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Mafi VIP, Soldera J. Palliative care for end-stage liver disease and acute on chronic liver failure: A systematic review. World J Methodol 2024; 14:95904. [DOI: 10.5662/wjm.v14.i4.95904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 06/20/2024] [Accepted: 07/03/2024] [Indexed: 07/26/2024] Open
Abstract
BACKGROUND End stage liver disease (ESLD) represents a growing health concern characterized by elevated morbidity and mortality, particularly among individual ineligible for liver transplantation. The demand for palliative care (PC) is pronounced in patients grappling with ESLD and acute on chronic liver failure (ACLF). Unfortunately, the historical underutilization of PC in ESLD patients, despite their substantial needs and those of their family caregivers, underscores the imperative of seamlessly integrating PC principles into routine healthcare practices across the entire disease spectrum.
AIM To comprehensively investigate the evidence surrounding the benefits of incorporating PC into the comprehensive care plan for individuals confronting ESLD and/or ACLF.
METHODS A systematic search in the Medline (PubMed) database was performed using a predetermined search command, encompassing studies published in English without any restrictions on the publication date. Subsequently, the retrieved studies were manually examined. Simple descriptive analyses were employed to summarize the results.
RESULTS The search strategies yielded 721 references. Following the final analysis, 32 full-length references met the inclusion criteria and were consequently incorporated into the study. Meticulous data extraction from these 32 studies was undertaken, leading to the execution of a comprehensive narrative systematic review. The review found that PC provides significant benefits, reducing symptom burden, depressive symptoms, readmission rates, and hospital stays. Yet, barriers like the appeal of transplants and misconceptions about PC hinder optimal utilization. Integrating PC early, upon the diagnosis of ESLD and ACLF, regardless of transplant eligibility and availability, improves the quality of life for these patients.
CONCLUSION Despite the substantial suffering and poor prognosis associated with ESLD and ACLF, where liver transplantation stands as the only curative treatment, albeit largely inaccessible, PC services have been overtly provided too late in the course of the illness. A comprehensive understanding of PC's pivotal role in treating ESLD and ACLF is crucial for overcoming these barriers, involving healthcare providers, patients, and caregivers.
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Affiliation(s)
- Vakaola I Pulotu Mafi
- Post-Graduate Program, Acute Medicine, University of South Wales, Cardiff CF37 1DL, United Kingdom
| | - Jonathan Soldera
- Post-Graduate Program, Acute Medicine, University of South Wales, Cardiff CF37 1DL, United Kingdom
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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] [MESH Headings] [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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Oliveira HM, Ramos JP, Rego F, Nunes R. Palliative care and end stage liver disease: A survey study comparing perspectives of hepatology and palliative care physicians and clinical scenarios that could require palliative care intervention. Clin Res Hepatol Gastroenterol 2024; 48:102416. [PMID: 38986810 DOI: 10.1016/j.clinre.2024.102416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 07/05/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND AND AIMS The prevalence and mortality of chronic liver disease has risen significantly. In end stage liver disease (ESLD) the survival of patients is approximately 2 years. Despite the poor prognosis and high symptom burden of these patients, integration of palliative care is reduced. We aim to analyze the agreement between palliative care and hepatology physicians of clinical scenarios that could require palliative care intervention. METHODS A cross-sectional study was conducted. Palliative care and hepatology physicians were surveyed. Using a five-point Likert scale, their perceptions of palliative care in ESLD were rated. Their agreement in clinical scenarios that could require palliative care intervention were evaluated. Analyses were conducted to assess any differences by primary role (hepatology vs. palliative care) and length of practice (<10 years vs. 10 years). RESULTS A total of 123 responses were obtained: 52% from palliative care and 48% from hepatology. The majority (66.7%) work in the field for up to ten years. There was a great consensus in 4 of the 8 clinical scenarios. In scenarios with less consensus, the area of activity and length of practice influence the reliance of physicians on palliative care. Involvement of palliative care in ESLD was considered "rare" by 30% and 61% consider difficult to predict the prognosis. More than 90% support medical training in both areas of activity. CONCLUSION The current involvement of palliative care is considered low, but there are clinical conditions that reveal a clear consensus and there's a unanimous view of the relevance of training.
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Affiliation(s)
- Hugo M Oliveira
- Department of Social Sciences and Health, Faculty of Medicine, University of Porto, Porto, Portugal; Palliative Care Unit, Matosinhos Local Health Unit, Matosinhos, Portugal.
| | - José Presa Ramos
- Hepatology Unit of Internal Medicine Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, 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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Manning ME, Fricker Z. Cardiopulmonary Resuscitation Outcomes and Trainee Perception of Code Status Discussions in Patients with Cirrhosis. Dig Dis Sci 2024; 69:2390-2400. [PMID: 38652391 DOI: 10.1007/s10620-024-08443-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Cardiopulmonary resuscitation (CPR) outcomes among patients with cirrhosis are poor, but factors associated with outcomes and provider awareness remain under-evaluated. AIMS We retrospectively investigated in-hospital CPR mortality among patients with cirrhosis, and, using these results, undertook an educational study among providers to improve knowledge of CPR outcomes and code status in patients with cirrhosis. METHODS We identified patients with cirrhosis admitted from 2012 to 2022 who underwent CPR at our center; the primary outcome was survival-to-discharge. A brief video based on these results was presented online to Internal Medicine residents, along with paired pre/post-surveys assessing attitudes toward holding code status conversations and knowledge of CPR outcomes in patients with cirrhosis. RESULTS 97 cases of CPR were identified. 27 patients (28%) survived to discharge post-CPR. A history of liver decompensation was significantly associated with lower survival (OR 0.21, p < 0.05). 22 residents participated in the educational intervention; afterward, their estimation of survival after CPR for patients with cirrhosis significantly improved (p < 0.05). Mean confidence in answering patient questions about prognosis, measured from 1 to 5, also significantly improved (2.4-"a little confident" vs. 3.8-"confident", p < 0.05). 59% of surveyed residents identified impact on liver transplant candidacy as at least a "somewhat significant" barrier to code status conversations. CONCLUSIONS We identified significant trainee uncertainty about outcomes in patients with cirrhosis. These deficits improved after an educational intervention and gave providers more confidence in holding informed code status conversations with patients with cirrhosis, a population that faces barriers to adequate code discussions.
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Affiliation(s)
- Margot E Manning
- Harvard Medical School, Boston, MA, USA.
- Internal Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Zachary Fricker
- Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Hepatology, & Nutrition, Beth Israel Deaconess Medical Center, Boston, MA, USA
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5
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Karvellas CJ, Bajaj JS, Kamath PS, Napolitano L, O'Leary JG, Solà E, Subramanian R, Wong F, Asrani SK. AASLD Practice Guidance on Acute-on-chronic liver failure and the management of critically ill patients with cirrhosis. Hepatology 2024; 79:1463-1502. [PMID: 37939273 DOI: 10.1097/hep.0000000000000671] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Affiliation(s)
- Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Jasmohan S Bajaj
- Virginia Commonwealth University, Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Patrick S Kamath
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | | | - Jacqueline G O'Leary
- Department of Medicine, Dallas Veterans Medical Center, University of Texas Southwestern Medical Center Dallas, Texas, USA
| | - Elsa Solà
- Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford, California, USA
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Bansal AD, Patel AA. Dialysis initiation for patients with decompensated cirrhosis when liver transplant is unlikely. Curr Opin Nephrol Hypertens 2024; 33:212-219. [PMID: 38038622 DOI: 10.1097/mnh.0000000000000959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to describe an approach that emphasizes shared decision-making for patients with decompensated cirrhosis and acute kidney injury when liver transplantation is either not an option, or unlikely to be an option. RECENT FINDINGS When acute kidney injury occurs on a background of decompensated cirrhosis, outcomes are generally poor. Providers can also be faced with prognostic uncertainty. A lack of guidance from nephrology and hepatology professional societies means that providers rely on expert opinion or institutional practice patterns. SUMMARY For patients who are unlikely to receive liver transplantation, the occurrence of acute kidney injury represents an opportunity for a goals of care conversation. In this article, we share strategies through which providers can incorporate more shared decision-making when caring for these patients. The approach involves creating prognostic consensus amongst multidisciplinary teams and then relying on skilled communicators to share the prognosis. Palliative care consultation can be useful when teams need assistance in the conversations.
