In formulating the search strategy, the command employed was as follows: ("end-stage liver disease" OR "ESLD" OR "cirrhosis" OR "acute on-chronic liver failure" OR "liver transplantation" OR "ACLF") AND ("palliative care" OR "end-of-life care" OR "hospice care" OR "palliative medicine" OR "comfort care"). The searches were conducted in September 2023, utilizing the electronic databases Medline (PubMed) and Google Scholar.

No constraints were placed on the date of publication, facilitating a thorough exploration of both historical and contemporary literature. However, language restrictions were implemented, confining the search to studies published in the English language. The inclusion of studies in the review adhered to the predefined Patients, Intervention, Comparison, Outcome criteria, ensuring a methodologically rigorous selection process.

For this systematic review, studies focusing on patients with ESLD exhibiting evidence of at least one of the following criteria were considered for inclusion: Liver cirrhosis accompanied by a clinical manifestation of decompensation; liver cirrhosis designated for LT; liver cirrhosis undergoing evaluation for LT; liver cirrhosis characterized by a Child-Turcotte-Pugh (CTP) classification predominantly falling within category B or C within the study's cohort (Child A ≤ 40%, or mean/median CTP score > 7); patients depicted with chronic and advanced liver ailments referred for LT evaluation.

On the other hand, studies were excluded if they were composed in languages other than English, involved participants below 18 years of age, pertained to acute hepatic failure, focused on metabolic liver disorders, included patients awaiting both liver and kidney transplantation, constituted editorials, comments, and anecdotal reports, or involved a combination of cirrhotic and non-cirrhotic subjects. Additionally, failure to access the complete texts of studies or inherent elevated bias risk served as grounds for exclusion.

The initial screening of studies retrieved through the search command, focusing on titles and abstracts, aimed to discern papers aligned with the predefined inclusion criteria. It was imperative to exclude studies that did not adhere to the inclusion criteria, particularly those categorized as reviews and guidelines. This rigorous screening process ensured the selection of studies that distinctly met the criteria, fostering precision and relevance in the ensuing stages.

Following the preliminary screening, the abstracts of the short-listed studies underwent a comprehensive review to ascertain their potential relevance to the research objectives. This step involved a meticulous evaluation to further refine the selection, considering the depth and specificity of each study in relation to the research focus.

The final screening phase involved a detailed assessment of the full-length papers, emphasizing the meticulous elimination of studies that did not align with the predefined inclusion criteria. This thorough scrutiny aimed to uphold the scientific rigor of the study by ensuring that the selected papers contribute meaningfully to the research objectives.

Subsequently, a comprehensive analysis of each eligible study was conducted, facilitating the standardized extraction of essential data encompassing population characteristics, study design, structural elements, results, and a concise summary. This systematic data extraction process served as a foundation for the subsequent quantitative and qualitative analysis.

The extracted data was meticulously tabulated to facilitate a structured and organized representation, enabling the identification of emerging trends and patterns within the selected studies.

Two experimental studies in patients with ESLD assessed the impact of specialist PC interventions. Shinall et al[9] conducted a randomized controlled trial (RCT) revealing that patients receiving PC had a lower hazard of readmission [hazard ratio (HR) = 0.36, 95%CI: 0.16-0.83, P = 0.017] and more days alive outside hospital (odds ratio = 3.97, 95%CI: 1.14-13.84, P = 0.030). However, this trial faced enrollment issues, ending prematurely with only 34% participation[9]. Bauman et al[6] highlighted underutilization of PC due to a lack of appropriate assessment tools for ESLD symptoms. They introduced an early PC intervention (EPCI), showing a 50% reduction in symptom burden (P < 0.05) and 43% reduction in depressive symptoms in ESLD patients awaiting LT. Limitations included a small sample size and limited follow-up, suggesting a need for future studies with larger samples and longer follow-up to validate EPCI benefits[6].

Several retrospective observational studies focused on assessing PC utilization and outcomes in patients with ESLD and related conditions were reviewed.

Gupta et al[10] found that inpatient PC consultation reduced 30-day readmission rates and hospital stays in alcohol-associated liver disease patients with ACLF scores ≥ 2, despite study limitations due to its retrospective nature. This study highlights the impact of PC on reducing healthcare utilization in specific ESLD subgroups.

