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Cullaro G, Chiou SH, Fenton C, Ge J, McCulloch CE, Rubin J, Shui AM, Yao F, Lai JC. Outpatient mean arterial pressure: A potentially modifiable risk for acute kidney injury and death among patients with cirrhosis. Liver Transpl 2024; 30:679-688. [PMID: 38535488 DOI: 10.1097/lvt.0000000000000359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 02/21/2024] [Indexed: 04/05/2024]
Abstract
Mean arterial blood pressure (MAP), which decreases as portal hypertension progresses, may be a modifiable risk factor among patients with cirrhosis. We included adults enrolled in the Functional Assessment in Liver Transplantation study. We completed latent class trajectory analyses to define MAP trajectories. We completed time-dependent Cox-regression analyses to test the association between outpatient MAP and 3 cirrhosis-related outcomes: (1) stage 2 acute kidney injury (AKI), defined as a ≥200% increase in serum creatinine from baseline; (2) a 5-point increase in the MELD-Na score, defined as the incidence of increase from initial MELD-Na; (3) waitlist mortality, defined as death on the waitlist. For each outcome, we defined MAP cut points by determining the maximally selected Log-rank statistic after univariable Cox-regression analyses. Among the 1786 patients included in this analysis, our latent class trajectory analyses identified 3 specific outpatient MAP trajectories: "stable-low," "stable-high," and "increasing-to-decreasing." However, >80% of patients were in a "stable-low" trajectory. We found in adjusted analyses that outpatient MAP was associated with each of our outcomes: Stage 2 AKI (adjusted hazard ratio 0.88 per 10 mm Hg increase in MAP [95% CI: 0.79-0.99]); 5-point increase in MELD-Na (adjusted hazard ratio: 0.91 [95% CI: 0.86-0.96]; waitlist mortality (adjusted hazard ratio: 0.89 [95% CI: 0.81-0.96]). For each outcome, we found that an outpatient MAP of 82 mm Hg was most associated with outcomes ( p <0.05 for all). Our study informs the association between outpatient MAP and cirrhosis-related outcomes. These findings, coupled with the identification of specific thresholds, lay the foundation for the trial of targeted outpatient MAP modulation in patients with cirrhosis.
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Affiliation(s)
- Giuseppe Cullaro
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Sy Han Chiou
- Department of Mathematical Sciences, University of Texas at Dallas, Richardson, Texas, USA
| | - Cynthia Fenton
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Jin Ge
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Jessica Rubin
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Amy M Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Frederick Yao
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Jennifer C Lai
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
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2
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Oliveira HM, Miranda HP, Rego F, Nunes R. Palliative care and end stage liver disease: A cohort analysis of palliative care use and factors associated with referral. Ann Hepatol 2024; 29:101518. [PMID: 38851396 DOI: 10.1016/j.aohep.2024.101518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/16/2024] [Accepted: 04/19/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION AND OBJECTIVES Prevalence and mortality of chronic liver disease have risen significantly. In end stage liver disease, the survival of patients is approximately two years. Despite the poor prognosis and high symptom burden of these patients, integration of palliative care is limited. We aim to assess associated factors and trends in palliative care use in recent years. MATERIALS AND METHODS A Multicenter retrospective cohort of patients with end stage liver disease who suffered in-hospital mortality between 2017 and 2019. Information regarding patient demographics, hospital characteristics, comorbidities, etiology, decompensations, and interventions was collected. Two-sided tests and logistic regression analysis were used to identify factors associated with palliative care use. RESULTS A total of 201 patients were analyzed, with a yearly increase in palliative care consultation: 26.7 % in 2017 to 38.3 % in 2019. Patients in palliative care were older (65.72 ± 11.70 vs. 62.10 ± 11.44; p = 0.003), had a lower Karnofsky functionality scale (χ=18.104; p = 0.000) and had higher rates of hepatic encephalopathy (32.1 % vs. 17.4 %, p = 0.007) and hepatocarcinoma (61.7 % vs. 26.2 %; p = 0.000). No differences were found for Model for End-stage Liver Disease (19.28 ± 6.60 vs. 19,90 ± 5.78; p = 0.507) or Child-Pugh scores (p = 0.739). None of the patients who die in the intensive care unit receive palliative care (0 % vs 31.6 %; p = 0.000). Half of the palliative care consultations occurred 6,5 days before death. CONCLUSIONS Palliative care use differs based on demographics, disease complications, and severity. Despite its increasing implementation, palliative care intervention occurs late. Future investigations should identify approaches to achieve an earlier and concurrent care model.
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Affiliation(s)
- Hugo M Oliveira
- Palliative Care Unit, Matosinhos Local Health Unit, Rua Dr. Eduardo Torres, Senhora da Hora, Matosinhos, Portugal; Department of Social Sciences and Health, Faculty of Medicine, University of Porto, Porto, Portugal.
| | | | - Francisca Rego
- Department of Social Sciences and Health, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Rui Nunes
- Department of Social Sciences and Health, Faculty of Medicine, University of Porto, Porto, Portugal.
