Palliative care engagement, advance care planning, and healthcare utilization in hepatobiliary malignancies.

Abstract

e24046 Background: Although advance care planning (ACP) is central to goal-concordant oncology care, its implementation in clinical practice is often absent or delayed, particularly in hepatobiliary cancers, where symptom burden is high and there are complex care needs. We examined how palliative care involvement relates to ACP documentation and healthcare utilization in patients with hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA). Methods: We conducted a retrospective cohort study of adults with advanced HCC or CCA evaluated at a tertiary hepatobiliary oncology clinic (2023-2025). The primary exposure was palliative care involvement (ever vs never) with referral timing categorized as early or late based on the median time from first oncology visit. Primary outcomes were advance directive documentation and any code-status update after the initial oncology visit. Group comparisons used Chi-squared/Fisher’s exact tests and Wilcoxon rank-sum tests for continuous variables. Results: Among HCC patients (n = 252), those seen by palliative care had higher rates of ACP documentation, including advance directives (69.6% vs. 32.5% p < 0.001) and code-status updates (60.9% vs. 13.2% p < 0.001). Patients who received palliative care had higher total hospital days (median 14.2 vs 6.45 p < 0.001) and a greater number of hospitalizations (median 2.5 vs 2.0, p < 0.001), while ICU admission rates, ICU days, and emergency department visits did not differ significantly between groups. Among patients who received palliative care, later referral was associated with a higher likelihood of hospitalization (97.1% vs 82.6%, p = 0.009) and a longer time from first oncology visit to hospitalization (median 159.0 vs 34.6 days, p < 0.001). Among patients with CCA (n = 122), palliative care involvement was associated with higher rates of advanced directives (73.7% vs 43.5% p = 0.002) and code-status updates (56.6% vs 17.4% p < 0.001). Patients seen by palliative care were more likely to be hospitalized (92.1% vs 60.9%, p < 0.001) and had more total hospital days (median 19.0 vs 8.0 days, p = 0.015), while other utilization metrics were similar. Conclusions: Across HCC and CCA, palliative care engagement was strongly associated with improved ACP documentation following the first oncology visit. Higher hospitalization rates among patients seen by palliative care likely reflect referral bias towards those with greater symptom burden and complexity. These findings overall support the early integration of palliative care alongside oncology care to normalize ACP and ensure alignment with patient goals.