Poonja et al[11] highlighted that many DC patients declined or delisted for LT were infrequently referred for PC, emphasizing the need for better symptom management tools and LT-PC partnership to enhance quality of life. The study identified prevalent symptoms among this patient population, underscoring the unmet need for comprehensive PC.

Lin et al[12] demonstrated machine learning's predictive capabilities in managing ESLD, aiding in mortality prediction and patient classification for acute or PC needs, with implications for wider use and validation across ethnicities. This study introduces innovative technology for improving risk stratification and personalized care in ESLD.

Puentes et al[13] revealed critical mortality rates among ESLD patients, emphasizing the practical use of Child-Pugh and MELD-Na scores for identifying PC candidates. These scoring systems serve as valuable tools for PC decision-making in ESLD.

Hudson et al[14] proposed prognostic screening tools for early intervention in cirrhotic patients upon hospital admission, offering a universally applicable strategy. This study proposes a practical approach to identifying high-risk ESLD patients for timely intervention.

Medici et al[15] emphasized the MELD score's potential utility for implementing PC, with acknowledgment of retrospective study limitations. The MELD score emerges as a practical clinical tool for guiding PC referrals in ESLD patients.

Deng et al[16] linked frailty to symptom burden in cirrhosis patients, highlighting the need for comprehensive assessment and PC co-management. This study underscores the importance of holistic care in managing frail ESLD patients.

Kathpalia et al[17] underscored the potential benefits of PC for cirrhotic patients facing LT-related mortality, advocating for early PC integration into decision-making. This study emphasizes the role of PC in improving outcomes for ESLD patients awaiting LT.

Thandassery et al[18] and Trebicka et al[19] linked ESLD and COVID-19 mortality, prompting PC considerations during pandemics, with retrospective study limitations. These studies highlight the unique challenges and considerations for PC in ESLD patients during public health emergencies.

Ufere et al[20] addressed gaps in PC utilization and training, necessitating better education and broader study designs to enhance care for advanced liver disease patients. This study emphasizes the need for improved PC education and integration into ESLD care.

Several prospective observational studies highlight the importance of integrating PC into the care of patients with ESLD.

Lamba et al[21] demonstrate that interdisciplinary communication interventions can facilitate early consensus on goals of care for terminally ill LT service patients, enhancing end-of-life care practices without altering mortality outcomes.

Vieira et al[22] emphasize the universal need for PC among ESLD patients, regardless of transplant eligibility. However, the study's limitations include a single-hospital sample and heterogeneous subgroup distribution, which could introduce bias.

Patel et al[23] identify inadequate PC quality in a veteran population diagnosed with ESLD, suggesting the use of International Classification of Diseases, Ninth Revision codes for patient cohort identification. The study's limitations include a small sample size and single-center data.

Orman et al[24] find that PC is underutilized and provided late to patients with severe liver disease, despite its association with reduced healthcare utilization and greater completion of advanced directives. Randomized trials are needed to evaluate PC's efficacy in this population.

A series of qualitative studies shed light on the challenges and barriers surrounding PC utilization and advance care planning (ACP) for patients with ESLD.

Patel et al[25] revealed low rates of PC consultation alongside high healthcare costs for ESLD patients, indicating racial and ethnic disparities in PC access. They propose targeted quality improvement initiatives to address these disparities.

Ufere et al[26] surveyed hepatologists and gastroenterologists, identifying cultural factors and unrealistic expectations as major barriers to PC and ACP utilization. Insufficient communication about end-of-life care and late engagement in ACP were also highlighted.

Patel et al[27] found that patients with DC received inadequate ACP, leading to overly aggressive life-sustaining treatments at the end of life. This study underscores the need for improved ACP throughout the illness trajectory.

Beck et al[28] suggested clear referral criteria, such as the MELD score, to expand PC access for LT patients. Educational interventions targeting attending physicians could enhance PC utilization.

Donlan et al[29] conducted educational interventions to dispel misconceptions about PC among ESLD patients and caregivers, emphasizing its role in enhancing illness understanding and coping mechanisms.

Shinall et al[9] identified barriers in LT patient care, including role boundaries and differences in clinical cultures, proposing comprehensive symptom assessment and support for caregivers to improve care quality.

Whitsett et al[30] highlighted gaps in PC education and confidence among transplant fellows, advocating for early consideration of palliative medicine and hospice in ESLD management due to its comparable morbidity and mortality rates to heart failure.