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3
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Manning ME, Ufere NN. Improving palliative care access for patients with cirrhosis. Clin Liver Dis (Hoboken) 2024; 23:e0204. [PMID: 38860127 PMCID: PMC11164013 DOI: 10.1097/cld.0000000000000204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/12/2024] [Indexed: 06/12/2024] Open
Affiliation(s)
- Margot E. Manning
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nneka N. Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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4
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Singal AG, Llovet JM, Yarchoan M, Mehta N, Heimbach JK, Dawson LA, Jou JH, Kulik LM, Agopian VG, Marrero JA, Mendiratta-Lala M, Brown DB, Rilling WS, Goyal L, Wei AC, Taddei TH. AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma. Hepatology 2023; 78:1922-1965. [PMID: 37199193 PMCID: PMC10663390 DOI: 10.1097/hep.0000000000000466] [Citation(s) in RCA: 222] [Impact Index Per Article: 222.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 05/19/2023]
Affiliation(s)
- Amit G. Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Josep M. Llovet
- Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Mount Sinai School of Medicine, New York, New York, USA
- Translational Research in Hepatic Oncology, Liver Unit, August Pi i Sunyer Biomedical Research Institute, Hospital Clinic, University of Barcelona, Catalonia, Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Catalonia, Spain
| | - Mark Yarchoan
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Neil Mehta
- University of California, San Francisco, San Francisco, California, USA
| | | | - Laura A. Dawson
- Radiation Medicine Program/University Health Network, Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Janice H. Jou
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
| | - Laura M. Kulik
- Northwestern Medical Faculty Foundation, Chicago, Illinois, USA
| | - Vatche G. Agopian
- The Dumont–University of California, Los Angeles, Transplant Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Jorge A. Marrero
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mishal Mendiratta-Lala
- Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Daniel B. Brown
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William S. Rilling
- Division of Interventional Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lipika Goyal
- Department of Medicine, Stanford School of Medicine, Palo Alto, California, USA
| | - Alice C. Wei
- Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Tamar H. Taddei
- Department of Medicine (Digestive Diseases), Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
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5
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Kearney A, Tiwari N, Cullen O, Legg A, Arbi I, Douglas C, Leggett B, Fenech M, Mina J, Hoey P, Skoien R. Improving palliative and supportive care in advanced cirrhosis: the HepatoCare model of integrated collaborative care. Intern Med J 2023; 53:1963-1971. [PMID: 37812158 DOI: 10.1111/imj.16248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/29/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Patients with advanced cirrhosis experience an unpredictable disease trajectory but are infrequently referred to palliative care (PC) services and rarely undertake advance care planning (ACP). AIM We assessed whether a novel model of care increased provision of meaningful PC in advanced cirrhosis compared with standard of care (SOC). METHODS Thirty consecutive hepatology clinic outpatients with advanced cirrhosis, meeting one or more cirrhosis-related PC referral criteria, consented to treatment in the HepatoCare clinic (PC physician, specialist liver nurse, pharmacist) in parallel with usual specialist hepatology care. A control cohort of 30 consecutive outpatients with advanced cirrhosis undergoing SOC treatment was retrospectively identified for comparison. The primary outcome was provision of meaningful PC using HepatoCare versus SOC. Additional clinical outcomes were assessed over 12 months or until death and significant differences were identified. RESULTS The intervention and control cohorts had similarly advanced cirrhosis (mean Child-Pugh scores 8.7 vs 8.2, P = 0.46; mean model for end-stage liver disease scores 14.4 vs 14.6, P = 0.88) but a lower 12-month mortality rate (33% HepatoCare vs 67% SOC; P = 0.02). The intervention cohort experienced higher uptake of formal ACP (100% vs 25% for the control cohort) and outpatient PC referral (100% vs 40%), and were more likely to die at home or in a PC bed/hospice (80% vs 30%). The majority of the HepatoCare cohort (81%) had medications safely deprescribed and experienced fewer unplanned admission days (470 vs 794). CONCLUSIONS HepatoCare is a novel multidisciplinary model of care that integrates effective PC and specialist hepatology management to improve outcomes in advanced cirrhosis.
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Affiliation(s)
- Alison Kearney
- Department of Palliative and Supportive Care, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
- School of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - Neha Tiwari
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Olivia Cullen
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Amy Legg
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Ismail Arbi
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Carol Douglas
- Department of Palliative and Supportive Care, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
- School of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - Barbara Leggett
- School of Medicine, The University of Queensland, St Lucia, Queensland, Australia
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Mary Fenech
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Joanne Mina
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Paris Hoey
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Richard Skoien
- School of Medicine, The University of Queensland, St Lucia, Queensland, Australia
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
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Verma S, Hingwala J, Low JTS, Patel AA, Verma M, Bremner S, Haddadin Y, Shinall MC, Komenda P, Ufere NN. Palliative clinical trials in advanced chronic liver disease: Challenges and opportunities. J Hepatol 2023; 79:1236-1253. [PMID: 37419393 DOI: 10.1016/j.jhep.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/14/2023] [Accepted: 06/21/2023] [Indexed: 07/09/2023]
Abstract
Patients with advanced chronic liver disease have a complex symptom burden and many are not candidates for curative therapy. Despite this, provision of palliative interventions remains woefully inadequate, with an insufficient evidence base being a contributory factor. Designing and conducting palliative interventional trials in advanced chronic liver disease remains challenging for a multitude of reasons. In this manuscript we review past and ongoing palliative interventional trials. We identify barriers and facilitators and offer guidance on addressing these challenges. We hope that this will reduce the inequity in palliative care provision in advanced chronic liver disease.
