PC clinicians reported high levels of comfort with symptom management and communication tasks, whereas transplant-focused clinicians expressed lower confidence. This discomfort may reflect limited formal training in primary PC competencies during subspecialty education. Comparatively, PC clinicians may have varying exposure to the complexities of liver disease trajectories, potentially contributing to transplant clinicians\\u0026rsquo; concerns about disease-specific knowledge among PC teams. These asymmetries in expertise can lead to fragmented and missed opportunities for collaboration. Structured co-management models, shared educational initiatives, and regular interdisciplinary case discussion may address these gaps and are under current study by LiverPAL trial (NCT05998330).\\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eEfforts to standardize PC integration in ESLD are complicated by the clinical heterogeneity of the disease itself.\\u003csup\\u003e\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u003c/sup\\u003e In our study, ESLD was operationalized as cirrhosis in the presence of at least one complication: ascites, hepatic encephalopathy, variceal hemorrhage, or jaundice. Clinicians may interpret the significance of these features differently based on disease trajectory and treatment response. For example, a patient with stable F2 varices may have minimal PC needs versus a patient with refractory ascites may prompt a more urgent consideration of supportive services.\\u003csup\\u003e\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u003c/sup\\u003e These variations in disease framing likely influenced how respondents understood and answered survey items. Future studies may benefit from stratifying response by disease severity or incorporating clinical vignettes.\\u003c/p\\u003e\\u003cp\\u003eSeveral study limitations must be acknowledged. The survey response rate was low, limiting generalizability even within a single academic institution. Additionally, the ambiguous survey question phrasing, as evidenced above, may have introduced interpretive challenges and reduced response reliability. Future studies should employ more rigorous survey design methodologies, including cognitive interviewing and item validation, to enhance clarity and reduce bias. Broader sampling across institutions and care settings, along with inclusion of additional stake holders such as patients, caregivers, and non-clinician team members will be essential to build a more comprehensive understanding of multidisciplinary barriers and facilitators to PC integration.\\u003c/p\\u003e\\u003cp\\u003eThis study is the first investigation to examine perspectives across diverse clinical specialties involved in the management of ESLD. Despite its exploratory nature, the findings point to broadly applicable themes and actionable strategies. Moving forward, institutions should develop structured co-management models that foster early collaboration, implement bi-directional educational curricula to strengthen both liver disease-specific and generalized PC competencies, standardize referral criteria or triggers, and enhance role clarity. Future research should expand this work to a national scale and examine how clinician perspectives translate into practice. Ultimately earlier, targeted, and more consistent integration of PC has the potential to improve quality of life and care experiences for patients across the ESLD continuum.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003ch2\\u003eEthics Approval and Consent to Participate:\\u003c/h2\\u003e\\u003cp\\u003e This study was reviewed and approved by the Northwestern University Institutional Review Board (STU00221461). All participants were practicing clinicians who provided informed consent prior to participation. All study procedures were conducted in accordance with the Declaration of Helsinki and institutional ethical standards.\\u003c/p\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003ch2\\u003eConsent for Publication\\u003c/h2\\u003e\\u003cp\\u003eNot applicable. This manuscript does not contain any individual person\\u0026rsquo;s data in any form (including individual details, images, or videos).\\u003c/p\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eCompeting Interests\\u003c/strong\\u003e\\u003cp\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e\\u003c/p\\u003e\\u003ch2\\u003eFunding Statement\\u003c/h2\\u003e\\u003cp\\u003eNone\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eNS: Conceptualization, Methodology, Writing \\u0026ndash; Original Draft. DG: Conceptualization, Methodology, Writing \\u0026ndash; Review \\u0026amp; Editing. KC: Formal Analysis. RO: Writing \\u0026ndash; Review \\u0026amp; Editing. AP: Writing \\u0026ndash; Review and Editing. AC: Writing \\u0026ndash; Review and Editing. JH: Writing \\u0026ndash; Review and Editing. LZ: Formal Analysis.