These qualitative studies collectively emphasize the need for targeted interventions, improved education, and enhanced interdisciplinary collaboration to optimize PC utilization and ACP for patients with ESLD.

These studies underscore the impact of PC on reducing healthcare utilization, such as reducing readmission rates and hospital stays, particularly in specific ESLD subgroups like alcohol-associated liver disease with ACLF scores ≥ 2.

According to Bajaj et al[32], the guideline panel, comprising six experts in hepatology and two guideline methodologists, officially presented ACLF practice recommendations in the American Journal of Gastroenterology[32]. The authors provided insights into the unique similarities, differences, and limitations of the three most widely used ACLF definitions: European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF; Europe), Asian-Pacific Association for the Study of the Liver (Asia), and North American Consortium for the Study of ESLD (NACSELD; North America). They suggested defining ACLF as a "potentially reversible condition in patients with chronic liver disease with or without cirrhosis that is associated with the potential for multiple organ failure and mortality within 3 months in the absence of treatment of underlying liver disease, liver support, or LT"[32].

In the EASL-CLIF criteria, ACLF occurs in patients with DC who develop additional organ failures. The NACSELD criteria were established later, primarily for patients hospitalized with cirrhosis and bacterial infections. These two criteria are essentially modifications of the EASL-CLIF criteria, where ACLF is defined by the presence of at least two extrahepatic organ failures, including shock, HE grades 3 or 4, renal replacement, and/or mechanical ventilation[35].

The CLIF consortium (CLIF-C) organ failure is associated with high mortality, and the score determines individual thresholds for organ failures, which may include all organs, including the liver[36]. The concept of ACLF, although debated in the last decade, has gained momentum with the publication of clinical guidelines, signifying its global acceptance[36]. However, despite several clinical study attempts, disease-modifying therapies for ACLF, such as granulocyte-colony-stimulating factor[37], the unselective interleukin-1 (IL-1) inhibitor Anakinra[38], or selective IL-1 beta inhibitor canakinumab[39], have failed to establish due to the complexity of its underlying pathophysiology, which is not yet well understood[32].

Currently, there is no approved or broadly accepted standard treatment option to modify the disease course, and short-term mortality rates range between 30%-50%, making LT the only curative approach[33-36]. However, a shortage of donor organs and numerous contraindications limit access to transplantation to a small proportion of ACLF patients. The complexity of treatment strategies, involving multiple organ systems and various medical specialties, underscores the pressing need for guidelines for diagnostic and therapeutic procedures in ACLF[33-36].

The scores developed by the EASL-CLIF-C have been shown to be accurate predictors of patient mortality[40-43], even in specific events in the course of the disease, such as spontaneous bacterial peritonitis[44,45], acute variceal bleeding[46,47], sepsis[48] and hepatorenal syndrome[49,50]. It is no surprising at all that a very robust study found that a CLIF-C ACLF score cutoff ≥ 70 identified patients with a 100% mortality within 28 days, indicating that these patients may reach a threshold of futility for further ongoing intensive support, and the best treatment options may include PC[51]. A retrospective study was conducted on hospitalized patients with cirrhosis admitted between January 2015 and December 2016, utilizing the Child–Pugh score and the MELD/Na score in January 2018. Approximately 51.1% of the patients had a MELD/Na score > 20, while 48.9% had a score < 20. The study findings indicated that 59.6% of patients had died within 12 months, suggesting that a MELD score > 20 could serve as a referral threshold for LT patients to PC[13]. These results highlight the significant need for PC among this patient population.

The transition from compensated to DC and ESLD is universally recognized by the occurrence of clinical complications, including ascites, hepatic encephalopathy, gastrointestinal bleeding, and jaundice[52]. This transition process can follow two distinct pathways: AD and progressive, non-AD (NAD). AD is characterized by the first or recurrent grade 2 or 3 ascites within less than 2 weeks, the first or recurrent acute hepatic encephalopathy in patients with previously normal consciousness, acute gastrointestinal bleeding, and any type of acute bacterial infection[36]. AD and ACLF predominantly occur in patients with a history of previous decompensation, representing further decompensation. The most severe form of AD is ACLF, primarily triggered by alcoholic hepatitis or infections[36,52]. Regardless of the cirrhosis etiology, AD manifests as ACLF in approximately 16% of cases; pre-ACLF in 17%; unstable decompensation in 22%, characterized by persistent albeit unstable inflammatory status resulting in further AD events within 1 year; and stable decompensation in 48%, with a stable decrease of systemic inflammation and no further AD for at least 1 year[53].