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Affiliation(s)
- Sumita Verma
- Brighton and Sussex Medical School and University Hospitals Sussex NHS Foundation Trust, Brighton, UK.
| | - Jay Hingwala
- University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Arpan A Patel
- Division of Digestive Diseases, University of California, Los Angeles, USA; Department of Gastroenterology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Manisha Verma
- Department of Medicine, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Stephen Bremner
- Brighton and Sussex Medical School and University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Yazan Haddadin
- Brighton and Sussex Medical School and University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | | | - Paul Komenda
- University of Manitoba, Winnipeg, Manitoba, Canada
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7
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Cisneros-Garza L, González-Huezo M, Moctezuma-Velázquez C, Ladrón de Guevara-Cetina L, Vilatobá M, García-Juárez I, Alvarado-Reyes R, Álvarez-Treviño G, Allende-Pérez S, Bornstein-Quevedo L, Calderillo-Ruiz G, Carrillo-Martínez M, Castillo-Barradas M, Cerda-Reyes E, Félix-Leyva J, Gabutti-Thomas J, Guerrero-Ixtlahuac J, Higuera-de la Tijera F, Huitzil-Melendez D, Kimura-Hayama E, López-Hernández P, Malé-Velázquez R, Méndez-Sánchez N, Morales-Ruiz M, Ruíz-García E, Sánchez-Ávila J, Torrecillas-Torres L. The second Mexican consensus on hepatocellular carcinoma. Part II: Treatment. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2022; 87:362-379. [DOI: 10.1016/j.rgmxen.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/20/2022] [Indexed: 10/25/2022] Open
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8
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Deng LX, Tana MM, Lai J. Thinking Ahead: Advance Care Planning for Patients With Cirrhosis. Clin Liver Dis (Hoboken) 2021; 19:7-11. [PMID: 35106142 PMCID: PMC8785911 DOI: 10.1002/cld.1157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Lisa X. Deng
- Department of MedicineUniversity of California, San FranciscoSan FranciscoCA
| | - Michele M. Tana
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of California, San FranciscoSan FranciscoCA,Division of Gastroenterology and HepatologyDepartment of MedicineZuckerberg San Francisco General HospitalSan FranciscoCA
| | - Jennifer C. Lai
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of California, San FranciscoSan FranciscoCA
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9
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Ufere NN. Advance Care Planning and Goals of Care Discussions in Advanced Liver Disease. CURRENT HEPATOLOGY REPORTS 2021; 20:77-84. [PMID: 35083111 PMCID: PMC8788995 DOI: 10.1007/s11901-021-00565-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 06/14/2023]
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.
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Affiliation(s)
- Nneka N. Ufere
- Liver Center, Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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10
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Low Rates of Advance Care Planning (ACP) Discussions Despite Readiness to Engage in ACP Among Liver Transplant Candidates. Dig Dis Sci 2021; 66:1446-1451. [PMID: 32500286 PMCID: PMC7714700 DOI: 10.1007/s10620-020-06369-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 05/23/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with end-stage liver disease awaiting liver transplantation (LT) are seriously ill and experience fluctuating periods of clinical decompensation. Discussion of a patient's advance care planning (ACP) wishes early in their dynamic disease course is critical to providing value-aligned care while awaiting LT. We aimed to evaluate current ACP documentation and assess readiness to engage in ACP in this population. METHODS We conducted a retrospective study of adults undergoing LT evaluation from January 2017 to June 2017 and assessed characteristics associated with documentation using logistic regression. We then administered a survey to LT candidates from March 2018 to May 2018 to determine self-reported readiness to engage in ACP (range 1 = not at all ready to 5 = very ready). RESULTS Among 170 LT candidates, median (interquartile range) age was 58 (53-65), 65% were men, MELDNa was 15 (11-21), and Child-Pugh A/B/C were 33/38/29%. Nine percent reported completing ACP prior to LT evaluation, but 0% had legal ACP forms or end-of-life wishes documented in the medical record. A durable power of attorney (DPOA) was discussed with 10%. In univariable analysis, white race (OR 4.16, p = 0.03) and female sex (OR 3.06, p = 0.04) were associated with ACP documentation, but Child-Pugh score and MELDNa were not. Of the 41 LT candidates who completed the ACP survey, 93% were ready to appoint a DPOA and 85% were ready to discuss end-of-life care. CONCLUSION There is a paucity of ACP documentation and identification of DPOA among LT candidates, despite patients reporting readiness to complete ACP and appoint a DPOA. These results reveal an opportunity for tools to facilitate discussions around ACP between clinicians, patients, and their caregivers.
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11
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Tandon P, Walling A, Patton H, Taddei T. AGA Clinical Practice Update on Palliative Care Management in Cirrhosis: Expert Review. Clin Gastroenterol Hepatol 2021; 19:646-656.e3. [PMID: 33221550 DOI: 10.1016/j.cgh.2020.11.027] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/07/2020] [Accepted: 11/14/2020] [Indexed: 02/07/2023]
Abstract
Care with palliative care principles (aka Palliative Care, PC) is an approach to care that focuses on improving the quality of life of patients and their caregivers who are facing life-limiting illness. It encompasses the assessment and management of symptoms and changes in functional status, the provision of advance care planning and goals of care discussions, prognostication and caregiver support. PC is applicable across the spectrum of cirrhosis regardless of transplant eligibility. Although a common misconception, PC is not synonymous with hospice care. Unfortunately, despite a high symptom burden and challenges with predicting disease course and mounting evidence to support the benefits of PC in patients with cirrhosis, comprehensive PC and referral to hospice are carried out infrequently and very late in the course of disease. In order to meet the needs of our increasingly prevalent cirrhosis population, it is important that all clinicians who care for these patients are able to work together to deliver PC as a standard of care. To date there are limited guidelines/guidance statements to direct clinicians in the area of PC and cirrhosis. Herein we present an evidence-based review of ten Best Practice Advice statements that address key issues pertaining to PC in patients with cirrhosis.