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Affiliation(s)
- Amar D Bansal
- Renal Electrolyte Division, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Arpan A Patel
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California
- Greater Los Angeles Veterans Affairs Healthcare System, Gastroenterology, Hepatology and Parenteral Nutrition, Los Angeles
- VA Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), North Hills, California, USA
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Pitzer S, Kutschar P, Paal P, Mülleder P, Lorenzl S, Wosko P, Osterbrink J, Bükki J. Barriers for Adult Patients to Access Palliative Care in Hospitals: A Mixed Methods Systematic Review. J Pain Symptom Manage 2024; 67:e16-e33. [PMID: 37717708 DOI: 10.1016/j.jpainsymman.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Access to palliative care services is variable, and many inpatients do not receive palliative care. An overview of potential barriers could facilitate the development of strategies to overcome factors that impede access for patients with palliative care needs. AIM To review the current evidence on barriers that impair, delay, or prohibit access to palliative care for adult hospital inpatients. DESIGN A mixed methods systematic review was conducted using an integrated convergent approach and thematic synthesis (PROSPERO ID: CRD42021279477). DATA SOURCES The Cochrane Library, MEDLINE, CINAHL, and PsycINFO were searched from 10/2003 to 12/2020. Studies with evidence of barriers for inpatients to access existing palliative care services were eligible and reviewed. RESULTS After an initial screening of 3,359 records and 555 full-texts, 79 studies were included. Thematic synthesis yielded 149 access-related phenomena in 6 main categories: 1) Sociodemographic characteristics, 2) Health-related characteristics, 3) Individual beliefs and attitudes, 4) Interindividual cooperation and support, 5) Availability and allocation of resources, and 6) Emotional and prognostic challenges. While evidence was inconclusive for most socio-demographic factors, the following barriers emerged: having a noncancer condition or a low symptom burden, the focus on cure in hospitals, nonacceptance of terminal prognosis, negative perceptions of palliative care, misleading communication and conflicting care preferences, lack of resources, poor coordination, insufficient expertise, and clinicians' emotional discomfort and difficult prognostication. CONCLUSION Hospital inpatients face multiple barriers to accessing palliative care. Strategies to address these barriers need to take into account their multidimensionality and long-standing persistence.
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Affiliation(s)
- Stefan Pitzer
- Institute of Nursing Science and Practice (S.P., P.K., P.M., J.O., J.B.), Paracelsus Medical University, Salzburg, Austria.
| | - Patrick Kutschar
- Institute of Nursing Science and Practice (S.P., P.K., P.M., J.O., J.B.), Paracelsus Medical University, Salzburg, Austria
| | - Piret Paal
- Institute of Palliative Care (P.P., S.L.), Paracelsus Medical University, Salzburg, Austria
| | - Patrick Mülleder
- Institute of Nursing Science and Practice (S.P., P.K., P.M., J.O., J.B.), Paracelsus Medical University, Salzburg, Austria
| | - Stefan Lorenzl
- Institute of Palliative Care (P.P., S.L.), Paracelsus Medical University, Salzburg, Austria
| | - Paulina Wosko
- Gesundheit Österreich GmbH (GÖG, Austrian Public Health Institute) (P.W.), Vienna, Austria
| | - Jürgen Osterbrink
- Institute of Nursing Science and Practice (S.P., P.K., P.M., J.O., J.B.), Paracelsus Medical University, Salzburg, Austria
| | - Johannes Bükki
- Institute of Nursing Science and Practice (S.P., P.K., P.M., J.O., J.B.), Paracelsus Medical University, Salzburg, Austria; Helios-Kliniken Schwerin (J.B.), Center for Palliative Medicine, Schwerin, Germany
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Shehadah A, Yu Naing L, Bapaye J, Malik S, Mohamed M, Khalid N, Munoz A, Jadhav N, Mushtaq A, Okolo P, Eskridge E. Early palliative care referral may improve end-of-life care in end-stage liver disease patients: A retrospective analysis from a non-transplant center. Am J Med Sci 2024; 367:35-40. [PMID: 37923293 DOI: 10.1016/j.amjms.2023.10.006] [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: 03/24/2023] [Revised: 06/22/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Patients with end-stage liver disease (ESLD) who are not transplant candidates often have a trajectory of rapid decline and death similar to patients with stage IV cancer. Palliative care (PC) services have been shown to be underutilized for such patients. Most studies examining the role of PC in ESLD have been done at transplant centers. Thus, determining the utilization and benefit of PC at a non-transplant tertiary center may help establish a standard of care in the management of patients with ESLD not eligible for transplant. METHODS We conducted a retrospective analysis of adult (>18 years) patients with ESLD admitted to Rochester Regional Health (RRH) system hospitals from 2012 to 2021. Patients were divided into groups based on the presence or absence of PC involvement. Baseline characteristics were recorded. The impact of PC was assessed by comparing the number of hospitalizations before and after the involvement of PC, comparing code status changes, health care proxy (HCP) assignments, Aspira catheter placements, and frequency of repeated paracentesis. RESULTS In our analysis of 576 patients, 41.1% (237 patients) received a PC consult (PC group), while 58.9% (339 patients) did not (no-PC group). Baseline characteristics were comparable. However, their mean number of admissions significantly decreased (15.66 vs. 3.49, p < 0.001) after PC involvement. Full code status was more prevalent in the no-PC group (67.8% vs. 18.6%, p < 0.001), while comfort care code status was more common in the PC group (59.9% vs. 20.6%, p < 0.001). Changes in code status were significantly higher in the PC group (77.6% vs. 29.2%, p < 0.001). The PC group had a significantly higher mortality rate (83.1% vs. 46.4%, p < 0.01). Patients in the PC group had a higher likelihood of having an assigned HCP (63.7% vs. 37.5%, p < 0.001). PC referral was associated with more frequent use of an Aspira catheter (5.9% vs. 0.9%, p < 0.001) and more frequent paracentesis (30.8% vs. 16.8%, p < 0.001). CONCLUSIONS In conclusion, our study provides compelling evidence of the diverse advantages of palliative care for patients with end-stage liver disease, including reduced admissions, improved goals of care, code status modifications, enhanced healthcare proxy assignments, and targeted interventions. These findings highlight the potential significance of early integration of palliative care in the disease trajectory to provide comprehensive, patient-centered care that addresses the unique needs and preferences of individuals with advanced liver disease.
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Affiliation(s)
- Ahmed Shehadah
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States.
| | - Le Yu Naing
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Jay Bapaye
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Sheza Malik
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Mohamed Mohamed
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Nida Khalid
- Department of Gastroenterology, Rochester General Hospital, Rochester, New York, United States
| | - Anisleidys Munoz
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Nagesh Jadhav
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Asim Mushtaq
- Department of Gastroenterology, Rochester General Hospital, Rochester, New York, United States
| | - Patrick Okolo
- Department of Gastroenterology, Rochester General Hospital, Rochester, New York, United States
| | - Etta Eskridge
- Department of Palliative Care, Rochester General Hospital, Rochester, New York, United States
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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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10
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Woodland H, Buchanan RM, Pring A, Dancox M, McCune A, Forbes K, Verne J. Inequity in end-of-life care for patients with chronic liver disease in England. Liver Int 2023; 43:2393-2403. [PMID: 37519025 DOI: 10.1111/liv.15684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 06/05/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND AND AIMS The World Health Assembly recommends integration of palliative care into treatment of patients with any life-limiting condition, yet patients with non-malignant disease are less likely to receive specialist palliative care (SPC). This study compares SPC offered to patients with hepatocellular carcinoma (HCC) versus patients with chronic liver disease without HCC (CLD without HCC). METHODS Patients who died from CLD or HCC over 5 years (2013-2017) in England were identified using a dataset linking national data on all hospital admissions (Hospital Episode Statistics - HES) with national mortality data from the Office for National Statistics (HES - ONS). The primary outcome was the proportion of patients who received inpatient SPC in their last year of life (LYOL). Secondary outcomes were (1) early inpatient SPC input and (2) the proportion dying in a hospice. The outcomes were compared between patients with HCC and CLD without HCC. RESULTS 29 669 patients were identified, 8143 of whom had HCC. Patients with HCC were significantly more likely to receive inpatient SPC input-adjusted OR 3.74 (95% CI 3.52-3.97) and early inpatient SPC input-adjusted OR 7.26 (95% CI 6.38-8.25) and die in a hospice OR 8.23 (95% CI 7.33-9.24) than patients with CLD without HCC. CONCLUSIONS These data highlight the stark inequity in access to SPC services between patients with HCC and patients with CLD without HCC in England. Addressing these inequities will improve end-of-life care for patients with CLD.
