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Berkhout SG, Fritsch K, Frankel AV, Sheehan K. Obligation and the “Gift of Life”: Understanding Frictions Surrounding Advance Care Planning and Goals of Care Discussions in Liver Transplantation. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2022.100102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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2
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Shinall MC, Karlekar M, Martin S, Gatto CL, Misra S, Chung CY, Porayko MK, Scanga AE, Schneider NJ, Ely EW, Pulley JM, Jerome RN, Dear ML, Conway D, Buie R, Liu D, Lindsell CJ, Bernard GR. COMPASS: A Pilot Trial of an Early Palliative Care Intervention for Patients With End-Stage Liver Disease. J Pain Symptom Manage 2019; 58:614-622.e3. [PMID: 31276810 PMCID: PMC6754773 DOI: 10.1016/j.jpainsymman.2019.06.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/24/2019] [Accepted: 06/25/2019] [Indexed: 12/25/2022]
Abstract
CONTEXT Palliative care interventions have shown promise in improving quality of life and reducing health-care utilization among patients with chronic organ failure. OBJECTIVES To evaluate the effect of a palliative care intervention for adults with end-stage liver disease. METHODS A randomized controlled trial of patients with end-stage liver disease admitted to the hepatology service at a tertiary referral center whose attending hepatologist indicated they would not be surprised if the patient died in the following year on a standardized questionnaire was performed. Control group patients received usual care. Intervention group patients received inpatient specialist palliative care consultations and outpatient phone follow-up by a palliative care nurse. The primary outcome was time until first readmission. Secondary outcomes included days alive outside the hospital, referral to hospice care, death, readmissions, patient quality of life, depression, anxiety, and quality of end-of-life care over 6 months. RESULTS The trial stopped early because of difficulties in accruing patients. Of 293 eligible patients, only 63 patients were enrolled, 31 in the intervention group and 32 in the control group. This pace of enrollment was only 25% of what the study had planned, and so it was deemed infeasible to complete. Despite stopping early, intervention group patients had a lower hazard of readmission (hazard ratio: 0.36, 95% confidence interval: 0.16-0.83, P = 0.017) and greater odds of having more days alive outside the hospital than control group patients (odds ratio: 3.97, 95% confidence interval: 1.14-13.84, P = 0.030). No other statistically significant differences were observed. CONCLUSION Logistical obstacles hindered completion of the trial as originally designed. Nevertheless, a preemptive palliative care intervention resulted in increased time to first readmission and more days alive outside the hospital in the first six months after study entry.
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Affiliation(s)
- Myrick C Shinall
- Section of Palliative Care, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, Tennessee, USA; Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Mohana Karlekar
- Section of Palliative Care, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara Martin
- Section of Palliative Care, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cheryl L Gatto
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sumi Misra
- Section of Palliative Care, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Tennessee Valley Geriatrics Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Chan Y Chung
- Vanderbilt Hepatology and Liver Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael K Porayko
- Vanderbilt Hepatology and Liver Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew E Scanga
- Vanderbilt Hepatology and Liver Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Natasha J Schneider
- Vanderbilt Hepatology and Liver Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, Tennessee, USA; Tennessee Valley Geriatrics Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jill M Pulley
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rebecca N Jerome
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mary Lynn Dear
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Douglas Conway
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Reagan Buie
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gordon R Bernard
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Affiliation(s)
- Aluko A. Hope
- RS Morrison (corresponding author) Department of Geriatrics and Palliative Medicine, and Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, 1 Gustave Levy Place, Box 1070, New York, New York, USA
| | - R. Sean Morrison
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, and Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York, USA
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4
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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: 22] [Impact Index Per Article: 3.7] [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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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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Rogal S, Mankaney G, Udawatta V, Good CB, Chinman M, Zickmund S, Bielefeldt K, Jonassaint N, Jazwinski A, Shaikh O, Hughes C, Humar A, DiMartini A, Fine MJ. Association between opioid use and readmission following liver transplantation. Clin Transplant 2016; 30:1222-1229. [PMID: 27409580 DOI: 10.1111/ctr.12806] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2016] [Indexed: 12/21/2022]
Abstract
The aim of this study was to assess the independent association between pre-transplant prescription opioid use and readmission following liver transplantation. We reviewed the medical records of all patients at a single medical center undergoing primary, single-organ, liver transplantation from 2004 to 2014. We assessed factors associated with hospital readmission 30 days and 1 year after hospital discharge using multivariable competing risk regression models. Among 1056 transplant recipients, 49 (4.6%) were prescribed pre-transplant prescription opioids. Readmission occurred in 421 (40%) patients within 30 days and 689 (65%) within 1 year. Patients with pre-transplant opioid use had a significantly higher risk of readmission at 30 days (HR 1.7; 95% CI 1.1-2.5) and a non-significantly elevated risk at 1 year (HR 1.4; 95% CI 1.0-1.9) when controlling for other potential confounders. Although pain was the major reason for readmission in only 12 (3%) patients at 30 days and 33 (6%) patients at 1 year, pre-transplant opioid use was significantly associated with pain-related readmission at both time points. In conclusion, prescription opioid use pre-transplantation was significantly associated with all-cause 30-day readmissions and pain-related readmissions at 30 days and 1 year.