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Affiliation(s)
- Puneeta Tandon
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada.
| | - Anne Walling
- VA Greater Los Angeles Healthcare System, Los Angeles, California; Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles, California
| | - Heather Patton
- Gastroenterology Section, VA San Diego Healthcare System, San Diego, California
| | - Tamar Taddei
- VA Connecticut Healthcare System, West Haven, and Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut
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12
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Waterman BL, Ramsey SU, Whitsett MP, Patel AA, Radcliff JA, Kotler DL, Winters AC, Woodrell CD, Ufere NN, Serper M, Walling AM, Jones CA, Kelly SG. Top Ten Tips Palliative Care Clinicians Should Know About End-Stage Liver Disease. J Palliat Med 2021; 24:924-931. [PMID: 33733875 DOI: 10.1089/jpm.2021.0097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
End-stage liver disease (ESLD) is an increasingly prevalent condition with high morbidity and mortality, especially for those ineligible for liver transplantation. Patients with ESLD, along with their family caregivers, have significant needs related to their quality of life, and there is increasing attention being paid to integration of palliative care (PC) principles into routine care throughout the disease spectrum. To provide upstream care for these patients and their family caregivers, it is essential for PC providers to understand their complex psychosocial and physical needs and to be aware of the unique challenges around medical decision making and end-of-life care for this patient population. This article, written by a team of liver and PC experts, shares 10 high-yield tips to help PC clinicians provide better care for patients with advanced liver disease.
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Affiliation(s)
- Brittany L Waterman
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sinthana U Ramsey
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Maureen P Whitsett
- Division of Gastroenterology and Hepatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arpan A Patel
- Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, California, USA.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Jacob A Radcliff
- Department of Pharmacy and Palliative Care Program, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Drew L Kotler
- Division of Palliative Care, Department of Medicine, Main Line Health, Radnor, Pennsylvania, USA
| | - Adam C Winters
- Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Christopher D Woodrell
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Nneka N Ufere
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anne M Walling
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine University of California, Los Angeles, USA
| | - Christopher A Jones
- Department of Medicine and Palliative Care Program, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sean G Kelly
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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13
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Mah JM, Djerboua M, Groome PA, Booth CM, Flemming JA. Transjugular intrahepatic portosystemic shunt for the treatment of refractory ascites: A population-based cohort study. CANADIAN LIVER JOURNAL 2020; 3:334-347. [DOI: 10.3138/canlivj-2020-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/22/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND: Randomized trials have shown that transjugular intrahepatic portosystemic shunt (TIPS) improves control of ascites compared with serial large volume paracentesis (LVP) in patients with refractory ascites. However, the effect of TIPS on liver transplant-free (LTF) survival is controversial. Our objective was to compare TIPS versus serial LVP on LTF survival in the general population of patients with refractory ascites. METHODS: This is a retrospective, population-based cohort study using linked administrative health data from Ontario, Canada. Adult patients identified with refractory ascites from January 1, 2008 to December 31, 2016 were included and followed until December 31, 2017. A propensity score was used to match patients treated with serial LVP to those who received TIPS in a 2:1 ratio. LTF survival was evaluated using Kaplan–Meier analysis and Cox proportional hazards regression with TIPS treated as a time-varying exposure. RESULTS: Overall, 4,935 patients with refractory ascites were identified and 488 patients were matched (325 serial LVP, 163 TIPS). The mean age was 58 years, 70% were male, 50% had viral hepatitis, the median model for end-stage liver disease (MELD) score was 12, 13% received liver transplant and the 1-year LTF survival was 72%. After TIPS, 80 patients (49%) had no further requirement for LVP by 6 months and 61 patients (37%) never required a repeat paracentesis. In survival analysis, there was marginally worse LTF survival in patients receiving TIPS (TIPS HR 1.29, 95% CI 1.00–1.67; p = .052). CONCLUSION: In this population-based study of patients with refractory ascites, TIPS was associated with improved control of ascites but not improved LTF survival.
