Palliative care for patients with a failed liver transplant

Changing end-of-life care practice for liver transplant service patients: structured palliative care intervention in the surgical intensive care unit

CONTEXT

Patients, families, and surgeons often have high expectations of life-saving surgery following liver transplantation (LT), despite the presence of a severe life-limiting underlying illness. Hence, transition from curative to palliative care is difficult and may create conflicts around goals of care.

OBJECTIVES

We hypothesized that early communication with physicians/families would improve end-of-life care practice in the LT service patients.

METHODS

Prospective, observational, pre/poststudy of consecutive LT service, surgical intensive care unit (SICU) patients, before and after a palliative care intervention was integrated. This included Part I (at admission), family support, prognosis, and patient preferences delineation; and Part II (within 72 hours), interdisciplinary family meeting. Data on goals-of-care discussions, do-not-resuscitate (DNR) orders, withdrawal of life support, and family perceptions were collected.

RESULTS

Seventy-nine LT patients with 21 deaths comprised the baseline group and 104 patients with 31 deaths the intervention group. Eighty-five percent of patients received Part I and 58% Part II of the intervention. Goals-of-care discussions on physician rounds increased from 2% to 38% of patient-days. During the intervention, although mortality rates were unchanged, DNR status increased (52-81%); withdrawal of life support increased (35-68%); DNR was instituted earlier; admission to DNR decreased (mean of 38-19 days); DNR to death time increased (two to four days); and SICU mean length of stay decreased (by three days). Family responses suggested more "time with family"/"time to say goodbye."

CONCLUSION

Interdisciplinary communication interventions with physicians and families resulted in earlier consensus around goals of care for dying LT patients. Early integration of palliative care alongside disease-directed curative care can be accomplished in the SICU without change in mortality and has the ability to improve end-of-life care practice in LT patients.

Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care

Workforce shortages, late referrals, and palliative care program resource constraints present significant barriers to meeting the needs of hospitalized patients facing serious illnesses. The Center to Advance Palliative Care convened a consensus panel to select criteria by which patients at high risk for unmet palliative care needs can be identified in advance for a palliative care screening assessment. The consensus panel developed primary and secondary criteria for two checklists-one to use for screening at the time of admission and one for daily patient rounds. The consensus panel believes that by implementing a checklist approach to screening patients for unmet palliative care needs, combined with educational initiatives and other system-change work, hospital staff engaged in day-to-day patient care can identify a majority of such needs, reserving specialty palliative care services for more complex problems.

Hoping for a miracle: supporting patients in transplantation and cardiac assist programs

PURPOSE OF REVIEW

Palliative medicine is often viewed as a medical specialty reserved for end of life care. This review focuses on the role that palliative care can play in transplant and cardiac assist device programs, along the continuum of a patient's disease course.

RECENT FINDINGS

In general, transplant and cardiac assist programs do not incorporate palliative medicine during the treatment course, but rather reserve it for when the patient is approaching death and is no longer a candidate for transplant or device therapy. There is a new shift, however, to viewing the practice of aggressive medicine and palliative medicine as 'shared care' so as to optimize the patient's quality of life throughout his or her illness.

CONCLUSION

Transplant and cardiac assist device programs should not exclude the practice of palliative care in their daily work. Palliative care is not 'giving up' rather it is optimizing the quality of a patient's life irrespective of the level of disease severity and prognosis.

Who receives specialist palliative care in Western Australia--and who misses out

OBJECTIVES

To describe the characteristics of Western Australian (WA) people who received, and did not receive, specialist palliative care (SPC) during their last 12 months of life.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

People who died between 1 July 2000 and 31 December 2002 in WA, and whose cause of death was from cancer or selected non-cancer conditions.

MAIN OUTCOME MEASURES

Use of SPC in the last 12 months of life.

RESULTS

There were 27,971 deaths from all causes in WA over the study period. Two-thirds (68%) of people who died of cancer received SPC, but less than one in ten (8%) who died of selected non-cancer conditions received SPC. Those who died of cancer were significantly less likely to receive SPC if they were single or widowed, aged > 85 years or lived in a region other than a major city. Of those who died of selected noncancer conditions, people other than those who were married were significantly less likely to have accessed SPC. Indigenous people were less likely to have accessed SPC, although this was not statistically significant (OR = 0.70, 95% CI: 0.36-1.34).

CONCLUSIONS

Within a WA context, this study confirms established international evidence for problems of access to SPC by non-cancer patients and other disadvantaged groups. Importantly, this evidence is provided at a population level, thus documenting the extent of inequities in palliative care service provision. By pointing to the areas of most critical need, this study assists in health service policy and planning.

Estimating the size of a potential palliative care population

OBJECTIVES

To develop a method for estimating the population who could potentially benefit from receiving palliative care in the last year of their lives, and then apply the estimates to the Western Australian population to ascertain characteristics of these people.

METHODS

Three estimates of the potential palliative care population, Minimal, Mid-range and Maximal, were developed through focus groups, interviews and the literature. These estimates were applied to the cohort of people who died in Western Australia between 1 July 2000 and 31 December 2002 by linking death records with hospital morbidity data through the Western Australian Data Linkage System.

RESULTS

Between 0.28% and 0.50% of people in the Western Australian population in any one year could potentially benefit from palliative care, many of whom die from conditions other than neoplasms. While neoplasms accounted for 59.5% of all underlying causes of deaths in the Minimal Estimate, heart failure (21.0%), renal failure (9.8%), chronic obstructive pulmonary disease (9.6%), Alzheimer's disease (4.0%), liver failure (3.2%), Parkinson's disease (1.3%), motor neurone disease (0.9%), HIV/AIDS (<0.01%) and Huntington's disease (<0.01%) accounted for other conditions in this estimate. The study was expanded to include Mid-range and Maximal Estimates. Characteristics of the Western Australian population in these three estimates are described.

CONCLUSIONS

Unlike traditional palliative care estimates that focus on malignant disease, this study included nonmalignant conditions in a set of three estimates of a potential palliative care population. By using population-based data to describe characteristics of people who compose palliative care populations, these results offer a tool for planning equitable healthcare services.

Transplantation and palliative care: the convergence of two seemingly opposite realities

One of the authors once asked a great transplant surgeon what came to his mind when asked about palliative care. He had two answers: the first,was somewhat simplistic; the second was profound. He said that this type of service was helpful in the ICU when there was not much more to be done surgically for a patient who was dying; the second, was a story about an individual whom he had transplanted three times (who survived!) because he and his team did not want the patient and family to give up hope. The second answer is fundamentally more in keeping with the philosophy of palliative care, despite the extraordinary specific circumstances. The surgeon demonstrated ongoing presence and non abandonment. This patient was palliated, although few surgeons could have accomplished this by doing two retransplantations! Fortunately, for the less gifted and lucky, there are many ways in which to continue a meaningful presence to an ailing or dying patient on a transplant service that do not require a transplantation procedure. One wonders why palliative care and transplantation have not been more formally acquainted in the past given the extensive overlap of the populations served, the nature of the day-to-day problems, and the intensity of the commitment to the patient. The time is ripe for a formal mutual acquaintance between palliative care specialists and transplant teams,perhaps in the format of a work group that is similar to the work groups that promoted excellence in palliative care, such as the End Stage Renal Disease Workgroup, that were grant funded by the Robert Wood Johnson Foundation. The fields of transplantation and palliative care have a treasure trove of experience that is lacking in the other that could be exchanged profitably with a great sense of satisfaction for all.