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Affiliation(s)
- Hazel Woodland
- Department of Population Health Sciences, University of Bristol, Bristol, UK
- Gastrointestinal Unit, Salisbury NHS Foundation Trust, Salisbury, UK
| | - Ryan M Buchanan
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Andy Pring
- Office for Health Improvement and Disparities, Department of Health and Social Care, London, UK
| | - Mark Dancox
- Office for Health Improvement and Disparities, Department of Health and Social Care, London, UK
| | - Anne McCune
- Department of Hepatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Karen Forbes
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Julia Verne
- Office for Health Improvement and Disparities, Department of Health and Social Care, London, UK
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11
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Kieffer SF, Tanaka T, Ogilvie AC, Gilbertson-White S, Hagiwara Y. Palliative Care and End-of-Life Outcomes in Patients Considered for Liver Transplantation: A Single-Center Experience in the US Midwest. Am J Hosp Palliat Care 2023; 40:1049-1057. [PMID: 36448659 DOI: 10.1177/10499091221142841] [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] [Indexed: 09/19/2023] Open
Abstract
Introduction: Previous research has shown limited palliative care (PC) utilization among patients evaluated for liver transplantation (LT) despite the cohort's significant symptom burden, high frequency of hospitalization and risk of rapid decompensation. Our aim was to evaluate patient characteristics and end-of-life (EOL) outcomes (i.e. ICU utilization, code status, advance care planning) associated with the use of PC services in patients who were evaluated for LT. Methods: We performed a single-center cross-sectional study comprised of 223 deceased patients evaluated for LT between 1/1/2017 and 12/31/2021. We evaluated demographic characteristics and EOL outcomes for differences between patients who received PC consultation and those who did not. EOL outcomes associated with PC use were assessed using logistic and linear regression analysis adjusted for patient demographics. Results: Patients who received PC consultation were younger (mean 57 vs. 61; P = 0.048), had higher Model for end-stage Liver Disease (MELD) scores (27.5 vs. 22; P = 0.001), higher rates of hepatic encephalopathy (96% vs. 84%, P = 0.005), and were more frequently declined for LT (77% vs. 57%; P = 0.008). Patients who received PC services were less likely to die in the ICU (OR = 0.07 [0.02-0.18]) and were more likely to have documented advance care planning (OR = 3.16 [1.47-6.97]), family meetings (OR = 6.58 [2.72-17.08]), and goals-of-care discussions (OR = 14.83 [4.39-69.29]). Conclusion: For patients being evaluated for LT, PC utilization differed based on demographics, disease complications and severity, and transplant status. Those who received PC services had higher quality EOL care planning and fewer ICU admissions.
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Affiliation(s)
- Sawyer F Kieffer
- Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Tomohiro Tanaka
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Iowa, Iowa City, IA, USA
| | - Amy C Ogilvie
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | | | - Yuya Hagiwara
- Division of General Internal Medicine, Department of Medicine, University of Iowa, Iowa City, IA, USA
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12
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van Zyl C, Storms AD, van Deen W, Cardenas V, Ellis R, Flores A, Donovan J, Chu L, Patel T, Enguidanos S. A Pilot Study of a Palliative Care Service Embedded in a Hepatology Clinic at a Large Public Hospital. J Palliat Med 2023; 26:776-783. [PMID: 36577037 PMCID: PMC10398730 DOI: 10.1089/jpm.2022.0438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 12/29/2022] Open
Abstract
Background: End-stage liver disease (ESLD) patients carry heavy symptom burdens and risk receiving aggressive and sometimes unwanted care at end of life. Palliative care (PC), which aims to alleviate symptoms and facilitate goal-concordant care in serious illness, may offer substantial benefits for ESLD patients but is not widely provided. Objectives: To assess the impact of PC integrated within hepatology (PCIH) services on health care utilization, advance care planning (ACP), and hospice enrollment. Design: We compared patients who received PCIH (n = 55) to a retrospective cohort (n = 57) receiving usual care in an outpatient hepatology clinic. Setting/Subjects: From June 2016 to November 2017, we enrolled patients receiving care in a U.S. public hospital clinic who met the following inclusion criteria: (1) ESLD with a Model for End-Stage Liver Disease score ≥20, (2) hepatology approval for PC referral, and (3) at least one advanced complication of ESLD. Measurements: We assessed patient demographics, clinical information, health care insurance status, health care utilization, completion of psychosocial assessments, and ACP using two-sided Fisher's exact test and Mann-Whitney U tests. Results: Patients receiving PCIH more frequently had goals of care discussions (87.3% vs. 21.2% p ≤ 0.01), completed ACP documentation (56.4% vs. 7.0%, p ≤ 0.01), psychosocial assessments (98.2% vs. 35.1%, p ≤ 0.01), and hospice enrollment (25.5% vs. 7.0%, p = 0.01). Patients receiving PCIH who were hospitalized also had fewer mean hospitalization days (13 vs. 19.7 days, p ≤ 0.01). Conclusions: Embedding PC services in a hepatology clinic is a promising strategy to improve care for ESLD patients in public hospitals.
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Affiliation(s)
- Carin van Zyl
- Department of Medicine, Division of Geriatric, Hospital, Palliative, and General Internal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Aaron D. Storms
- Department of Medicine, Division of Geriatric, Hospital, Palliative, and General Internal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Welmoed van Deen
- Gehr Family Center for Health Systems Science, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Erasmus School of Health Policy and Management, Health Technology Assessment Section, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Valeria Cardenas
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA
| | - Robin Ellis
- Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Alicia Flores
- Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - John Donovan
- Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Medicine, Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lily Chu
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Tanu Patel
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Susan Enguidanos
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA
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13
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Singal AK, Kuo YF, Reddy KR, Bataller R, Kwo P. Healthcare burden and outcomes of hepatorenal syndrome among cirrhosis-related hospitalisations in the US. Aliment Pharmacol Ther 2022; 56:1486-1496. [PMID: 36196562 DOI: 10.1111/apt.17232] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/07/2022] [Accepted: 09/11/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Hepatorenal syndrome (HRS) contributes to significant morbidity and mortality in hospitalised patients with cirrhosis. AIMS To examine recent trends, magnitude and outcomes of HRS in the National Inpatient Sample (NIS) database METHODS: Among the NIS database on cirrhosis hospitalisations (2016-2019) due to alcohol (ALD), chronic viral hepatitis (CVH), or NASH and complicated by acute kidney injury (AKI) were analyzed. RESULTS Of 113,454 hospitalisations, 18,735 (16.5%) had HRS (mean age 56 years, 36% females, 68% whites, 80% ALD, 7% NASH) with a stable trend over time. Among 1:1 propensity-matched 36,090 hospitalisations, the odds of HRS were 12% higher in NASH versus CVH. Based on weighted national estimates, there were 27,180 (8.3 per 100,000 US population) HRS hospitalisations in 2019, with economic burden of $4.2 billion USD. Mean hospitalisation and total charges (ALD vs. CVH vs. NASH) were 11 versus 10.8 versus 9.2 days and 151,000 versus 157,000 versus 120,000 USD, respectively; p < 0.001. In-hospital mortality was 18.9%, higher in HRS (25.8 vs. 12%, p < 0.001), and decreased by 15% annually. Survivors were more likely to be discharged to short- or long-term care facilities (HRS vs. non-HRS [42 vs. 27%, p < 0.001]); only 28.7% received palliative care. CONCLUSION HRS was the cause of AKI in 16.5% of patients hospitalised with cirrhosis and conferred significant healthcare burden with 27,180 HRS hospitalisations in 2019 and requiring an estimated 4.2 billion USD for hospital care. While there has been a decrease in in-hospital mortality over time, it remained high at 23.7% in 2019 in those with HRS.
