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Oliveira HM, Miranda HP, Rego F, Nunes R. Palliative care and end stage liver disease: A cohort analysis of palliative care use and factors associated with referral. Ann Hepatol 2024; 29:101518. [PMID: 38851396 DOI: 10.1016/j.aohep.2024.101518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/16/2024] [Accepted: 04/19/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION AND OBJECTIVES Prevalence and mortality of chronic liver disease have risen significantly. In end stage liver disease, the survival of patients is approximately two years. Despite the poor prognosis and high symptom burden of these patients, integration of palliative care is limited. We aim to assess associated factors and trends in palliative care use in recent years. MATERIALS AND METHODS A Multicenter retrospective cohort of patients with end stage liver disease who suffered in-hospital mortality between 2017 and 2019. Information regarding patient demographics, hospital characteristics, comorbidities, etiology, decompensations, and interventions was collected. Two-sided tests and logistic regression analysis were used to identify factors associated with palliative care use. RESULTS A total of 201 patients were analyzed, with a yearly increase in palliative care consultation: 26.7 % in 2017 to 38.3 % in 2019. Patients in palliative care were older (65.72 ± 11.70 vs. 62.10 ± 11.44; p = 0.003), had a lower Karnofsky functionality scale (χ=18.104; p = 0.000) and had higher rates of hepatic encephalopathy (32.1 % vs. 17.4 %, p = 0.007) and hepatocarcinoma (61.7 % vs. 26.2 %; p = 0.000). No differences were found for Model for End-stage Liver Disease (19.28 ± 6.60 vs. 19,90 ± 5.78; p = 0.507) or Child-Pugh scores (p = 0.739). None of the patients who die in the intensive care unit receive palliative care (0 % vs 31.6 %; p = 0.000). Half of the palliative care consultations occurred 6,5 days before death. CONCLUSIONS Palliative care use differs based on demographics, disease complications, and severity. Despite its increasing implementation, palliative care intervention occurs late. Future investigations should identify approaches to achieve an earlier and concurrent care model.
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Affiliation(s)
- Hugo M Oliveira
- Palliative Care Unit, Matosinhos Local Health Unit, Rua Dr. Eduardo Torres, Senhora da Hora, Matosinhos, Portugal; Department of Social Sciences and Health, Faculty of Medicine, University of Porto, Porto, Portugal.
| | | | - Francisca Rego
- Department of Social Sciences and Health, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Rui Nunes
- Department of Social Sciences and Health, Faculty of Medicine, University of Porto, Porto, Portugal.
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Kearney A, Tiwari N, Cullen O, Legg A, Arbi I, Douglas C, Leggett B, Fenech M, Mina J, Hoey P, Skoien R. Improving palliative and supportive care in advanced cirrhosis: the HepatoCare model of integrated collaborative care. Intern Med J 2023; 53:1963-1971. [PMID: 37812158 DOI: 10.1111/imj.16248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/29/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Patients with advanced cirrhosis experience an unpredictable disease trajectory but are infrequently referred to palliative care (PC) services and rarely undertake advance care planning (ACP). AIM We assessed whether a novel model of care increased provision of meaningful PC in advanced cirrhosis compared with standard of care (SOC). METHODS Thirty consecutive hepatology clinic outpatients with advanced cirrhosis, meeting one or more cirrhosis-related PC referral criteria, consented to treatment in the HepatoCare clinic (PC physician, specialist liver nurse, pharmacist) in parallel with usual specialist hepatology care. A control cohort of 30 consecutive outpatients with advanced cirrhosis undergoing SOC treatment was retrospectively identified for comparison. The primary outcome was provision of meaningful PC using HepatoCare versus SOC. Additional clinical outcomes were assessed over 12 months or until death and significant differences were identified. RESULTS The intervention and control cohorts had similarly advanced cirrhosis (mean Child-Pugh scores 8.7 vs 8.2, P = 0.46; mean model for end-stage liver disease scores 14.4 vs 14.6, P = 0.88) but a lower 12-month mortality rate (33% HepatoCare vs 67% SOC; P = 0.02). The intervention cohort experienced higher uptake of formal ACP (100% vs 25% for the control cohort) and outpatient PC referral (100% vs 40%), and were more likely to die at home or in a PC bed/hospice (80% vs 30%). The majority of the HepatoCare cohort (81%) had medications safely deprescribed and experienced fewer unplanned admission days (470 vs 794). CONCLUSIONS HepatoCare is a novel multidisciplinary model of care that integrates effective PC and specialist hepatology management to improve outcomes in advanced cirrhosis.