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Affiliation(s)
- Jeffrey M Mah
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | | | - Patti A Groome
- ICES, Queen’s University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Christopher M Booth
- ICES, Queen’s University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Jennifer A Flemming
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
- ICES, Queen’s University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
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14
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Macken L, Bremner S, Gage H, Touray M, Williams P, Crook D, Mason L, Lambert D, Evans CJ, Cooper M, Timeyin J, Steer S, Austin M, Parnell N, Thomson SJ, Sheridan D, Wright M, Isaacs P, Hashim A, Verma S. Randomised clinical trial: palliative long-term abdominal drains vs large-volume paracentesis in refractory ascites due to cirrhosis. Aliment Pharmacol Ther 2020; 52:107-122. [PMID: 32478917 DOI: 10.1111/apt.15802] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/12/2020] [Accepted: 04/28/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Palliative care remains suboptimal in end-stage liver disease. AIM To inform a definitive study, we assessed palliative long-term abdominal drains in end-stage liver disease to determine recruitment, attrition, safety/potential effectiveness, questionnaires/interview uptake/completion and make a preliminary cost comparison. METHODS A 12-week feasibility nonblinded randomised controlled trial comparing large-volume paracentesis vs long-term abdominal drains in refractory ascites due to end-stage liver disease with fortnightly home visits for clinical/questionnaire-based assessments. Study success criteria were attrition not >50%, <10% long-term abdominal drain removal due to complications, the long-term abdominal drain group to spend <50% ascites-related study time in hospital vs large-volume paracentesis group and 80% questionnaire/interview uptake/completion. RESULTS Of 59 eligible patients, 36 (61%) were randomised, 17 to long-term abdominal drain and 19 to large-volume paracentesis. Following randomisation, median number (IQR) of hospital ascitic drains (long-term abdominal drain group vs large-volume paracentesis group) were 0 (0-1) vs 4 (3-7); week 12 serum albumin (g/L) and serum creatinine (μmol/L) were 29 (26.5-32.5) vs 30 (25-35) and 104.5 (81-115.5) vs 127 (63-158) respectively. Total attrition was 42% (long-term abdominal drain group 47%, large-volume paracentesis group 37%). Median (IQR) fortnightly community/hospital/social care ascites-related costs and percentage study time in hospital were lower in the long-term abdominal drain group, £329 (253-580) vs £843 (603-1060) and 0% (0-0.74) vs 2.75% (2.35-3.84) respectively. Self-limiting cellulitis/leakage occurred in 41% (7/17) in the long-term abdominal drain group vs 11% (2/19) in the large-volume paracentesis group; peritonitis incidence was 6% (1/17) vs 11% (2/19) respectively. Questionnaires/interview uptake/completion were ≥80%; interviews indicated that long-term abdominal drains could transform the care pathway. CONCLUSIONS The REDUCe study demonstrates feasibility with preliminary evidence of long-term abdominal drain acceptability/effectiveness/safety and reduction in health resource utilisation. TRIAL REGISTRATION ISRCTN30697116, date assigned: 07/10/2015.
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15
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Verma M, Tapper EB, Singal AG, Navarro V. Nonhospice Palliative Care Within the Treatment of End-Stage Liver Disease. Hepatology 2020; 71:2149-2159. [PMID: 32167615 PMCID: PMC10362480 DOI: 10.1002/hep.31226] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 02/19/2020] [Indexed: 01/03/2023]
Abstract
Palliative care (PC) that has evolved from a focus on end-of-life care to an expanded form of holistic care at an early stage for patients with serious illnesses and their families is commonly referred to as nonhospice PC (or early PC). Patients with end-stage liver disease (ESLD) suffer from a high symptom burden and a deteriorated quality of life (QOL), with uncertain prognosis and limited treatment options. Caregivers of these patients also bear an emotional and physical burden similar to that of caregivers for patients with cancer. Despite the proven benefits of nonhospice PC for other serious illnesses and cancer, there are no evidence-based structures and processes to support its integration within the routine care of patients with ESLD and their caregivers. In this article, we review the current state of PC for ESLD and propose key structures and processes to integrate nonhospice PC within routine hepatology practice. Results found that PC is highly underutilized within ESLD care, and limited prospective studies are available to demonstrate methods to integrate PC within routine hepatology practices. Hepatology providers report lack of training to deliver PC along with no clear prognostic criteria on when to initiate PC. A well-informed model with key structures and processes for nonhospice PC integration would allow hepatology providers to improve clinical outcomes and QOL for patients with ESLD and reduce health care costs. Educating hepatology providers about PC principles and developing clear prognostic criteria for when and how to integrate PC on the basis of individual patient needs are the initial steps to inform the integration. The fields of nonhospice PC and hepatology have ample opportunities to partner clinically and academically.
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Affiliation(s)
- Manisha Verma
- Department of Digestive Diseases and Transplantation, Einstein Healthcare Network, Philadelphia, PA
| | - Elliot B Tapper
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI
| | - Amit G Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Victor Navarro
- Department of Digestive Diseases and Transplantation, Einstein Healthcare Network, Philadelphia, PA
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16
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Patel A, Ufere NN. Integrating Palliative Care in the Management of Patients With Advanced Liver Disease. Clin Liver Dis (Hoboken) 2020; 15:136-140. [PMID: 32395238 PMCID: PMC7206323 DOI: 10.1002/cld.936] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 01/26/2020] [Indexed: 02/04/2023] Open
Abstract
http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-4-reading-patel a video presentation of this article.
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Affiliation(s)
- Arpan Patel
- Digestive DiseasesUniversity of California Los AngelesLos AngelesCA,GastroenterologyWest Los Angeles Veterans Affairs Medical CenterLos AngelesCA
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17
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Patel A, Asch S, Antonio AL, Kanwal F, Lorenz K, Riopelle D, Dickey A, Larkin J, Lee M, Walling A. Measuring the Quality of Palliative Care for Patients with End-Stage Liver Disease. Dig Dis Sci 2020; 65:2562-2570. [PMID: 31927765 PMCID: PMC7223418 DOI: 10.1007/s10620-019-05983-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/27/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND/AIMS We examined the quality of palliative care received by patients with decompensated cirrhosis using an explicit set of palliative care quality indicators (QIs) for patients with end-stage liver disease (PC-ESLD). METHODS We identified patients newly diagnosed with decompensated cirrhosis at a single veterans health center and followed up them for 2 years or until death. We piloted measurement of PC-ESLD QIs in all patients confirmed to have ESLD using a chart abstraction tool. RESULTS Out of 167 patients identified using at least one sampling strategy, 62 were confirmed to meet ESLD criteria with chart abstraction. Ninety-eight percent of veterans in the cohort were male, mean age at diagnosis was 61 years, and 74% were White. The overall QI pass rate was 68% (64% for information care planning QIs and 76% for supportive care QIs). Patients receiving specialty palliative care consultation were more likely to receive information care planning QIs (67% vs. 37%, p = 0.02). The best performing sampling strategy had a sensitivity of 62% and specificity of 60%. CONCLUSION Measuring the quality of palliative care for patients with ESLD is feasible in the veteran population. Our single-center data suggest that the quality of palliative care is inadequate in the veteran population with ESLD, though patients offered specialty palliative care consultation and those affected by homelessness, drug, and alcohol abuse may receive better care. Our combination of ICD-9 codes can be used to identify a cohort of patients with ESLD, though better sensitivity and specificity may be needed.