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Affiliation(s)
- Ashwani K Singal
- Department of Medicine, University of SD Sanford School of Medicine, Sioux Falls, South Dakota, USA.,Division of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, South Dakota, USA
| | - Yong-Fang Kuo
- Department of Biostatistics, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramon Bataller
- Division of Gastroenterology and Hepatology, UPMC, Pittsburgh, Philadelphia, USA
| | - Paul Kwo
- Division of Gastroenterology and Hepatology, Stanford University Medical School, Stanford, California, USA
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14
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Johnson AW, Byriel B, Rubeck J, Ghabril M, Orman ES. Standardized Criteria Increases Palliative Care Consultation Utilization in Patients With End-Stage Liver Disease: A Pilot Study. Am J Hosp Palliat Care 2022:10499091221127984. [PMID: 36167488 DOI: 10.1177/10499091221127984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Context: Patients with end-stage liver disease have high symptom burden and high healthcare utilization, which may be improved by palliative care consultation. Objectives: We sought to determine if implementing standardized palliative care consultation criteria in hospitalized patients with end-stage liver disease would increase palliative care utilization and improve patient outcomes. Methods: We conducted a retrospective cohort study of hospitalized patients with end-stage liver disease. Patients under the age of 18, received a previous liver transplant, or admitted for liver transplantation were not included. Patients with end-stage liver disease meeting two or more of the following criteria were included: (i)Child Pugh C cirrhosis, (ii)2 or more liver related hospitalizations within 6 months, (iii) current alcohol use with alcoholic cirrhosis, and (iv) unsuitable for transplantation work up. We compared consults before and after implementation of the criteria, and we compared outcomes in patients who did and did not see palliative care. Results: With implementation, consults increased (2/25 (8%) vs 11/33 (33%), p = .020). Palliative care was associated with higher completion of health care representative documentation (66.7% vs 35.7%, P = .20) and physician orders for scope of treatment forms (16.7% vs 0%, P = 0.13). Patients seen by palliative care had a higher rate of discharges with hospice (30.8% vs 0, P = .002). Conclusions: Implementation of standardized palliative care consultation criteria for patients with end-stage liver disease increased palliative care utilization. Patients seen by palliative care had increased discharges with hospice services and a trend towards higher completion rates of advanced directives.
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Affiliation(s)
- Amy W Johnson
- Division of General Internal Medicine & Geriatrics, 12250Indiana University School of Medicine, Indianapolis. IN, USA
| | - Benjamin Byriel
- Gastroenterology Fellowship, Department of Medicine, 12250Indiana University School of Medicine, Indianapolis. IN, USA
| | | | - Marwan Ghabril
- Division of Gastroenterology & Hepatology, 12250Indiana University School of Medicine, Indianapolis. IN, USA
| | - Eric S Orman
- Division of Gastroenterology & Hepatology, 12250Indiana University School of Medicine, Indianapolis. IN, USA
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15
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Rogal SS, Hansen L, Patel A, Ufere NN, Verma M, Woodrell CD, Kanwal F. AASLD Practice Guidance: Palliative care and symptom-based management in decompensated cirrhosis. Hepatology 2022; 76:819-853. [PMID: 35103995 PMCID: PMC9942270 DOI: 10.1002/hep.32378] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/14/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Shari S. Rogal
- Departments of Medicine and Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare Center, Pittsburgh, Pennsylvania, USA
| | - Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland, Oregon, USA
| | - Arpan Patel
- Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Nneka N. Ufere
- Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Manisha Verma
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, 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 Veterans Affairs Medical Center, Bronx, New York, USA
| | - Fasiha Kanwal
- Sections of Gastroenterology and Hepatology and Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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16
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Shinall MC, Bonnet K, Schlundt D, Verma M. Integrating Specialist Palliative Care in the Liver Transplantation Evaluation Process: A Qualitative Analysis of Hepatologist and Palliative Care Provider Views. Liver Transpl 2022; 28:678-688. [PMID: 34743396 PMCID: PMC8994529 DOI: 10.1002/lt.26364] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/30/2021] [Accepted: 11/03/2021] [Indexed: 01/13/2023]
Abstract
Patients undergoing evaluation for liver transplantation face heavy burdens of symptoms, health care use, and mortality. In other similarly ill populations, specialist palliative care has been shown to benefit patients, but specialist palliative care is infrequently used for liver transplantation patients. This project aims to describe the potential benefits of and barriers to specialist palliative care integration in the liver transplantation process. We performed qualitative analysis of transcripts from provider focus groups followed by a community engagement studio of patients and caregivers. Focus groups consisted of 14 palliative care specialists and 10 hepatologists from 11 institutions across the United States and Canada. The community engagement studio comprised patients and caregivers of patients either currently on the liver transplantation waiting list or recently after transplant. The focus groups identified 19 elements of specialist palliative care that could benefit this patient population, including exploring patients' illness understanding and expectations; assessing physical symptoms comprehensively; discussing patient values; and providing caregiver support, a safe space to discuss noncurative options, and anticipatory guidance about likely next steps. Identified barriers included role boundaries, differences in clinical cultures, limitations of time and staff, competing goals and priorities, misconceptions about palliative care, limited resources, changes in transplant status, and patient complexity. Community studio participants identified many of the same opportunities and barriers. This study found that hepatologists, palliative care specialists, patients, and caregivers identified areas of care for liver transplantation patients that specialist palliative care can improve and address.
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Affiliation(s)
- Myrick C. Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN,Section of Palliative Care, Vanderbilt University Medical Center, Nashville, TN
| | | | - David Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN
| | - Manisha Verma
- Department of Medicine, Einstein Healthcare Network, Philadelphia, PA
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17
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Vijeratnam SS, Candy B, Craig R, Marshall A, Stone P, Low JTS. Palliative Care for Patients with End-Stage Liver Disease on the Liver Transplant Waiting List: An International Systematic Review. Dig Dis Sci 2021; 66:4072-4089. [PMID: 33433811 DOI: 10.1007/s10620-020-06779-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/09/2020] [Indexed: 01/21/2023]
Abstract
People with end-stage liver disease on the liver transplant waiting list have high symptom burden, which can successfully be addressed by specialist palliative care. Potential tensions with the perceived curative nature of liver transplant make delivering specialist palliative care challenging. This systematic review seeks to establish what is known on the impact of specialist palliative care for patients on liver transplant waiting lists, healthcare professionals' perspectives of providing specialist palliative care for this population, and uptake of advance care planning (ACP). Medline, Embase, and CINAHL were searched to May 5, 2020. Qualitative and quantitative findings were grouped together according to main relevant themes. Eight studies of mixed quality and mainly quantitative, were identified. Findings suggest early palliative care intervention improve patients' symptoms and prompt ACP conversations, but patients on the waiting list receive limited palliative care input. Liver physicians' lack of clarity on referral criteria and liver transplant patients' concerns of being abandoned, were reasons for reluctance to refer to specialist palliative care. They felt referral to specialist palliative care is appropriate only for patients receiving hospice or end of life care. Uptake and understanding of ACP and goals of care designation by patients is poor. This review found evidence of benefit of specialist palliative care for patients on liver transplant waiting lists, but found in a limited understanding of their role. Evidence is limited to studies from North America. Future research is needed to understand better how palliative care could be provided into this clinical environment.