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Affiliation(s)
- Shari Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA. .,Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Division of Gastroenterology, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA. .,Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Gautham Mankaney
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Viyan Udawatta
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Matthew Chinman
- VISN 4 Mental Illness Research and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,RAND Corporation, Pittsburgh, PA, USA
| | - Susan Zickmund
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Klaus Bielefeldt
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Naudia Jonassaint
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alison Jazwinski
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Obaid Shaikh
- Division of Gastroenterology, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Christopher Hughes
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Abhinav Humar
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Andrea DiMartini
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Rakoski MO, Volk ML. Palliative care for patients with end-stage liver disease: An overview. Clin Liver Dis (Hoboken) 2015; 6:19-21. [PMID: 31040978 PMCID: PMC6490632 DOI: 10.1002/cld.478] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Mina O. Rakoski
- Division of Gastroenterology and HepatologyUniversity of Michigan Health SystemAnn ArborMI
| | - Michael L. Volk
- Department of MedicineDirector of Transplant Hepatology, Division Head, Gastroenterology, Loma Linda University HealthLoma LindaCA
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Potosek J, Curry M, Buss M, Chittenden E. Integration of palliative care in end-stage liver disease and liver transplantation. J Palliat Med 2015; 17:1271-7. [PMID: 25390468 DOI: 10.1089/jpm.2013.0167] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Patients with end-stage liver disease (ESLD) have a life-limiting illness that causes multiple distressing symptoms and negatively affects quality of life (QOL). This population traditionally has not had much attention within the palliative care community. DISCUSSION This article provides an evidence-based review of palliative care issues that patients with ESLD and those awaiting liver transplant face, including approaches to prognosis, symptom management, advance care planning, and end-of-life care. CONCLUSION Tremendous opportunity exists to integrate palliative medicine into the care of these patients.
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Affiliation(s)
- Jamie Potosek
- 1 Department of Hematology/Oncology, Providence Regional Cancer Center , Lacey, Washington
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9
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Abstract
Liver disease results in over four million physician visits and over 750,000 hospitalizations per year in the USA. Those with chronic liver disease frequently progress to cirrhosis, end-stage liver disease (ESLD), and death. Patients with ESLD experience numerous complications, including muscle cramps, confusion (hepatic encephalopathy), protein calorie malnutrition, muscle wasting, fluid overload (ascites, edema), bleeding (esophagogastric variceal hemorrhage), infection (spontaneous bacterial peritonitis), fatigue, anxiety, and depression. Despite significant improvements in palliation of these complications, patients still suffer reduced quality of life and must confront the fact that their disease will often inexorably progress to death. Liver transplantation is a valid option in this setting, increasing the duration of survival and palliating many of the symptoms. However, many patients die waiting for an organ or are not candidates for transplantation due to comorbid illness. Others receive a transplant but succumb to complications of the transplant itself. Patients and families must struggle with simultaneously hoping for a cure while facing a life-threatening illness. Ideally, the combination of palliative care with life-sustaining therapy can maximize the patients' quality and quantity of life. If it becomes clear that life-sustaining therapy is no longer an option, these patients are then already in a system to help them with end-of-life care.