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Affiliation(s)
- Alison Kearney
- Department of Palliative and Supportive Care, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
- School of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - Neha Tiwari
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Olivia Cullen
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Amy Legg
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Ismail Arbi
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Carol Douglas
- Department of Palliative and Supportive Care, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
- School of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - Barbara Leggett
- School of Medicine, The University of Queensland, St Lucia, Queensland, Australia
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Mary Fenech
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Joanne Mina
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Paris Hoey
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Richard Skoien
- School of Medicine, The University of Queensland, St Lucia, Queensland, Australia
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
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Abstract
BACKGROUND Cirrhosis is the outcome of chronic liver disease of any etiology due to progressive liver injury and fibrosis. Consequently, cirrhosis leads to portal hypertension and liver dysfunction, progressing to complications like ascites, variceal bleeding, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, cirrhotic cardiomyopathy, sarcopenia, hepatocellular carcinoma, and coagulation disorders. End-stage liver disease leads to an impaired quality of life, loss of social and economic productivity, and reduced survival. METHODS This narrative review explains the pathophysiology of complications of cirrhosis, the diagnostic approach and innovative management, with focus on data from India. A comprehensive literature search of the published data was performed in regard with the spectrum, diagnosis, and management of cirrhosis and its complications. RESULTS There is a change in the epidemiology of metabolic syndrome, lifestyle diseases, alcohol consumption and the spectrum of etiological diagnosis in patients with cirrhosis. With the advent of universal vaccination and efficacious long-term viral suppression agents for chronic hepatitis B, availability of direct-acting antiviral agents for chronic hepatitis C, and a booming liver transplantation programme across the country, the management of complications is essential. There are several updates in the standard of care in the management of complications of cirrhosis, such as hepatorenal syndrome, hepatocellular carcinoma, and hepatic encephalopathy, and new therapies that address supportive and palliative care in advanced cirrhosis. CONCLUSION Prevention, early diagnosis, appropriate management of complications, timely transplantation are cornerstones in the management protocol of cirrhosis and portal hypertension. India needs improved access to care, outreach of public health programmes for viral hepatitis care, health infrastructure, and disease registries for improved healthcare outcomes. Low-cost initiatives like immunization, alcohol cessation, awareness about liver diseases, viral hepatitis elimination, and patient focused decision-making algorithms are essential to manage liver disease in India.
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Key Words
- AIH, autoimmune hepatitis
- ALP, alkaline phosphatase
- AVB, acute variceal bleeding
- BMI, body mass index
- CLD, chronic liver disease
- CSPH, clinically significant portal hypertension
- CTP, Child Turcotte Pugh Score
- DAAs, direct-acting antiviral agents
- GGT, gamma glutamyl transpeptidase
- HBV, hepatitis B virus
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- HE, hepatic encephalopathy
- HR, hazard ratio
- HRQoL, health-related quality of life
- HVPG, hepatic vein pressure gradient
- MELD, Model for End Stage Liver disease
- MetS, metabolic syndrome
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- NSBB, Non-selective beta blockers
- NVHCP, National Viral Hepatitis Control programme
- SAAG, Serum-ascites albumin gradient
- SBP, spontaneous bacterial peritonitis
- WHO, World Health Organization
- cirrhosis, ascites
- hepatic encephalopathy
- hepatocellular carcinoma
- portal hypertension
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Kabaria S, Gupta K, Bhurwal A, Patel AV, Rustgi VK. Predictors of do-not-resuscitate order utilization in decompensated cirrhosis hospitalized patients: A nationwide inpatient cohort study. Ann Hepatol 2021; 22:100284. [PMID: 33160032 DOI: 10.1016/j.aohep.2020.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Decompensated cirrhosis carries high inpatient morbidity and mortality. Consequently, advance care planning is an integral aspect of medical care in this patient population. Our study aims to identify do-not-resuscitate (DNR) order utilization and demographic disparities in decompensated cirrhosis patients. PATIENTS OR MATERIALS AND METHODS Nationwide Inpatient Sample was used to extract the cohort of patients from January 1st, 2016 to December 31st, 2017, based on the most comprehensive and recent data. The first cohort included hospitalized patients with decompensated cirrhosis. The second cohort included patients with decompensated cirrhosis with at least one contraindication for liver transplantation. RESULTS A cohort of 585,859 decompensated cirrhosis patients was utilized. DNR orders were present in 14.2% of hospitalized patients. DNR utilization rate among patients with relative contraindication for liver transplantation was 15.0%. After adjusting for co-morbid conditions, disease severity, and inpatient mortality, African-American and Hispanic patient populations had significantly lower DNR utilization rates. There were regional, and hospital-level differences noted. Moreover, advanced age, advanced stage of decompensated cirrhosis, inpatient mortality, and relative contraindications for liver transplantation (metastatic neoplasms, dementia, alcohol misuse, severe cardiopulmonary disease, medical non-adherence) were independently associated with increased DNR utilization rates. CONCLUSIONS The rate of DNR utilization in patients with relative contraindications for liver transplantation was similar to patients without any relative contraindications. Moreover, there were significant demographic and hospital-level predictors of DNR utilization. This information can guide resource allocation in educating patients and their families regarding prognosis and outcome expectations.