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Affiliation(s)
- Shan Shan Vijeratnam
- Camden, Islington ELiPSe and UCLH and HCA Palliative Care Service, CNWL-Central and North West London NHS Foundation Trust, 2nd Floor Wing B, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Bridget Candy
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Rachel Craig
- Palliative Care Department, Royal Free London NHS Trust, Pond Street, London, NW3 2QG, UK
| | - Aileen Marshall
- Sheila Sherlock Liver Unit, Royal Free Hospital, University College London, London, UK
- Institute of Liver and Digestive Health, UCL Royal Free Campus, Pond Street, London, NW3 2QG, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Joseph T S Low
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
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18
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Patel AA, Woodrell C, Ufere NN, Hansen L, Tandon P, Verma M, Lai J, Pinotti R, Rakoski M. Developing Priorities for Palliative Care Research in Advanced Liver Disease: A Multidisciplinary Approach. Hepatol Commun 2021; 5:1469-1480. [PMID: 34510839 PMCID: PMC8435283 DOI: 10.1002/hep4.1743] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/28/2021] [Accepted: 04/19/2021] [Indexed: 02/04/2023] Open
Abstract
Individuals with advanced liver disease (AdvLD), such as decompensated cirrhosis (DC) and hepatocellular carcinoma (HCC), have significant palliative needs. However, little research is available to guide health care providers on how to improve key domains related to palliative care (PC). We sought to identify priority areas for future research in PC by performing a comprehensive literature review and conducting iterative expert panel discussions. We conducted a literature review using search terms related to AdvLD and key PC domains. Individual reviews of these domains were performed, followed by iterative discussions by a panel consisting of experts from multiple disciplines, including hepatology, specialty PC, and nursing. Based on these discussions, priority areas for research were identified. We identified critical gaps in the available research related to PC and AdvLD. We developed and shared five key priority questions incorporating domains related to PC. Conclusion: Future research endeavors focused on improving PC in AdvLD should consider addressing the five key priorities areas identified from literature reviews and expert panel discussions.
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Affiliation(s)
- Arpan A. Patel
- Vatche and Tamar Manoukian Division of Digestive DiseasesDepartment of MedicineDavid Geffen School of Medicine at University of California Los AngelesLos AngelesCAUSA
- Veterans Affairs Greater Los Angeles Healthcare SystemLos AngelesCAUSA
| | - Christopher Woodrell
- Brookdale Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount SinaiNew YorkNYUSA
- James J. Peters Veterans Affairs Medical CenterBronxNYUSA
| | - Nneka N. Ufere
- Gastrointestinal UnitDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Lissi Hansen
- School of NursingOregon Health Sciences UniversityPortlandORUSA
| | - Puneeta Tandon
- Department of MedicineCirrhosis Care ClinicEdmontonALCanada
- Liver Transplant UnitUniversity of AlbertaEdmontonALCanada
| | - Manisha Verma
- Department of Digestive Diseases and TransplantationEinstein Healthcare NetworkPhiladelphiaPAUSA
| | - Jennifer Lai
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Rachel Pinotti
- Gustave L. and Janet W. Levy LibraryIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Mina Rakoski
- Division of Gastroenterology and HepatologyLoma Linda University HealthLoma LindaCAUSA
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19
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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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20
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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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21
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Vieira Silva S, Freire E, Pessegueiro Miranda H. Palliative Care in End-Stage Liver Disease Patients Awaiting Liver Transplantation: Review. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:417-428. [PMID: 33251291 DOI: 10.1159/000507336] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/17/2020] [Indexed: 01/15/2023]
Abstract
Introduction End-stage liver disease (ESLD) is the advanced phase of most liver diseases. The cure is liver transplantation (LT), only available for a minority of patients. This review summarizes the evidence regarding palliative care (PC) in ESLD patients awaiting LT. Methods Review of the literature available in Medline, Scopus and Web of Knowledge, with keywords ESLD and PC. Results Fifteen of the 230 articles reviewed met the inclusion criteria. Ten main themes were addressed: symptom burden; perspectives of life-sustaining treatment and comfort for patients, families and health professionals; goals of care discussions; patient and family needs; quality of life; PC and survival; referral to PC, barriers and opportunities; integration of PC; outpatient care and cost-effectiveness analysis. The referral of patients to PC was only evaluated in a few studies, all of which reported low referral rates. Better knowledge of how PC professionals can support other professionals was considered important, and also better ways to integrate PC were considered essential. Conclusion ESLD patients awaiting LT have a significant need for PC and, despite the insufficient response, were reported to benefit from this type of care. Future research is essential to determine the means to overcome barriers and better integrate PC for ESLD patients awaiting LT.
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Affiliation(s)
- Sara Vieira Silva
- Equipa Intra-Hospitalar de Suporte de Cuidados Paliativos, Serviço de Medicina, Centro Hospitalar e Universitário do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Elga Freire
- Equipa Intra-Hospitalar de Suporte de Cuidados Paliativos, Serviço de Medicina, Centro Hospitalar e Universitário do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Helena Pessegueiro Miranda
- Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal.,Unidade de Transplantação Hepato-bilio-pancreática, Centro Hospitalar e Universitário do Porto, Porto, Portugal.,Instituto de Saúde Publica da Universidade do Porto (ISPUP), Universidade do Porto, Porto, Portugal
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22
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Gustafson C, Song MK. State of the Science of Palliative Care in Solid Organ Transplantation. Prog Transplant 2020; 30:382-395. [PMID: 32930042 DOI: 10.1177/1526924820958156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Both solid organ transplant candidates and recipients and their family caregivers have complex care needs and may benefit from palliative care. But palliative care is not often considered as part of transplant care despite palliative care being promoted as an important component of transplant care both before and after solid organ transplantation. Further, the current state of the science of palliative care in solid organ transplantation has not been well-documented. OBJECTIVE To describe the state of the science of palliative care in solid organ transplant and identify gaps in the literature. METHODS Four electronic databases were searched using controlled vocabulary words and synonymous free text to find articles on palliative care and solid organ transplant. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist were also used. RESULTS Twenty articles were included in the final review for synthesis, 18 of which involved transplants for adults only. Twelve articles described palliative care for patients before transplant, four articles examined palliative care for patients after transplant, primarily at the end-of-life, and four articles described transplant provider perspectives on palliative care. The reviewed evidence suggested that patients could be benefited by palliative care both pre and posttransplant, particularly for symptom management and advance care planning and that transplant providers faced many barriers to implementing palliative care in practice. DISCUSSION There is limited research on palliative care following solid organ transplantation, particularly outside of hospice care. Much of the prior research on this topic has described adult patients.
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Affiliation(s)
- Carolina Gustafson
- Nell Hodgson Woodruff School of Nursing, 15792Emory University, Atlanta, GA, USA
| | - Mi-Kyung Song
- Nell Hodgson Woodruff School of Nursing, 15792Emory University, Atlanta, GA, USA
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23
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Hernaez R, Patel A, Jackson LK, Braun UK, Walling AM, Rosen HR. Considerations for Prognosis, Goals of Care, and Specialty Palliative Care for Hospitalized Patients With Acute-on-Chronic Liver Failure. Hepatology 2020; 72:1109-1116. [PMID: 32416642 DOI: 10.1002/hep.31316] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 03/26/2020] [Accepted: 04/02/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Ruben Hernaez
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, TX Center, Houston, TX.,VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX.,Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Arpan Patel
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA.,Division of Gastroenterology and Hepatology, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, CA
| | - Leanne K Jackson
- Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX.,Section of Rehabilitation and Extended Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Ursula K Braun
- VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX.,Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX.,Section of Rehabilitation and Extended Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Anne M Walling
- Department of Medicine, University of California, Los Angeles, CA.,VA Greater Los Angeles Health System, Los Angeles, CA
| | - Hugo R Rosen
- Department of Medicine, University of Southern California (USC), Los Angeles, CA.,USC Research Center for Liver Diseases, Los Angeles, CA
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24
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Peng JK, Chang HH, Higginson IJ, Gao W. Intensive care utilization in patients with end-stage liver disease: A population-based comparative study of cohorts with and without comorbid hepatocellular carcinoma in taiwan. EClinicalMedicine 2020; 22:100357. [PMID: 32462117 PMCID: PMC7240333 DOI: 10.1016/j.eclinm.2020.100357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND End-of-life intensive care may be futile and can be a cause of distress to both patients and their families. This study aimed to understand the utilization of intensive care and its associated factors in patients with End-stage liver disease (ESLD) during terminal hospitalization. METHODS Population-based retrospective cohort study using the National Health Institute Research Database of Taiwan. All adult patients with ESLD who died during their hospitalization in 2010-2013 were included. FINDINGS Of the 14,247 patients with ESLD, the majority (60·8%) was comorbid with hepatocellular carcinoma (HCC). Patients with ESLD only were younger, more deprived, more alcohol-related, and less likely to receive palliative care prior to terminal hospitalization (6·0% vs 29·2% with HCC). Compared to patients with comorbid HCC, relatively more patients without HCC were admitted to ICU (59·6% vs 22·3%), receiving CPR (11·1% vs 4·3%) and mechanical ventilation (36·3% vs 12·5%) during terminal hospitalization. Etiology of alcoholic hepatitis, esophageal varices, septicemia, pneumonia and respiratory failure, and renal failure were associated with a higher probability of ICU admission (adjusted rate ratio (aRR) range: 1·09-2·09). Prior palliative care was associated with lower probability of ICU admission (aRR range: 0·24-0·38). INTERPRETATION The intensive care utilization by patients with ESLD in their terminal hospitalization was substantial in Taiwan. Those who are not comorbid with HCC need more attention, especially in terms of their palliative care needs, choices regarding intensive care, and their healthcare utilization. FUNDING National Institute of Health Research Health Applied Research Collaboration (ARC) South London.