\\u003c/p\\u003e\\u003ch2\\u003eData Availability\\u003c/h2\\u003e\\u003cp\\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to ethical and confidentiality restrictions related to participant privacy but are available from the corresponding author on reasonable request and with approval from the Northwestern University Institutional Review Board.\\u003c/p\\u003e\\n\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eRogal SS, Hansen L, Patel A, Ufere NN, Verma M, Woodrell CD, et al. AASLD Practice Guidance: Palliative care and symptom-based management in decompensated cirrhosis. Hepatology. 2022;76(3):819\\u0026ndash;53.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eFricker ZP, Serper M, Current, Knowledge. Barriers to Implementation, and Future Directions in Palliative Care for End-Stage Liver Disease. Liver Transpl. 2019;25(5):787\\u0026ndash;96.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eChen H, Johnston A, Palmer A, Mickenbecker M, O'Sullivan T, Clark P. Too little, too late: Palliation and end-stage liver disease. J Gastroenterol Hepatol. 2021;36(8):2303\\u0026ndash;6.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eAkhras A, Nabi S, Santana K, et al. Evaluating the Impact of Early Palliative Care Consultation on 30-Day and 90-Day Readmissions Among Patients With Decompensated Cirrhosis: A National Perspective. J Clin Gastroenterol Published online August. 2025;20. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1097/MCG.0000000000002235\\u003c/span\\u003e\\u003cspan address=\\\"10.1097/MCG.0000000000002235\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eShehadah A, Yu Naing L, Bapaye J, et al. Early palliative care referral may improve end-of-life care in end-stage liver disease patients: A retrospective analysis from a non-transplant center. Am J Med Sci. 2024;367(1):35\\u0026ndash;40. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1016/j.amjms.2023.10.006\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.amjms.2023.10.006\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eMafi VIP, Soldera J. Palliative care for end-stage liver disease and acute on chronic liver failure: A systematic review. World J Methodol. 2024;14(4):95904. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.5662/wjm.v14.i4.95904\\u003c/span\\u003e\\u003cspan address=\\\"10.5662/wjm.v14.i4.95904\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. Published 2024 Dec 20.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eKanagalingam G, Allen J, Chin GH, Lee HM. Palliative care \\u0026amp; chronic liver disease: barriers to care, health disparities \\u0026amp; the role of health literacy. Ann Palliat Med. 2025;14(4):353\\u0026ndash;68. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.21037/apm-25-15\\u003c/span\\u003e\\u003cspan address=\\\"10.21037/apm-25-15\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eHasjim BJ, Harris A, Balbale SN, et al. Social Disadvantage and Disparities in Chronic Liver Disease: A Systematic Review. Am J Gastroenterol. 2024;120(7):1548\\u0026ndash;66. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.14309/ajg.0000000000003171\\u003c/span\\u003e\\u003cspan address=\\\"10.14309/ajg.0000000000003171\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. Published 2024 Oct 30.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eUfere NN, Donlan J, Waldman L, Patel A, Dienstag JL, Friedman LS, et al. Physicians' Perspectives on Palliative Care for Patients With End-Stage Liver Disease: A National Survey Study. Liver Transpl. 2019;25(6):859\\u0026ndash;69.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eOliveira HM, Ramos JP, Rego F, Nunes R. Palliative care and end stage liver disease: A survey study comparing perspectives of hepatology and palliative care physicians and clinical scenarios that could require palliative care intervention. Clin Res Hepatol Gastroenterol. 2024;48(7):102416. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1016/j.clinre.2024.102416\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.clinre.2024.102416\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eMassachusetts General Hospital. \\u003cem\\u003eLiverPAL: A Trial of Inpatient Palliative Care for Patients With Advanced Liver Disease\\u003c/em\\u003e; NCT05998330. ClinicalTrials.gov. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://clinicaltrials.gov/study/NCT05998330\\u003c/span\\u003e\\u003cspan address=\\\"https://clinicaltrials.gov/study/NCT05998330\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. Published August 18, 2023. Accessed [September 16, 2025].\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eMafi VIP, Soldera J. Palliative care for end-stage liver disease and acute on chronic liver failure: A systematic review. World J Methodol. 2024;14(4):95904. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.5662/wjm.v14.i4.95904\\u003c/span\\u003e\\u003cspan address=\\\"10.5662/wjm.v14.i4.95904\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. Published 2024 Dec 20.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eKusztos V. \\u003cem\\u003eACLF: A Tipping Point in Chronic Liver Disease.