In contrast, NAD is characterized by the progressive development of any single event (58%-72%) or any combination (28%-42%) of slow ascites formation, hepatic encephalopathy grade 1-2 or higher if manageable in an outpatient setting, or progressive jaundice in non-cholestatic cirrhosis[36]. NAD is mainly represented by the first decompensation, occurring in 58% to 72% of patients, and usually does not require hospitalization[52]. Even when presenting with two or more decompensating events, a significant proportion of these patients may be managed as outpatients or in the day-hospital setting. This also applies to many patients with further decompensation represented by refractory ascites and mild to moderate recurrent encephalopathy free of other complications[19]. Thus, it appears that AD and NAD impact the clinical course of cirrhosis differently, with AD mostly representing further decompensation and NAD mostly the first decompensating event.

These studies collectively emphasize the importance of holistic care, early PC integration into clinical decision-making, and the necessity for improved PC education and integration into ESLD care to enhance patient outcomes, especially during unique challenges like public health emergencies.

The American Association for the Study of Liver Diseases (AASLD) defines PC as “multidisciplinary, specialized medical care that addresses the physical, spiritual, and psychosocial needs of patients with serious illness and their caregivers”[31,54]. According to the World Health Organization, PC is “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering using early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual”[55]. AASLD emphasizes that PC can be provided at any stage of a serious illness and concurrently with disease-directed and curative treatments, including organ transplants[56]. Over the past decade, there has been an expansion in the body of evidence supporting early PC, extending to individuals with non-malignant conditions which carry a poor prognosis and intense suffering such as cirrhosis[56,57]. Some authors recognize the challenge clinicians face in determining the ideal timing for involving specialized PC teams due to the unpredictable disease trajectory and the potential for curative LT[58]. Overall, the majority of studies included in this review advocate for the early initiation of PC for patients with cirrhosis who develop ESLD or ACLF. This suggests that the diagnosis of cirrhosis represents the earliest point at which PC should be offered to these patients, making it the preferred stage to initiate PC.

From the outset, the aim of the study is to comprehensively investigate the evidence surrounding the benefits of incorporating PC care of patients with ESLD and/or ACLF. This systemic review addresses the underexplored utilization of PC in patients with ESLD and acute on chronic liver disease. The study focuses on the evidence based literatures that sought the advantages of integrating PC into the comprehensive management of patients with ESLD and ACLF. Thus aiming to contribute valuable insights to the evolving landscape of ESLD and ACLF management. In these studies, the diagnosis of ESLD and ACLF was made by a liver specialist or a qualified physician in the field, who then referred the patient to a PC at various stages of his or her life. The experience and education level of the healthcare personal who provide the PC are not even acknowledged in the studies included in this systemic review. PC management typically involves a team comprising physicians, nurses, chaplains, social workers, and other providers[31].

Globally, there is a growing recognition of the benefits of PC across disease states, including DC or ACLF. Evidently, a substantial body of evidence supports the integration of curative and PC approaches for patients with DC. Outpatient PC in patients with DC is associated with improved symptoms, enhanced care coordination, and better anticipatory planning[56,57]. The AASLD, through its Practice Guidelines Committee, has provided PC guidance specifically for patients with cirrhosis, addressing issues relevant to adult patients with DC. The decision to commission guidance rather than a guideline stems from the paucity of RCT on PC in DC[31]. While PC can be considered irrespective of the cirrhosis stage, the notable physical, psychosocial, and financial burden in this group has led to the development of guidance tailored to adult patients with DC[31].

PC, though underutilized, addresses the myriad challenges encountered by patients with DC or ESLD and their families. For example, a significant underutilization of PC services, particularly in older, non-white patients with cirrhosis on the LT waitlist was observed[11,59], which was corroborated by the National Inpatient Survey[60]. The lack of PC support has a negative impact on the quality of life of non-transplant candidates with ESLD[11,59]. Although an increase PC services utilization has been observed in the past decade[25,60], only a few ESLD patients declining or delisted for LT are referred for PC services[11,58,59], and they are commonly referred within a few days or weeks before their death[17,61]. Therefore, it is paramount to advocate for the systemic implementation of PC principles and resources to alleviate the physical and emotional burden on the ESLD patient population and their families[62].