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Affiliation(s)
- Anne M Larson
- Swedish Liver Center, 1101 Madison Street #200, Seattle, WA, 98104, USA,
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11
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Lamba S, Murphy P, McVicker S, Harris Smith J, Mosenthal AC. Changing end-of-life care practice for liver transplant service patients: structured palliative care intervention in the surgical intensive care unit. J Pain Symptom Manage 2012; 44:508-19. [PMID: 22765967 DOI: 10.1016/j.jpainsymman.2011.10.018] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 10/09/2011] [Accepted: 10/12/2011] [Indexed: 11/24/2022]
Abstract
CONTEXT Patients, families, and surgeons often have high expectations of life-saving surgery following liver transplantation (LT), despite the presence of a severe life-limiting underlying illness. Hence, transition from curative to palliative care is difficult and may create conflicts around goals of care. OBJECTIVES We hypothesized that early communication with physicians/families would improve end-of-life care practice in the LT service patients. METHODS Prospective, observational, pre/poststudy of consecutive LT service, surgical intensive care unit (SICU) patients, before and after a palliative care intervention was integrated. This included Part I (at admission), family support, prognosis, and patient preferences delineation; and Part II (within 72 hours), interdisciplinary family meeting. Data on goals-of-care discussions, do-not-resuscitate (DNR) orders, withdrawal of life support, and family perceptions were collected. RESULTS Seventy-nine LT patients with 21 deaths comprised the baseline group and 104 patients with 31 deaths the intervention group. Eighty-five percent of patients received Part I and 58% Part II of the intervention. Goals-of-care discussions on physician rounds increased from 2% to 38% of patient-days. During the intervention, although mortality rates were unchanged, DNR status increased (52-81%); withdrawal of life support increased (35-68%); DNR was instituted earlier; admission to DNR decreased (mean of 38-19 days); DNR to death time increased (two to four days); and SICU mean length of stay decreased (by three days). Family responses suggested more "time with family"/"time to say goodbye." CONCLUSION Interdisciplinary communication interventions with physicians and families resulted in earlier consensus around goals of care for dying LT patients. Early integration of palliative care alongside disease-directed curative care can be accomplished in the SICU without change in mortality and has the ability to improve end-of-life care practice in LT patients.
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Affiliation(s)
- Sangeeta Lamba
- New Jersey Medical School, University of Medicine and Dentistry of New Jersey, University Hospital, Newark, NJ 07103, USA
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12
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Crone CC, Marcangelo MJ, Shuster JL. An approach to the patient with organ failure: transplantation and end-of-life treatment decisions. Med Clin North Am 2010; 94:1241-54, xii. [PMID: 20951281 DOI: 10.1016/j.mcna.2010.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Organ transplantation offers an opportunity for extended survival and enhanced quality of life to patients with end-stage organ disease. Significant challenges are associated with both pre- and post-transplantation care, however, that require awareness of psychiatric issues in this patient population. Ventricular assist devices have added another dimension to patient care and to quality-of-life considerations. Unfortunately, effective incorporation of palliative care and end-of-life discussions is frequently overlooked during caretaking of these patients.
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Affiliation(s)
- Catherine C Crone
- Department of Psychiatry, George Washington University, Washington, DC, USA.
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Swetz KM, Carey EC, Rho RH, Mauck WD, Whitford KJ, Moynihan TJ, Kaur JS, Coyne PJ, Smith TJ. Safe use of opioids to manage pain in patients with cirrhosis. Mayo Clin Proc 2010; 85:959; author reply 960. [PMID: 20884829 PMCID: PMC2947971 DOI: 10.4065/mcp.2010.0294] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Hoping for a miracle: supporting patients in transplantation and cardiac assist programs. Curr Opin Support Palliat Care 2009; 2:252-5. [PMID: 19069309 DOI: 10.1097/spc.0b013e32831a7280] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Palliative medicine is often viewed as a medical specialty reserved for end of life care. This review focuses on the role that palliative care can play in transplant and cardiac assist device programs, along the continuum of a patient's disease course. RECENT FINDINGS In general, transplant and cardiac assist programs do not incorporate palliative medicine during the treatment course, but rather reserve it for when the patient is approaching death and is no longer a candidate for transplant or device therapy. There is a new shift, however, to viewing the practice of aggressive medicine and palliative medicine as 'shared care' so as to optimize the patient's quality of life throughout his or her illness. CONCLUSION Transplant and cardiac assist device programs should not exclude the practice of palliative care in their daily work. Palliative care is not 'giving up' rather it is optimizing the quality of a patient's life irrespective of the level of disease severity and prognosis.