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Affiliation(s)
- Arpan Patel
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Steven Asch
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | | | - Fasiha Kanwal
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Karl Lorenz
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Deborah Riopelle
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Anna Dickey
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Jennifer Larkin
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Martin Lee
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Anne Walling
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
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18
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Ufere NN, Donlan J, Waldman L, Dienstag JL, Friedman LS, Corey KE, Hashemi N, Carolan P, Mullen AC, Thiim M, Bhan I, Nipp R, Greer JA, Temel JS, Chung RT, El-Jawahri A. Barriers to Use of Palliative Care and Advance Care Planning Discussions for Patients With End-Stage Liver Disease. Clin Gastroenterol Hepatol 2019; 17:2592-2599. [PMID: 30885884 PMCID: PMC6745282 DOI: 10.1016/j.cgh.2019.03.022] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 02/28/2019] [Accepted: 03/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Despite evidence for the benefits of palliative care (PC) referrals and early advance care planning (ACP) discussions for patients with chronic diseases, patients with end-stage liver disease (ESLD) often do not receive such care. We sought to examine physicians' perceptions of the barriers to PC and timely ACP discussions for patients with ESLD. METHODS We conducted a cross-sectional survey of hepatologists and gastroenterologists who provide care to adult patients with ESLD, recruited from the American Association for the Study of Liver Diseases 2018 membership registry. Using a questionnaire adapted from prior studies, we assessed physicians' perceptions of barriers to PC use and timely ACP discussions; 396 of 1236 eligible physicians (32%) completed the questionnaire. RESULTS The most commonly cited barriers to PC use were cultural factors that affect perception of PC (by 95% of respondents), unrealistic expectations from patients about their prognosis (by 93% of respondents), and competing demands for clinicians' time (by 91% of respondents). Most respondents (81%) thought that ACP discussions with patients who have ESLD typically occur too late in the course of illness. The most commonly cited barriers to timely ACP discussions were insufficient communication between clinicians and families about goals of care (by 84% of respondents) and insufficient cultural competency training about end-of-life care (81%). CONCLUSION There are substantial barriers to use of PC and timely discussions about ACP-most hepatologists and gastroenterologists believe that ACP occurs too late for patients with ESLD. Strategies are needed to overcome barriers and increase delivery of high-quality palliative and end-of-life care to patients with ESLD.
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Affiliation(s)
- Nneka N. Ufere
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - John Donlan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Lauren Waldman
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Jules L. Dienstag
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | | | - Kathleen E. Corey
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Nikroo Hashemi
- Division of Gastroenterology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston MA, USA
| | - Peter Carolan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Alan C. Mullen
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Michael Thiim
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Irun Bhan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Ryan Nipp
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Joseph A. Greer
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Jennifer S. Temel
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Raymond T. Chung
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Areej El-Jawahri
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
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19
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Najafian N, Sack JS, DeLisle AM, Jakab S. Advance Care Planning for Patients with Cirrhosis in a Structured Inpatient/Outpatient Hepatology Program. J Palliat Med 2019; 22:1445-1448. [DOI: 10.1089/jpm.2018.0261] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Nilofar Najafian
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jordan S. Sack
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Angela M. DeLisle
- Northeast Medical Group, Yale New Haven Health, New Haven, Connecticut
| | - Simona Jakab
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut
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20
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Sprange A, Ismond KP, Hjartarson E, Chavda S, Carbonneau M, Kowalczewski J, Watanabe SM, Brisebois A, Tandon P. Advance Care Planning Preferences and Readiness in Cirrhosis: A Prospective Assessment of Patient Perceptions and Knowledge. J Palliat Med 2019; 23:552-557. [PMID: 31618102 DOI: 10.1089/jpm.2019.0244] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background: In 2014, the province of Alberta launched a campaign to promote public awareness of advance care planning (ACP) and its associated two-part documentation-a Goals of care designation (GCD, a medical order written by a health care practitioner detailing wishes for care) and a personal directive (PD, a document naming a surrogate decision maker). Notably, unlike the GCD, the PD can be self-initiated independent of a health practitioner. Objective: Two years after the campaign, we aimed to assess knowledge and recall of participation in ACP among cirrhosis patients. Design/Setting: Consecutive adult cirrhosis patients attending one of two specialty cirrhosis clinics in Edmonton, Alberta, were surveyed. Results: Ninety-seven patients were included. Mean model for end-stage liver disease was 12. Although 97% of patients indicated it was extremely important to know the reality of their illness, only 53% understood that cirrhosis would affect their future quality of life. Thirty-three percent of patients had completed a PD and 14% had completed a GCD. Seventy-eight percent of patients believed a GCD was important to them and 85% preferred to complete it in an outpatient clinic setting. Only a minority of patients who had taken the initiative to complete a PD in the community also had a GCD. Conclusions: Despite efforts to raise awareness of and educate Albertans about ACP, <20% of cirrhosis patients have a completed GCD. Additional strategic prioritization is required in both patients and providers to ensure that health practitioner-facilitated ACP is carried out as standard-of-care in all patients with cirrhosis.