Although, a very relevant limitation that might contribute to the underutilization of PC in ESLD is the lack of tools identifying distressing symptoms correlating with the optimal time for PC referral[6]. It is important to notice that low rates of PC consultation in patients with ESLD might incur into significant costs for these terminally ill patients[23,25,27,28,63,64] and an increase in undesired suffering, as ESLD patients receive ACP consultations too late in the course of their disease[23,26]. PC referral during hospital admissions that concludes in death is often belated and inefficacious, as it often fails to reduce anxiety symptoms[65]. Despite all the addressed above, the hepatology community recognizes PC as underutilized in ESLD and ACLF[65]. Nevertheless, pre-emptive PC intervention in the management of patients with ESLD can result in increase in time to the first readmission and more days alive outside the hospital for admitted ESLD patients[63].

LT stands as the sole cure for ESLD and ACLF, but annual LT rates remain stagnant due to various obstacles such as donor availability, financial constraints, active substance use, mental health disorders, and lack of social support[66]. Clinical scoring systems, including the CTP score, MELD, and ACLF grade, have been developed to predict mortality in cirrhosis patients[29]. ACLF grade at 3-7 days post-admission, MELD score and CLIF-C ACLF scores may identify patients for whom continued care is futile[6,34,51,67]. Although, it is rather challenging to identify the point of irreversible liver deterioration warranting referral for PC[18,68], machine learning models might help us distinguish patients with better expected survival[22].

Disparities in PC referral extend to the delivery of PC in cirrhosis patients specifically. Financially and socially vulnerable groups are less likely to receive PC referrals upon hospital admission[36]. The misconception that PC is synonymous with end of life care persists in medical settings, that can be persistently propagated by attending physicians, potentially contributing to its underutilization in the transplant setting[28]. Also, the misconception that is a synonym to hospice care is also very common. It is important that fellow physicians, patients and their families receive education on PC, so to recognize its potential to support their understanding of illness and coping[26,29].

While the impact of PC on patients with ESLD and ACLF remains an understudied area, innovative care models have emerged to enhance the utilization of PC in these patients. For example, patients who denied or were delisted from LT or which experienced worsening MELD scores on the transplant list can enrolled in hospice care, and some of these patients might be successfully transplanted while in hospice care[39]. Also, PC consultation might reduce readmission rates and hospital stay in patients with cirrhosis[17,63], while improving physical and physiological suffering[6].

A study conducted by Adejumo et al[69] reported that PC consultation was associated with a lower risk for 30- and 90-day readmissions (HR = 0.42, 95%CI: 0.38–0.47 and 0.38, 95%CI: 0.34–0.42, respectively). This association resulted in reduced burden on healthcare resource utilization and improvement in cost savings during subsequent readmissions[69]. Lamba et al[21] implemented a single-centered, 2-tiered structured intervention, assessing automatic PC integration for cirrhosis and LT patients admitted to the Surgical Intensive Care Unit (SICU)[21]. The first part focused on reviewing prognosis, advanced directives, and symptom management within 24 hours of SICU admission. The second part involved a family meeting with both primary and PC teams to review the goals of care. The outcomes of this intervention included increased goals of care meetings (from 2% to 38%), increased do not resuscitate rates (from 52% to 81%), increased withdrawal from life support (from 35% to 68% of cases), and a decreased SICU mean length of stay by 3 days, all achieved without a change in mortality rates. This suggests that only patients undergoing futile care had life-sustaining care withdrawn. Additionally, interdisciplinary communication interventions with physicians and families in the SICU may lead to earlier consensus around goals of care for dying LT service patients. Early integration of PC alongside aggressive, disease-focused, curative care in the SICU for LT patients can be accomplished without a change in mortality and can improve end of life care practices in such patients[21].

These studies collectively indicate a benefit with PC across the continuum of care in heterogeneous patient populations, particularly those struggling with uncertainties such as the population with DC, which experiences significant stress, anxiety, and decreased quality of life[67]. Early PC referral could provide a benefit to caregivers of patients with cirrhosis who also suffer while caring for loved ones with this illness. Early PC integration has been shown to reduce depression and anxiety among caregivers, such as spouses, children, and parents[70].

