Background and Aims: Palliative care referral for end-stage liver disease (ESLD) is uncommon and usually occurs late. We aimed to review the rate of early palliative care referral (EPCR) in ESLD patients, its associations, and its impacts on resource utilization and survival. Methods: A retrospective review of all patients with ESLD admitted to a single Hepatology Unit between 2013 and 2016. Inclusion criteria for study entry were at least two admissions for decompensated liver disease within a 6-month period and not eligible for liver transplantation. The EPCR group was defined as those patients who received palliative care referral at least 30 days prior to mortality. Results: A total of 74 patients were included in the study. EPCR rate was 19%. On multivariate analysis, EPCR was associated with hepatocellular carcinoma (OR 4.47, 95% CI 1.02-19.5, P = 0.047) and negatively associated with alcoholic liver disease (OR 0.16, 95% CI 0.032-0.88 P = 0.035). There was no difference in survival based on EPCR status. Hospitalization costs were lower in the EPCR group (P = 0.027). There was also a significantly lower number of endoscopies (P = 0.009) and blood transfusions (P = 0.001) in the EPCR group. EPCR was also associated with higher rates of outpatient palliative care and advanced care planning. Conclusions: EPCR in ESLD was uncommon and associated with hepatocellular carcinoma and lack of alcoholic liver disease. EPCR was associated with decreased resource utilization and further high quality studies are required to confirm the benefits of EPCR in ESLD.

BackgroundEvidence exists for the use of palliative sedation for people approaching the last days of life with refractory and intolerable symptoms. It is a third-line intervention that deliberately lowers the conscious state to relieve intolerable and refractory symptoms. This level of intervention is not routinely used in primary care, and there is a lack of guidelines for palliative sedation in this context. ObjectiveThis article provides some key information about palliative sedation and global issues faced by all individuals involved. A tertiary centre case study is used to illustrate the key points. Given this form of therapy may be required for palliative patients in the community, another aim of this article is to provide an overview for primary care practitioners to raise their awareness of such therapy and the issues related to it.

How can we help people achieve their own goals with limited life expectancies? This is the "art of the possible" in palliative care. Patients with a range of diagnoses are incredibly consistent in their expectations: "please manage my physical symptoms (not as an end in itself and without affecting the clarity of my thinking or communication) so that I can do the other things that are important in my life"-meaningful time with family and friends, and physical independence for as long as possible. Each aspect of personhood (physical, emotional, social, sexual and existential) is important at differing levels for every person as he/ she faces a life-limiting illness. Palliative care is the ultimate personalised medicine when we seriously seek to address patients' priorities.

Background: Diabetes is increasingly prevalent globally, including in palliative care. Guidelines vary as to the ideal glycemic goals for patients near the end of life. The relationship between hyperglycemia and attributable symptoms late in life remains ill defined. Objective: To pilot the association between blood glucose level (BGL) and symptoms (nausea, fatigue, pain, and appetite) and mortality in palliative care patients with diabetes. Design: This prospective observational consecutive cohort study consisted of 17 patients with diabetes admitted to an inpatient palliative care unit. Repeat measures of BGL and symptom distress scores using the patientreported Symptom Assessment Scale (SAS) were recorded during a five-month period as was patient mortality. The association between BGL and SAS domains was assessed using negative binomial regression and the association between mortality and high versus low BGL was determined using log-rank statistics and Kaplan-Meier curves. Results: All patients had malignancy: 15 had type 2 diabetes and 2 had steroid-induced diabetes. A total of 121 patient observation days were included in the analysis. BGL was inversely associated with patient-reported SAS for nausea (incidence rate ratio [IRR] = 0.83, 95% confidence interval [CI] = 0.70-0.99, p = 0.04), but not other symptoms. Insulin usage was also associated with decreased nausea (IRR = 0.24, 95% CI = 0.09-0.60, p = 0.002). Survival did not differ between low-and high-BGL groups. Conclusion: These findings warrant a larger multisite consecutive cohort study and a re-exploration of current clinical practice. Ultimately, interventional trials comparing strict versus more liberal glycemic control on symptom management and survival are the ideal design to better understand differing levels of glycemic control at the end of life.