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Affiliation(s)
- Jen-Kuei Peng
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Address: Bessemer Road, London, SE5 9PJ, United Kingdom
- Department of Family Medicine, National Taiwan University College of Medicine, Address: No.1 Jen-Ai Road, Section 1, Taipei 100, Taiwan
- Department of Family Medicine, National Taiwan University Hospital, Address: No.7, Chung Shan South Road, Taipei 100, Taiwan
- Corresponding author: Tel.: 886-2-928595969
| | - Hao-Hsiang Chang
- Department of Family Medicine, National Taiwan University College of Medicine, Address: No.1 Jen-Ai Road, Section 1, Taipei 100, Taiwan
- Department of Family Medicine, National Taiwan University Hospital, Address: No.7, Chung Shan South Road, Taipei 100, Taiwan
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Address: Bessemer Road, London, SE5 9PJ, United Kingdom
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Address: Bessemer Road, London, SE5 9PJ, United Kingdom
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25
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Holden JH, Shamseddeen H, Johnson AW, Byriel B, Subramoney K, Cheng YW, Saito A, Ghabril M, Chalasani N, Sachs GA, Orman ES. Palliative Care and Hospice Referrals in Patients with Decompensated Cirrhosis: What Factors Are Important? J Palliat Med 2020; 23:1066-1075. [PMID: 32091954 DOI: 10.1089/jpm.2019.0501] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Palliative care (PC) and hospice care are underutilized for patients with end-stage liver disease, but factors associated with these patterns of utilization are not well understood. Objective: We examined patient-level factors associated with both PC and hospice referrals in patients with decompensated cirrhosis (DC). Design: Retrospective cohort study. Setting/Subjects: Patients with DC hospitalized at a single tertiary center and followed for one year. Measurements: We assessed PC and hospice referrals during follow-up and examined patient-level factors associated with the receipt of PC and/or hospice, as well as associated clinical outcomes. We also examined late referrals (within one week of death). Results: Of 397 patients, 61 (15.4%) were referred to PC, 71 (17.9%) were referred to hospice, and 99 (24.9%) were referred to PC and/or hospice. Two hundred patients (50.4%) died during the one-year follow-up. In multivariable logistic regression, referral to PC was associated with increased comorbidity burden, ascites, increased MELD (Model for End-Stage Liver Disease)-Na score, lack of listing for liver transplant, and unmarried status. Hospice referral was associated with increased comorbidities, portal vein thrombosis, and hepatocellular carcinoma. PC referrals were late in 68.5% of cases, and hospice referrals were late in 62.7%. Late PC referrals were associated with younger age and married status. Late hospice referrals were associated with younger age and recent alcohol use. Conclusions: PC and hospice is underutilized in patients with DC, and most referrals are late. Patient-level factors associated with these referrals differ between PC and hospice.
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Affiliation(s)
- John H Holden
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Hani Shamseddeen
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Amy W Johnson
- Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, USA
| | - Benjamin Byriel
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Kavitha Subramoney
- Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, USA
| | - Yao-Wen Cheng
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, California, USA
| | - Akira Saito
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Greg A Sachs
- Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, USA.,Regenstrief Institute, Inc., Indianapolis, Indiana
| | - Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
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26
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Barnes A, Woodman RJ, Kleinig P, Briffa M, To T, Wigg AJ. Early palliative care referral in patients with end stage liver disease is associated with reduced resource utilisation. J Gastroenterol Hepatol 2019; 35:840-845. [PMID: 31613397 DOI: 10.1111/jgh.14877] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/14/2019] [Accepted: 09/17/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Palliative care referral for end stage liver disease (ESLD) is uncommon and usually occurs late. We aimed to review the rate of early palliative care referral (EPCR) in ESLD patients, its associations, and its impacts on resource utilisation and survival. METHODS A retrospective review of all patients with ESLD admitted to a single hepatology unit between 2013 and 2016. Inclusion criteria for study entry were at least two admissions for decompensated liver disease within a six month period and not eligible for liver transplantation. The EPCR group was defined as those patients who received palliative care referral at least 30 days prior to mortality. RESULTS 74 patients were included in the study. EPCR rate was 19%. On multivariate analysis EPCR was associated with hepatocellular carcinoma (OR 4.47, 95% CI 1.02-19.5, p=0.047), and negatively associated with alcoholic liver disease (OR 0.16, 95% CI 0.032-0.88 p=0.035). There was no difference in survival based on EPCR status. Hospitalization costs were lower in the EPCR group (p=0.027). There was also a significantly lower number of endoscopies (p=0.009), and blood transfusions (p=0.001) in the EPCR group. EPCR was also associated with higher rates of outpatient palliative care and advanced care planning. CONCLUSIONS EPCR in ESLD was uncommon and associated with hepatocellular carcinoma and lack of alcoholic liver disease. EPCR was associated with decreased resource utilisation and further high quality studies are required to confirm the benefits of EPCR in ESLD.
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Affiliation(s)
- Alex Barnes
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, Australia
| | - Richard J Woodman
- Department of Epidemiliology and Biostatistics, College of Medicine and Public Health, Flinders University of South Australia, Australia
| | - Paul Kleinig
- Southern Adelaide Palliative Care Services, Australia
| | | | - Timothy To
- Southern Adelaide Palliative Care Services, Australia
| | - Alan J Wigg
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, Australia
- College of Medicine and Public Health, Flinders University of South Australia, Australia
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27
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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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28
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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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29
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Fricker ZP, Serper M. Current Knowledge, Barriers to Implementation, and Future Directions in Palliative Care for End-Stage Liver Disease. Liver Transpl 2019; 25:787-796. [PMID: 30758901 DOI: 10.1002/lt.25434] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 02/10/2019] [Indexed: 02/07/2023]
Abstract
End-stage liver disease (ESLD) is associated with a high degree of morbidity and mortality as well as symptom burden. Despite this, the rate of consultation with palliative care (PC) providers remains low, and invasive procedures near the end of life are commonplace. Studies show that involvement of PC providers improves patient satisfaction, and evidence from other chronic diseases demonstrates reduced costs of care and potentially increased survival. Better integration of PC is imperative but hindered by patient and provider misconceptions about its role in the care of patients with ESLD, specifically among candidates for liver transplantation. Additionally, reimbursement barriers and lack of provider knowledge may contribute to PC underutilization. In this review, we discuss the benefits of PC in ESLD, the variability of its delivery, and key stakeholders' perceptions about its use. Additionally, we identify barriers to more widespread PC adoption and highlight areas for future research.
