Advance Care Planning and Goals of Care Discussions in Advanced Liver Disease

Abstract

Purpose of Review Advance care planning (ACP) has been shown to improve multiple outcomes in patients with serious illnesses; however, patients with advanced liver disease, or cirrhosis, rarely receive timely ACP. The purpose of this review is to evaluate the current state of ACP for patients with advanced liver disease and to provide practical guidance for integrating early ACP into routine outpatient hepatology care. Recent Findings Due to multiple patient-, physician-, and systems-level barriers, patients with advanced liver disease have low rates of timely ACP engagement. Early identification and preparation of a surrogate decision-maker, enhancing clinician ACP communication skills, use of patient-centered educational tools, optimizing outpatient processes for ACP documentation, and early referral to specialty palliative care may help to improve current deficits in ACP for this population. Summary Provision of early ACP to patients with advanced liver disease may better ensure that patients receive medical care that is consistent with their goals and values.

Improving palliative care access for patients with cirrhosis

“…Important clinical milestones that should trigger early ACP are shown in Table 2. [6] Improving symptom management in hepatology care Symptom management is a large domain of PC, and there is a growing body of literature addressing the physical and psychological symptom burden of patients with AdvLD. [7] Brief targeted assessments, such as the Edmonton Symptom Assessment Scale (ESAS), can be used to screen for common symptoms, including fatigue, sleep disturbances, depression, anxiety, and more.…”

“…As part of ACP, hepatology clinicians can also initiate the simple process of health care proxy identification for patients; this can ensure that the patient’s wishes are legally and ethically upheld by their chosen decision maker in the case of severe disease progression. Important clinical milestones that should trigger early ACP are shown in Table 2 6 …”

Serious Illness Communication in Cirrhosis Care: Tools to Improve Illness Understanding, Prognostic Understanding, and Care Planning

“… 5 , 6 When patients do not understand their illness, prognosis, or care options, they may be more likely to choose high-intensity treatments that are not consistent with their values and may not sustain their lives meaningfully. 7 SIC has been associated with reduced patient and family emotional distress, increased satisfaction with care, and often leads to the delivery of goal-concordant care. 8 Having SIC can help clinicians and patients build trusted relationships and ensure that patients and their surrogate decision-makers feel supported, understood, and in some control of what might otherwise be a very unpredictable, uncertain disease course.…”

“…Care planning is the component of SIC in which providers help patients and their care partners to: (1) identify goals and values that are reflective of patient preferences, (2) help with in-the-moment decision-making in the setting of major medical decisions, and (3) assist with ACP early in the course of illness, including designation and preparation of surrogate decision-makers, and documentation of preferences for goals of care including preferences for end-of-life care. 7 Care planning has been demonstrated to increase satisfaction and reduce emotional distress in patients with chronic illnesses. 8 Many patients with cirrhosis report that they are open to having conversations about their values and the care they would want to receive.…”