Patients with end stage liver disease and decompensated cirrhosis have an average life expectancy of 2 years without transplant.  Outcomes are worse among those who are frail.  Symptoms are common, including pain, ascites, encephalopathy, and pruritus.  Patients with end stage liver disease are often some of the most disadvantaged patients we care for.  Caregiver burden is immense; divorce is common.  Some will go on to receive a transplant, but many will not.  Many are confused about the diagnosis and feel poorly supported.  Prognosis is fraught, as the worse your prognosis (i.e. lower your chance of survival), the higher you move on the transplant list.  Advance care planning is rare (or serious illness communication for those of you who don’t consider this advance care planning).  Outcomes of in-hospital CPR are worse for patients with end stage liver disease than outcomes for patients with advanced cancer. Though integration of geriatrics and palliative care into the care of patients with end stage liver disease holds obvious potential, major barriers remain.   In this week’s podcast, we talk with Jen Lai, Ricky Shinall, Nneka Ufere, and Arpan Patel about end stage liver disease from a geriatrics and palliative care perspective.  We talk about the tension patients face between putting on the “best face” to be listed for transplant (e.g. full code, goals focused on extending life).  We talk about the potential and limitations of the MELD score for prognosis, and how frailty further stratified risk for older patients with end stage liver disease.  We discuss what is needed in terms of improved communication around the time of diagnosis, creating a safe space for serious illness communication, and resources for patients and caregivers (including this Canadian information resource). And we have a round robin about treatment of common and challenging symptoms – yogurt makes a surprise appearance. And…Radiohead! Great request…thank you Nneka! -@AlexSmithMD