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Affiliation(s)
- Zachary P Fricker
- Division of Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Marina Serper
- Division of Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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30
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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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31
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Place of death and factors associated with hospital death in patients who have died from liver disease in England: a national population-based study. Lancet Gastroenterol Hepatol 2019; 4:52-62. [DOI: 10.1016/s2468-1253(18)30379-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 10/25/2018] [Accepted: 10/26/2018] [Indexed: 12/13/2022]
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32
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Thomas T, Chandan JS, Bhala N. Unmet needs in end-of-life care for chronic liver disease. Lancet Gastroenterol Hepatol 2019; 4:6-7. [DOI: 10.1016/s2468-1253(18)30386-8] [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: 11/19/2018] [Accepted: 11/19/2018] [Indexed: 11/15/2022]
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33
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Carvalho JR, Vasconcelos M, Marques da Costa P, Marinho RT, Fatela N, Raimundo M, Carvalhana S, Ramalho F, Cortez-Pinto H, Velosa J. Identifying palliative care needs in a Portuguese liver unit. Liver Int 2018; 38:1982-1987. [PMID: 29682885 DOI: 10.1111/liv.13865] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 04/12/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Chronic liver disease is a major worldwide cause of morbidity and mortality. Palliative care policies are not clearly established in chronic liver disease. The NECPAL CCOMS-ICO© (NECesidades PALiativas/Palliative Needs) is a tool to identify palliative care needs, including a section for liver disease. AIM The aim of this study was to identify palliative care needs in liver patients hospitalised in a tertiary referral Liver Unit. METHODS Single-centre prospective observational study. One hundred and twenty patients with cirrhosis were included and NECPAL questionnaire was applied to all patients in a 7-month period. RESULTS 84.2% of patients were considered as requiring palliative intervention; however, clinicians identified those needs only in 65.8% of the cases and caregivers in 6.7% of the cases; less than 8% of the patients were referred for palliative care consultation. An excessive use of healthcare resources (positive answer to question 3) was strongly associated with a positive need for palliative care (positive NECPAL): OR 7.305, CI 95% 2.54-20.995, P < .001). An excessive use of healthcare facilities has a sensitivity of 84.2% and a specificity of 42.1% for prediction of a positive NECPAL result (AUC 0.710, 95% CI 0.570-0.850, P = .004). CONCLUSIONS The NECPAL CCOMS-ICO© represents a feasible and easy-to-use tool to identify palliative care needs in patients with chronic liver disease.
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Affiliation(s)
- Joana Rita Carvalho
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - Mariana Vasconcelos
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - Pedro Marques da Costa
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - Rui Tato Marinho
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - Narcisa Fatela
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - Miguel Raimundo
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - Sofia Carvalhana
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - Fernando Ramalho
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - Helena Cortez-Pinto
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - José Velosa
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
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Oud L. Patterns of palliative care utilization among patients with end stage liver disease during end-of-life hospitalizations: A population-level analysis. J Crit Care 2018; 48:290-295. [PMID: 30269008 DOI: 10.1016/j.jcrc.2018.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 09/08/2018] [Accepted: 09/10/2018] [Indexed: 01/11/2023]
Abstract
PURPOSE To investigate the patterns and predictors of palliative care (PC) utilization across ICU- and non ICU-managed patients with end-stage liver disease (ESLD) during end-of-life hospitalization. MATERIALS AND METHODS The Texas Inpatient Public Use Data File was used to perform a retrospective, population-based cohort study of patients with ESLD and end-of-life hospitalization during 2005-2014. PC use among ICU- and non ICU-managed patients was examined. Logistic regression modeling was used to identify predictors of PC. RESULTS We studied 30,301 patients, of which 5484 (18.1%) had reported PC and 24,174 (79.8%) were admitted to ICU. Between 2005 and 2014 PC use among ICU- and non ICU-managed patients increased from 0.5% to 32.9% and 7.1% to 47.0%, respectively, while ICU admission rate rose from 76.5% to 82.9%. PC use was reduced with rising APR-DRG illness severity (adjusted odds ratio, "extreme" vs. "minor" 0.36 [95% confidence interval, 0.24-0.54]), ICU admission (0.60 [0.55-0.65]), and use of mechanical ventilation (0.75 [0.70-0.81]). CONCLUSIONS There was persistent gap in use of PC among ICU-managed patients with ESLD during end-of-life hospitalization. ICU utilization rose, unexpectedly, despite the increasing use of PC in this cohort, and PC utilization was, paradoxically, lower among patients with the highest need.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, Odessa, TX 79763, USA.
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35
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Abstract
It is currently estimated that 5.7 million Americans live with heart failure. Of these, less than 3000 will receive a heart transplant this year, according to the US Department of Health and Human Services Organ Procurement and Transplantation Network. With successful transplantation can come significant emotional and physical symptoms that are not always addressed. Although palliative care is an interdisciplinary subspecialty designed to alleviate multiple domains of suffering in serious illness, many mistakenly associate it solely with the end of life. Traditionally associated with cancer, research into the role of palliative care in other chronic illnesses and complex life-changing therapies such as solid organ transplantation remains scarce but is nonetheless developing. Here, we try to investigate a potential role for palliative care for heart transplant recipients. Early research thus far has demonstrated importance of early involvement of palliative care teams and the significant improvement of physical and emotional symptoms in the pre- and post-transplant period. Nevertheless, more research is warranted to determine the ideal timing of palliative care integration, the effects on health care resource utilization, and whether improving quality of life can affect morbidity and mortality. By understanding these critical elements and others we may be able to develop a model for the role of palliative care for heart transplant patients.
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36
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Hudson B, Hunt V, Waylen A, McCune CA, Verne J, Forbes K. The incompatibility of healthcare services and end-of-life needs in advanced liver disease: A qualitative interview study of patients and bereaved carers. Palliat Med 2018; 32:908-918. [PMID: 29393806 DOI: 10.1177/0269216318756222] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Liver disease represents the third commonest cause of death in adults of working age and is associated with an extensive illness burden towards the end of life. Despite this, patients rarely receive palliative care and are unlikely to be involved in advance care planning discussions. Evidence addressing how existing services meet end-of-life needs, and exploring attitudes of patients and carers towards palliative care, is lacking. AIM To explore the needs of patients and carers with liver disease towards the end of life, evaluate how existing services meet need, and examine patient and carer attitudes towards palliative care. DESIGN Qualitative study - semi-structured interviews analysed using thematic analysis. Settings/participants: A total of 17 participants (12 patients, 5 bereaved carers) recruited from University Hospitals Bristol. RESULTS Participants described escalating physical, psychological and social needs as liver disease progressed, including disabling symptoms, emotional distress and uncertainty, addiction, financial hardship and social isolation. End-of-life needs were incompatible with the healthcare services available to address them; these were heavily centred in secondary care, focussed on disease modification at the expense of symptom control and provided limited support after curative options were exhausted. Attitudes towards palliative care were mixed, however, participants valued opportunities to express future care preferences (particularly relating to avoidance of hospital admission towards the end of life) and an increased focus on symptomatic and logistical aspects of care. CONCLUSION The needs of patients with liver disease and their carers are frequently incompatible with the healthcare services available to them towards the end of life. Novel strategies, which recognise the life-limiting nature of liver disease explicitly and improve coordination with community services, are required if end-of-life care is to improve.
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Affiliation(s)
- Benjamin Hudson
- 1 University Hospitals Bristol NHS Foundation Trust, Bristol, UK.,2 Bristol Medical School, University of Bristol, Bristol, UK
| | - Victoria Hunt
- 1 University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Andrea Waylen
- 3 Bristol Dental School, University of Bristol, Bristol, UK
| | | | | | - Karen Forbes
- 1 University Hospitals Bristol NHS Foundation Trust, Bristol, UK.,2 Bristol Medical School, University of Bristol, Bristol, UK
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37
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Langberg KM, Kapo JM, Taddei TH. Palliative care in decompensated cirrhosis: A review. Liver Int 2018; 38:768-775. [PMID: 29112338 DOI: 10.1111/liv.13620] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 10/30/2017] [Indexed: 12/16/2022]
Abstract
Decompensated cirrhosis is an illness that causes tremendous suffering. The incidence of cirrhosis is increasing and rates of liver transplant, the only cure, remain stagnant. Palliative care is focused on improving quality of life for patients with serious illness by addressing advanced care planning, alleviating physical symptoms and providing emotional support to the patient and family. Palliative care is used infrequently in patients with decompensated cirrhosis. The allure of transplant as a potential treatment option for cirrhosis, misperceptions about the role of palliative care and difficulty predicting prognosis in liver disease are potential contributors to the underutilization of palliative care in this patient population. Studies have demonstrated some benefit of palliative care in patients with decompensated cirrhosis but the literature is limited to small observational studies. There is evidence that palliative care consultation in other patient populations lowers hospital costs and ICU utilization and improves symptom control and patient satisfaction. Prospective randomized control trials are needed to investigate the effects of palliative care on traditional- and patient-reported outcomes as well as cost of care in decompensated cirrhosis for transplant eligible and ineligible patient populations.