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Hardin KA, Meyers F, Louie S. Integrating palliative care in severe chronic obstructive lung disease. COPD 2008; 5:207-20. [PMID: 18671146 DOI: 10.1080/15412550802237366] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Palliative care services for patients with chronic obstructive pulmonary disease (COPD) have been limited in most health care schemes despite the significant impact its symptoms can have on quality of life (QOL). Palliative care must be integrated to address physical and emotional distress and QOL deterioration more effectively. Multi-factorial barriers in current health care systems impede the provision of palliative care, including the lack of familiarity among health care professionals. There are sparse evidence-based studies and guidelines for clinicians to better recognize the need for palliative care in COPD patients compared to the large experience and resources available to cancer patients and hospice care. The multidisciplinary approach of palliative care should help COPD patients navigate through the continuum of chronic disease management. Highest QOL, not necessarily the highest physiologic goals, with relief of physical and emotional suffering, are most important to patients. Hospice care, the last phase of palliative care, can be offered to COPD patients when their goal of care has changed from life-prolonging therapies to comfort treatment. We suggest a scheme for identifying COPD patients for palliative care and for delivering simultaneous disease-directed care to help patients live life to the fullest. Pulmonary rehabilitation offers the best venue for incorporating palliative care. We review the need for, barriers to, and key activities for integrating palliative care into the current health care management of patients living with COPD.
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Affiliation(s)
- Kimberly A Hardin
- Department of Internal Medicine, UCD Health System Pulmonary Rehabilitation Program, University of California, Davis, Sacramento, CA 95817, USA
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Medici V, Rossaro L, Wegelin JA, Kamboj A, Nakai J, Fisher K, Meyers FJ. The utility of the model for end-stage liver disease score: a reliable guide for liver transplant candidacy and, for select patients, simultaneous hospice referral. Liver Transpl 2008; 14:1100-6. [PMID: 18668666 DOI: 10.1002/lt.21398] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Patients with chronic liver disease are referred late to hospice or never referred. There are several barriers to timely referral. First, liver transplantation (LT) and hospice care have always been perceived as mutually exclusive. Yet the criteria for hospice referral and for LT are more similar than different (for example, advanced liver disease and imminent death). Second, physicians, patients, and families have not had a reliable metric to guide referral. However, many patients wait for transplantation but never receive an organ. We hypothesized that the Model for End-Stage Liver Disease (MELD) score already in use to prioritize LT could be used in selected patients for concurrent hospice referral. Furthermore, we hypothesized that patients awaiting LT can receive hospice care and remain eligible for transplantation. Patients with advanced or end-stage liver disease were referred to the University of California Davis Health System hospice program. We correlated the MELD score at admission to length of stay (LOS) in hospice. A total of 157 end-stage liver disease patients were admitted to the hospice service. At the time of hospice admission the mean MELD score was 21 (range, 6-45). The mean length of hospice stay was 38 days (range, 1-329 days). A significant correlation was observed between hospice LOS and MELD score at hospice admission (P < 0.01). Six patients were offered a liver graft while on the combined (LT and hospice) program. MELD can be used to guide clinician recommendation to families about hospice care, achieving one of the national benchmark goals of increasing hospice care duration beyond the current median of 2-3 weeks. A higher MELD score might augment physician judgment as to hospice referral. Hospice care for selected patients may be an effective strategy to improve the care of end-stage liver disease patients waiting for LT.
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Affiliation(s)
- Valentina Medici
- Department of Internal Medicine, University of California, Davis, Sacramento, CA 95817, USA.
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