Palliative Care for Patients with End-Stage Liver Disease

Abstract

Liver disease results in over four million physician visits and over 750,000 hospitalizations per year in the USA. Those with chronic liver disease frequently progress to cirrhosis, end-stage liver disease (ESLD), and death. Patients with ESLD experience numerous complications, including muscle cramps, confusion (hepatic encephalopathy), protein calorie malnutrition, muscle wasting, fluid overload (ascites, edema), bleeding (esophagogastric variceal hemorrhage), infection (spontaneous bacterial peritonitis), fatigue, anxiety, and depression. Despite significant improvements in palliation of these complications, patients still suffer reduced quality of life and must confront the fact that their disease will often inexorably progress to death. Liver transplantation is a valid option in this setting, increasing the duration of survival and palliating many of the symptoms. However, many patients die waiting for an organ or are not candidates for transplantation due to comorbid illness. Others receive a transplant but succumb to complications of the transplant itself. Patients and families must struggle with simultaneously hoping for a cure while facing a life-threatening illness. Ideally, the combination of palliative care with life-sustaining therapy can maximize the patients' quality and quantity of life. If it becomes clear that life-sustaining therapy is no longer an option, these patients are then already in a system to help them with end-of-life care.

Palliative care in cirrhosis with decompensation

“…Many people had multiple admissions during a single year (51%) and unplanned readmissions (36%), despite appropriate referrals for outpatient care: this is not accounted for by people having planned readmissions for paracentesis. Given that the more frequent the readmission rate, the greater the risk of subsequent mortality, targeting this group of people for specialist palliative care referral could enhance both quality of life and advance health planning rates.…”

Ascites, refractory ascites and hyponatremia in cirrhosis

“…If the patient is not a transplant candidate, consideration for destination TIPS or serial LVPs should be assessed as well as referral to palliative care services. Referral to palliative care for patients with advanced liver disease has been shown to objectively improve clinical and patient-reported outcomes and this service’s role in both transplant and non-transplant settings will need to be further explored [27,28]. Regardless, the development of ascites is a serious complication of advanced cirrhosis and portal hypertension, and reporting to the patient on their prognosis is critical.…”

Palliative Care and Health Care Utilization for Patients With End-Stage Liver Disease at the End of Life

“…Despite increased attention paid to improving end-of-life care for patients with liver disease 6, 7 , little is known about the current quality of care, resources, and costs associated with treating these patients. A study using the Health and Retirement Survey found that patients with cirrhosis report worse health status and require more caregiver support compared to age-matched patients without cirrhosis, but the sample was limited to Medicare recipients and hospital illness experiences and costs were not detailed 8 .…”