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Affiliation(s)
- Karl M Langberg
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer M Kapo
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Tamar H Taddei
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, West Haven, CT, USA
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Palliative Care for People With Hepatocellular Carcinoma, and Specific Benefits for Older Adults. Clin Ther 2018; 40:512-525. [PMID: 29571567 DOI: 10.1016/j.clinthera.2018.02.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 02/28/2018] [Accepted: 02/28/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE Hepatocellular carcinoma (HCC), the most common type of primary liver cancer, has a rapidly rising prevalence in the United States and a very poor overall rate of survival. This epidemic is driven by the cohort of aging Baby Boomers with hepatitis C viral infection and the increasing prevalence of cirrhosis as a result of nonalcoholic steatohepatitis. Because curative options are limited, the disease course creates, in patients and their families, distressing uncertainty around prognosis and treatment decisions. Older adults are disproportionately affected by HCC and have more comorbidities, adding to the complexity of the disease. This population would benefit from increased access to palliative care services, which can potentially complement the treatments throughout the disease trajectory. The purpose of this review was to use existing evidence to propose a new model of palliative care integration in patients with HCC. Thus, we focus on the HCC stage and the treatment algorithm, the ways that palliative care can offer support in this population at each stage, as well as elements that can enhance patient and family support throughout the entire disease trajectory, with an emphasis on the care of older adults with HCC. METHODS This is a narrative review in which we identify evidence-based ways that palliative care can help younger and older adults with HCC and their families, at each stage of HCC and throughout the disease trajectory. FINDINGS We propose ways to integrate HCC and palliative care based on the existing evidence in both fields. Palliative care offers support in symptom management, advanced care planning, and decision making in ways that are specific to each stage of HCC. We also discuss the evidence that illustrates the palliative care needs of patients with HCC that span the entire course of illness, including coping with the stigmatization of liver disease, addressing informational needs at different stages, and discussing quality of life longitudinally. IMPLICATIONS Integrating palliative care into the treatment of patients with HCC has the potential to improve outcomes, although more research is needed to build this evidence base.
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Wentlandt K, Weiss A, O'Connor E, Kaya E. Palliative and end of life care in solid organ transplantation. Am J Transplant 2017; 17:3008-3019. [PMID: 28976070 DOI: 10.1111/ajt.14522] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 09/17/2017] [Accepted: 09/22/2017] [Indexed: 01/25/2023]
Abstract
Palliative care is an interprofessional approach that focuses on quality of life of patients who are facing life-threatening illness. Palliative care is consistently associated with improvements in advance care planning, patient and caregiver satisfaction, quality of life, symptom burden, and lower healthcare utilization. Most transplant patients have advanced chronic disease, significant symptom burden, and mortality awaiting transplant. Transplantation introduces new risks including perioperative death, organ rejection, infection, renal insufficiency, and malignancy. Numerous publications over the last decade identify that palliative care is well-suited to support these patients and their caregivers, yet access to palliative care and research within this population are lacking. This review describes palliative care and summarizes existing research supporting palliative intervention in advanced organ failure and transplant populations. A proposed model to provide palliative care in parallel with disease-directed therapy in a transplant program has the potential to improve symptom burden, quality of life, and healthcare utilization. Further studies are needed to elucidate specific benefits of palliative care for this population. In addition, there is a tremendous need for education, specifically for clinicians, patients, and families, to improve understanding of palliative care and its benefits for patients with advanced disease.
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Affiliation(s)
- K Wentlandt
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - A Weiss
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - E O'Connor
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - E Kaya
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Rush B, Walley KR, Celi LA, Rajoriya N, Brahmania M. Palliative care access for hospitalized patients with end-stage liver disease across the United States. Hepatology 2017; 66:1585-1591. [PMID: 28660622 DOI: 10.1002/hep.29297] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 02/28/2017] [Accepted: 05/20/2017] [Indexed: 12/12/2022]
Abstract
UNLABELLED Patients with end-stage liver disease (ESLD) often have a high symptom burden. Historically, palliative care (PC) services have been underused in this population. We investigated the use of PC services in patients with ESLD hospitalized across the United States. We used the Nationwide Inpatient Sample to conduct a retrospective nationwide cohort analysis. All patients >18 years of age admitted with ESLD, defined as those with at least two liver decompensation events, were included in the analysis. A multivariate logistic regression model predicting referral to PC was created. We analyzed 55,208,382 hospitalizations from the 2006-2012 Nationwide Inpatient Sample, with 39,349 (0.07%) patients meeting study inclusion. PC consultation was performed in 1,789 (4.5%) ESLD patients. The rate of PC referral in ESLD increased from 0.97% in 2006 to 7.1% in 2012 (P < 0.01). In multivariate analysis, factors associated with lower referral to PC were Hispanic race (odds ratio [OR], 0.77; 95% confidence interval [CI], 0.66-0.89; P < 0.01) and insurance coverage (OR, 0.74; 95% CI, 0.65-0.84; P < 0.01). Factors associated with increased referral to PC were age (per 5-year increase, OR, 1.05; 95% CI, 1.03-1.08; P < 0.01), do-not-resuscitate status (OR, 16.24; 95% CI, 14.20-18.56; P < 0.01), treatment in a teaching hospital (OR, 1.25; 95% CI, 1.12-1.39; P < 0.01), presence of hepatocellular carcinoma (OR, 2.00; 95% CI, 1.71-2.33; P < 0.01), and presence of metastatic cancer (OR, 2.39; 95% CI, 1.80-3.18; P < 0.01). PC referral was most common in west coast hospitals (OR, 1.81; 95% CI, 1.53-2.14; P < 0.01) as well as large-sized hospitals (OR, 1.49; 95% CI, 1.22-1.82; P < 0.01). CONCLUSION From 2006 to 2012 the use of PC in ESLD patients increased substantially; socioeconomic, geographical, and ethnic barriers to accessing PC were observed. (Hepatology 2017;66:1585-1591).
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Affiliation(s)
- Barret Rush
- Department of Medicine, Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.,Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA.,Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Keith R Walley
- Department of Medicine, Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.,Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Leo A Celi
- Beth Israel Deaconess Medical Center, Boston, MA
| | - Neil Rajoriya
- Department of Medicine, Division of Gastroenterology, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Mayur Brahmania
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA.,Department of Medicine, Division of Gastroenterology, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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Santivasi WL, Strand JJ, Mueller PS, Beckman TJ. The Organ Transplant Imperative. Mayo Clin Proc 2017; 92:940-946. [PMID: 28499512 DOI: 10.1016/j.mayocp.2017.03.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/27/2017] [Accepted: 03/13/2017] [Indexed: 12/25/2022]
Abstract
More than 120,000 US patients were listed for solid organ transplants in 2016. Although data are scarce, we suspect that many of these patients will die while awaiting transplant and without engaging in goals-of-care discussions with their physicians. The challenges of addressing goals of care in patients with malignancy, end-stage renal disease, and heart failure have been studied. However, there is sparse literature on addressing goals of care throughout the dynamic process of transplant assessment and listing. We propose the concept of an organ transplant imperative, which is the perceived obligation by patients and health care providers to proceed with organ transplant and to avoid advance care planning and triggered goals-of-care discussions, even in situations in which patients' clinical trajectories have worsened, resulting in poor quality of life and low likelihood of meaningful survival. We situate this concept within the paradigms of clinical inertia and the treatment and technological imperatives. We illustrate this concept by describing a patient with end-stage liver disease (ESLD) who was hoping for a liver transplant, who was caught between the conflicting perspectives of specialist and primary care physicians, and who died of complications of ESLD without experiencing the benefits of advance care planning. Greater awareness of the transplant imperative should generate a shared understanding among specialists, generalists, and patients and will provide opportunities for more formalized involvement of palliative medicine experts in the care of transplant patients.
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Affiliation(s)
| | - Jacob J Strand
- Section of Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Paul S Mueller
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Thomas J Beckman
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.
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