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Affiliation(s)
- Savan Kabaria
- Internal Medicine, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States.
| | - Kapil Gupta
- Division of Gastroenterology and Hepatology, Robert Wood Johnson School of Medicine, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States
| | - Abhishek Bhurwal
- Division of Gastroenterology and Hepatology, Robert Wood Johnson School of Medicine, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States
| | - Anish V Patel
- Division of Gastroenterology and Hepatology, Robert Wood Johnson School of Medicine, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States
| | - Vinod K Rustgi
- Division of Gastroenterology and Hepatology, Robert Wood Johnson School of Medicine, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States
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Truitt K, Khan SS, Gregory DL, Chuzi S, VanWagner LB. Deaths from hepatocellular carcinoma are more likely to occur in medical facilities than deaths from other cancers: 2003-2018. Liver Int 2021; 41:1489-1493. [PMID: 33932082 PMCID: PMC8822953 DOI: 10.1111/liv.14915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/09/2021] [Accepted: 04/24/2021] [Indexed: 12/27/2022]
Abstract
Place of death is a key indicator of quality of end-of-life care, and most people with a terminal diagnosis prefer to die at home. Home has surpassed the hospital as the most common location of all-cause and total cancer-related deaths in the United States. However, trends in place of death due to hepatocellular carcinoma (HCC), which is uniquely comanaged by hepatologists and oncologists, have not been described. We analysed US death certificate data from 2003 to 2018 for the proportion of deaths over time at medical facilities, nursing facilities, hospice facilities and home, for HCC and non-HCC cancer. The proportion of deaths increased from 0.6% to 15.2% in hospice facilities (P trend < 0.0001) but did not change at home. In multivariable analysis, persons with HCC were more likely than persons with non-HCC cancer to die in medical facilities, while persons with HCC were less likely to die at home.
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Affiliation(s)
- Katie Truitt
- Department of Internal Medicine, Northwestern McGaw/Northwestern Hospital, Chicago, IL, USA
| | - Sadiya S. Khan
- Department of Medicine, Division of Cardiology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dyanna L. Gregory
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sarah Chuzi
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lisa B. VanWagner
- Department of Medicine, Division of Gastroenterology and Hepatology and Department of Preventive Medicine-Epidemiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Ufere NN, Halford JL, Caldwell J, Jang MY, Bhatt S, Donlan J, Ho J, Jackson V, Chung RT, El-Jawahri A. Health Care Utilization and End-of-Life Care Outcomes for Patients With Decompensated Cirrhosis Based on Transplant Candidacy. J Pain Symptom Manage 2020; 59:590-598. [PMID: 31655192 PMCID: PMC7024665 DOI: 10.1016/j.jpainsymman.2019.10.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/14/2019] [Accepted: 10/17/2019] [Indexed: 12/19/2022]
Abstract
CONTEXT Patients with decompensated cirrhosis have high rates of health care utilization at end of life (EOL). However, the impact of transplant candidacy on intensity of EOL care is currently unknown. OBJECTIVES To assess the relationship between transplant candidacy and intensity of EOL care in the last year of life in an ambulatory cohort of patients with decompensated cirrhosis. METHODS We performed a retrospective analysis of 230 patients with decompensated cirrhosis who were evaluated for liver transplantation in a large health care system between 1/1/2010 and 12/31/2017 and died by 6/20/2018. We compared health care utilization in the last year of life and EOL care outcomes between transplant-listed (n = 133) and nonlisted (n = 97) patients. We examined predictors of palliative and hospice care utilization using multivariate logistic regression. RESULTS During the last year of life, patients had a median of three hospitalizations (IQR 2-5) and spent a median of 31 days (IQR 16-49) in the hospital. In all, 80% of patients died in the hospital, with 70% dying in the intensive care unit. The majority (70.0%) received a life-sustaining procedure (mechanical ventilation, renal replacement therapy, or cardiopulmonary resuscitation) during their terminal hospitalization, which did not differ between transplant-listed and nonlisted patients (74.4% vs. 63.9%, P = 0.09). Transplant-listed patients had lower odds of receiving specialty palliative care (odds ratio 0.43, P = 0.005). Patients with hepatocellular carcinoma had higher odds of receiving hospice care (odds ratio 2.03, P = 0.049). CONCLUSION Patients with decompensated cirrhosis had intensive health care utilization during their last year of life regardless of transplant candidacy. Further work is needed to optimize their EOL care, particularly for patients who are ineligible for transplantation.
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Affiliation(s)
- Nneka N Ufere
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | | | | | | | - Sunil Bhatt
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John Donlan
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Janet Ho
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Jackson
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond T Chung
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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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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