\\u003c/em\\u003e Liver Fellow Network, AASLD. April 14, 2025. Accessed September 16, 2025. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.aasld.org/liver-fellow-network/core-series/back-basics/aclf-tipping-point-chronic-liver-disease\\u003c/span\\u003e\\u003cspan address=\\\"https://www.aasld.org/liver-fellow-network/core-series/back-basics/aclf-tipping-point-chronic-liver-disease\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-palliative-care\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"pcar\",\"sideBox\":\"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/pcar/default.aspx\",\"title\":\"BMC Palliative Care\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7871200/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7871200/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eEnd-stage liver disease (ESLD) carries a high symptom burden and mortality, yet palliative care (PC) is often introduced late. Timely, needs-based PC integration remains inconsistent and multidisciplinary perspectives poorly understood.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMeasures:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe surveyed 55 clinicians across five specialties (transplant hepatology, transplant surgery, gastroenterology, general internal medicine, and palliative care) at a single academic institution in Chicago, IL. Domains included timing of PC referral, symptom management comfort, terminology preferences, perceived barriers, and role clarity.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eIntervention:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA cross-sectional survey administered via REDCap evaluated attitudes toward PC integration and interdisciplinary role delineation in ESLD care.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eOutcomes:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e89% of respondents endorsed PC for transplant-ineligible patients, though opinions varied on pre-transplant integration. Significant specialty-based differences emerged in perceived barriers, symptom management confidence and PC ownership. PC clinicians reported the highest confidence across symptom domains, while transplant providers reported discomfort with advance care planning and complex symptom management. Divergent views on use of long-term abdominal drains and role ownership highlighted variability in clinical priorities, practice pattern, and threshold for intervention.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions/Lessons:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eDespite broad support for PC in advanced ESLD, integration remains limited by role uncertainty, training gaps, and stigma. Specialty-specific discomfort with holistic assessment and symptom management underscores the need for targeted education and co-management models. Enhanced collaboration and role clarity are critical to ensure equitable PC access across the ESLD trajectory.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Integrating Palliative Care in End-Stage Liver Disease: A Multidisciplinary Perspective on Communication, Terminology, and Educational Gaps\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-11-11 16:19:48\",\"doi\":\"10.21203/rs.3.rs-7871200/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2025-11-10T08:01:03+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-11-08T03:37:59+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-11-03T16:16:54+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"275925011107292886427000959131748251203\",\"date\":\"2025-10-30T17:16:05+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"212819937346702291992128064823814784013\",\"date\":\"2025-10-29T15:53:05+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"163230229051460544417601234391954658356\",\"date\":\"2025-10-29T15:38:56+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-10-29T15:35:52+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2025-10-21T08:41:32+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-10-18T00:50:18+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-10-18T00:50:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Palliative Care\",\"date\":\"2025-10-15T19:11:06+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-palliative-care\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"pcar\",\"sideBox\":\"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/pcar/default.aspx\",\"title\":\"BMC Palliative Care\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"6cda7c7b-7dca-40dd-9d06-6fe66fea5679\",\"owner\":[],\"postedDate\":\"November 11th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-11-25T16:38:30+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-11-11 16:19:48\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7871200\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7871200\",\"identity\":\"rs-7871200\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}