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Affiliation(s)
- Ashleigh Sprange
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Kathleen P Ismond
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Emma Hjartarson
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Swati Chavda
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle Carbonneau
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jan Kowalczewski
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Sharon M Watanabe
- Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Amanda Brisebois
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Puneeta Tandon
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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21
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Woodland H, Hudson B, Forbes K, McCune A, Wright M. Palliative care in liver disease: what does good look like? Frontline Gastroenterol 2019; 11:218-227. [PMID: 32419913 PMCID: PMC7223359 DOI: 10.1136/flgastro-2019-101180] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/08/2019] [Accepted: 08/11/2019] [Indexed: 02/04/2023] Open
Abstract
The mortality rate from chronic liver disease in the UK is rising rapidly, and patients with advanced disease have a symptom burden comparable to or higher than that experienced in other life-limiting illnesses. While evidence is limited, there is growing recognition that care of patients with advanced disease needs to improve. Many factors limit widespread provision of good palliative care to these patients, including the unpredictable trajectory of chronic liver disease, the misconception that palliative care and end-of-life care are synonymous, lack of confidence in prescribing and lack of time and resources. Healthcare professionals managing these patients need to develop the skills to ensure effective delivery of core palliative care, with referral to specialist palliative care services reserved for those with complex needs. Core palliative care is best delivered by the hepatology team in parallel with active disease management. This includes ensuring that discussions about disease trajectory and advance care planning occur alongside active management of disease complications. Liver disease is strongly associated with significant social, psychological and financial hardships for patients and their carers; strategies that involve the wider multidisciplinary team at an early stage in the disease trajectory help ensure proactive management of such issues. This review summarises the evidence supporting palliative care for patients with advanced chronic liver disease, presents examples of current best practice and provides pragmatic suggestions for how palliative and disease-modifying care can be run in parallel, such that patients do not miss opportunities for interventions that improve their quality of life.
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Affiliation(s)
- Hazel Woodland
- Department of Hepatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Ben Hudson
- Department of Hepatology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Karen Forbes
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Anne McCune
- Department of Liver Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Mark Wright
- Department of Hepatology, University Hospital Southampton, Southampton, UK
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22
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Bergenholtz H, Timm HU, Missel M. Talking about end of life in general palliative care - what's going on? A qualitative study on end-of-life conversations in an acute care hospital in Denmark. BMC Palliat Care 2019; 18:62. [PMID: 31345196 PMCID: PMC6657144 DOI: 10.1186/s12904-019-0448-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 07/18/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND End-of-life (EOL) conversations in hospital should serve to give patients the opportunity to consider future treatment options and help them clarify their values and wishes before it becomes relevant to make decisions about treatment. However, it is known that EOL conversations are not performed systematically in hospital. This may mean that patients and their relatives do not address EOL issues. There is a lack of knowledge about who is responsible for conducting these conversations, and when and under what circumstances they are conducted. The aim of this study was to explore the existing practices regarding EOL conversations in an acute care hospital setting. METHODS The design was Interpretive Description and the methods for the data collection included: 1. Participatory observational studies in a pulmonary medical and surgical ward (a total of 66 h); 2. Four focus group interviews with healthcare professionals (n = 14) from the wards. The analysis followed Spradley's ethnosemantic analysis. RESULTS The results revealed three cultural categories related to: 1. The physical and organizational setting; 2. The timing of EOL conversations and competencies and roles in addressing EOL issues and 3. Topics addressed in EOL conversations. The EOL conversations were part of daily clinical practice, but there was a lack of competencies, roles were unclear and the physical and organizational environment was not conducive to the conversations. The topics of the EOL conversations revolved around a "here-and-now" status of the patient's disease progression and decisions about the level of treatment. To a lesser extent, the conversations included the patient's and relatives' thoughts and wishes concerning EOL, which allowed long-term care planning. CONCLUSION This study demonstrates that there are several barriers to talking about EOL in an acute care hospital setting, and future strategies must address an overall approach. In order to provide patients and their relatives with better opportunities to express their EOL wishes, there is a need for clearer roles and guidelines in an interdisciplinary approach to EOL conversations, alongside improved staff competencies and changes to the organizational and physical environment.
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Affiliation(s)
- Heidi Bergenholtz
- Holbaek Hospital, Smedelundsgade 60, 4300, Holbæk, Region Zealand, Denmark. .,REHPA, Knowledge Centre for Rehabilitation and Palliative Care, National Institute of Public Health, University of Southern Denmark, Vestergade 17, 5800, Nyborg, Denmark.