Cirrhosis is linked to a diminished health-related quality of life, posing challenges due to various stressors encompassing physical, cognitive, psychological, and social aspects. Studies have consistently revealed that patients with DC face variable mortality rates ranging from 20% to 80% over five years. The disease trajectory is progressive, marked by declining health, increasing symptom burden, and frequent hospitalizations. While LT has proven to be a curative option, only a minority of patients survive to receive it[70]. There is an unmet PC need for cirrhosis patients and their caregivers, with only a few of them receiving PC or hospice care referrals, often occurring late in the disease course[61,71,72].

Several identified barriers hinder the implementation of PC for patients with ESLD and/or ACLF, such as a shortage of specialty PC providers, the absence of evidence-based referral criteria, a lack of role clarity between specialists, the stigma associating PC with "giving up" on curative treatments, insufficient provider training, competing demands on providers' time, and prognostic uncertainty[26]. Additionally, many symptoms experienced by individuals with ESLD are highly liver-specific and are longitudinally managed by liver teams. The process of transplant waitlisting and evaluation itself acts as a barrier to PC due to potential conflicts between transplantation and PC, although these patients undergoing transplant evaluation tend to receive lower-quality end of life care[58,64,73]. Notably, PC competencies for hepatologists have not been developed, as hepatology training does not routinely include PC training.

AASLD guideline statements emphasize that patients with ESLD and their caregivers frequently face substantial unmet PC needs across psychological, physical, social, financial, and spiritual dimensions. The recommendations advocate for the assessment of unmet PC needs and the consideration of specialty PC consultation for all patients with DC and their caregivers. Importantly, the guidance clarifies that disease-directed care, such as transplantation evaluation and listing, should not preclude the delivery of PC or specialty PC consultation for patients with DC.

Clearly, obstacles impeding the delivery of quality PC for patients with ESLD or ACLF include a shortage of PC specialists and inadequate training for healthcare providers, including hepatologists, as PC training is typically not integrated into hepatology training programs. Therefore, it is imperative to mandate PC training for healthcare professionals in subspecialty hepatology departments who are directly responsible for the care of patients with ESLD/ACLF[74-77].

Acknowledging the shortage of specialty PC providers, the AASLD recommends that hepatology clinicians take a pivotal role in providing primary PC services to patients with cirrhosis. This role includes conducting symptom assessment and management, facilitating basic ACP activities such as identifying surrogate decision-makers, offering counselling, and making referrals for additional support when necessary and feasible[31].

Artificial intelligence (AI) holds significant promise in the field of healthcare, particularly in prognosticating patients with complex conditions such as LT, ESLD or ACLF[78-80]. By leveraging advanced algorithms and machine learning techniques, these systems can analyze vast amounts of patient data, including clinical variables, imaging studies, and laboratory results, to identify patterns and predict disease progression[81-84]. In the context of PC for patients with ESLD or ACLF, AI-driven prognostic models could assist healthcare providers in selecting those individuals who are most likely to benefit from PC interventions. This tailored approach may optimize resource allocation and improve outcomes by ensuring that PC services are directed towards those who stand to benefit the most.

Our study exhibits several limitations. Primarily, due to the retrospective nature of our discharge database, our analysis is susceptible to coding errors and missing data. While transplant patients represent a minority group, the non-transplant patient group is inadequately assessed in only a few studies. The prospective and retrospective studies utilized to elucidate the impact of PC in ESLD and/or ACLF predominantly consist of non-randomized trials, observational studies, or relatively small-scale investigations. Notably, the transplant and ineligible transplant populations differ, each harboring unique sources of suffering and care disparities. Consequently, findings from studies in one population may lack generalizability to the other, necessitating separate investigations.

Future directions for the effective implementation of PC into clinical hepatology involve commitments to bridge the research gap, advocate for essential health policy changes, instigate relevant cultural shifts, and foster essential clinical innovation. Prospective and randomized trials on integrated PC interventions for patients with ESLD and ACLF are crucial, with a specific focus on evaluating the PC needs of both transplant and non-transplant patient groups. Emphasis should be placed on assessing symptom burden and quality of life rather than solely focusing on the intervention's impact on mortality. Collaborative efforts between LT and PC services could enhance the quality of life in this patient population.