The writing was on the wall: Decision making near the end of life in advanced liver disease.

The important role of palliative care in the management of end stage liver disease is now well established, but a number of barriers related to physicians and patients may still impede timely referral. In this article, an anonymised patient's clinical course is described, one which ends in what most would regard as a 'bad death'. This despite the fact that his history clearly indicated a poor prognosis. The reasons behind the clinical decision to escalate care are explored in light of current evidence. These include increasing optimism around the utility of organ support, lack of consensus around use of prognostic scores, examples of liberal approaches to transplantation for alcoholic hepatitis and acute-on-chronic liver disease, the transplant imperative, and patient preference. A case is made that if a patient has expressed a clear preference to pursue life-sustaining treatment, there will be occasions where a 'bad death' is morally acceptable. It is concluded that palliative care should be integral to the care of patients with advanced liver disease, but that hepatologists should be upskilled and become more comfortable around clinical uncertainty. [ABSTRACT FROM AUTHOR]