| | - Helle Ussing Timm
- REHPA, Knowledge Centre for Rehabilitation and Palliative Care, National Institute of Public Health, University of Southern Denmark, Vestergade 17, 5800, Nyborg, Denmark
| | - Malene Missel
- Rigshospitalet, Blegdamsvej 9, 2000, Copenhagen, Denmark
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23
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Esteban JPG, Rein L, Szabo A, Saeian K, Rhodes M, Marks S. Attitudes of Liver and Palliative Care Clinicians toward Specialist Palliative Care Consultation for Patients with End-Stage Liver Disease. J Palliat Med 2019; 22:804-813. [DOI: 10.1089/jpm.2018.0553] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
| | - Lisa Rein
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aniko Szabo
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kia Saeian
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mary Rhodes
- Section of Palliative Care, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sean Marks
- Section of Palliative Care, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
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24
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Ufere NN, Donlan J, Waldman L, Patel A, Dienstag JL, Friedman LS, Corey KE, Hashemi N, Carolan P, Mullen AC, Thiim M, Bhan I, Nipp R, Greer J, Temel J, Chung RT, El-Jawahri A. Physicians' Perspectives on Palliative Care for Patients With End-Stage Liver Disease: A National Survey Study. Liver Transpl 2019; 25:859-869. [PMID: 30963669 PMCID: PMC6529275 DOI: 10.1002/lt.25469] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/24/2019] [Indexed: 12/12/2022]
Abstract
Specialty palliative care (PC) is underused for patients with end-stage liver disease (ESLD). We sought to examine attitudes of hepatologists and gastroenterologists about PC for patients with ESLD. We conducted a cross-sectional survey of these specialists who provide care to patients with ESLD. Participants were recruited from the American Association for the Study of Liver Diseases membership directory. Using a questionnaire adapted from prior studies, we examined physicians' attitudes about PC and whether these attitudes varied based on patients' candidacy for liver transplantation. We identified predictors of physicians' attitudes about PC using linear regression. Approximately one-third of eligible physicians (396/1236, 32%) completed the survey. Most (95%) believed that centers providing care to patients with ESLD should have PC services, and 86% trusted PC clinicians to care for their patients. Only a minority reported collaborating frequently with inpatient (32%) or outpatient (11%) PC services. Most believed that when patients hear the term PC, they feel scared (94%) and anxious (87%). Most (83%) believed that patients would think nothing more could be done for their underlying disease if a PC referral was suggested. Physicians who believed that ESLD is a terminal condition (B = 1.09; P = 0.006) reported more positive attitudes about PC. Conversely, physicians with negative perceptions of PC for transplant candidates (B = -0.22; standard error = 0.05; P < 0.001) reported more negative attitudes toward PC. In conclusion, although most hepatologists and gastroenterologists believe that patients with ESLD should have access to PC, they reported rarely collaborating with PC teams and had substantial concerns about patients' perceptions of PC. Interventions are needed to overcome misperceptions of PC and to promote collaboration with PC clinicians for patients with ESLD.
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Affiliation(s)
- Nneka N. Ufere
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - John Donlan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Lauren Waldman
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Arpan Patel
- Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Jules L. Dienstag
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | | | - Kathleen E. Corey
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Nikroo Hashemi
- Division of Gastroenterology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston MA, USA
| | - Peter Carolan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Alan C. Mullen
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Michael Thiim
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Irun Bhan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Ryan Nipp
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Joseph Greer
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Jennifer Temel
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Raymond T. Chung
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Areej El-Jawahri
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
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Abstract
PURPOSE OF REVIEW End-stage liver disease (ESLD) is associated with high symptom burden, poor quality of life, and significant healthcare costs. Palliative care, which is not synonymous with hospice or end-of-life care, is a multidisciplinary model of care that focuses on patient-centered goals with the intent of improving quality of life and reducing suffering. This review will summarize current literature supporting the benefits of early integration of palliative care in patients in this population. RECENT FINDINGS Advance care planning (ACP) and goals of care discussions have been associated with improved quality of life, decreased anxiety, and improved satisfaction with care for both the patient and the caregiver. These discussions are beneficial to all patients with ESLD, including those listed for liver transplantation. SUMMARY Despite the resounding benefits of palliative care for patients with other advanced diseases, palliative care remains underutilized in liver disease. There is an urgent need for education of hepatology/transplant providers as well as development of society guidelines to help dissemination and acceptability of palliative care for patients with ESLD.
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Mazzarelli C, Prentice WM, Heneghan MA, Belli LS, Agarwal K, Cannon MD. Palliative care in end-stage liver disease: Time to do better? Liver Transpl 2018; 24:961-968. [PMID: 29729119 DOI: 10.1002/lt.25193] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/28/2018] [Accepted: 04/08/2018] [Indexed: 12/12/2022]
Abstract
Optimal involvement of palliative care (PC) services in the management of patients with decompensated cirrhosis and end-stage liver disease (ESLD) is limited. This may result from both ignorance and the failure to recognize the spectrum and unpredictability of the underlying liver condition. Palliative care is a branch of medicine that focuses on quality of life (QoL) by optimizing symptom management and providing psychosocial, spiritual, and practical support for both patients and their caregivers. Historically, palliative care has been underutilized for patients with decompensated liver disease. This review provides an evidence-based analysis of the benefits of the integration of palliative care into the management of patients with ESLD. Liver Transplantation 24 961-968 2018 AASLD.
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Affiliation(s)
- Chiara Mazzarelli
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom.,Hepatology and Gastroenterology Unit, ASST Ospedale Niguarda, Milan, Italy
| | - Wendy M Prentice
- Cicely Saunders Institute, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Luca S Belli
- Hepatology and Gastroenterology Unit, ASST Ospedale Niguarda, Milan, Italy
| | - Kosh Agarwal
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Mary D Cannon
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
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Brisebois A, Tandon P. Early Integration of Advance Care Planning (ACP) into Cirrhosis Care: Why We Need It. ACTA ACUST UNITED AC 2018. [DOI: 10.1007/s11901-018-0391-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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