Dying with End Stage Liver Disease with Cirrhosis: Insights from SUPPORT

Prognostic models and factors identifying end-of-life in non-cancer chronic diseases: a systematic review

BACKGROUND

Precise prognostic information, if available, is very helpful for guiding treatment decisions and resource allocation in patients with non-cancer non-communicable chronic diseases (NCDs). This study aimed to systematically review the existing evidence, examining prognostic models and factors for identifying end-of-life non-cancer NCD patients.

METHODS

Electronic databases, including Medline, Embase, CINAHL, Cochrane Library, PsychINFO and other sources, were searched from the inception of these databases up until June 2023. Studies published in English with findings mentioning prognostic models or factors related to identifying end-of-life in non-cancer NCD patients were included. The quality of studies was assessed using the Quality in Prognosis Studies tool.

RESULTS

The analysis included data from 41 studies, with 16 focusing on chronic obstructive pulmonary diseases (COPD), 10 on dementia, 6 on heart failure and 9 on mixed NCDs. Traditional statistical modelling was predominantly used for the identified prognostic models. Common predictors in COPD models included dyspnoea, forced expiratory volume in 1 s, functional status, exacerbation history and body mass index. Models for dementia and heart failure frequently included comorbidity, age, gender, blood tests and nutritional status. Similarly, mixed NCD models commonly included functional status, age, dyspnoea, the presence of skin pressure ulcers, oral intake and level of consciousness. The identified prognostic models exhibited varying predictive accuracy, with the majority demonstrating weak to moderate discriminatory performance (area under the curve: 0.5-0.8). Additionally, most of these models lacked independent external validation, and only a few underwent internal validation.

CONCLUSION

Our review summarised the most relevant predictors for identifying end-of-life in non-cancer NCDs. However, the predictive accuracy of identified models was generally inconsistent and low, and lacked external validation. Although efforts to improve these prognostic models should continue, clinicians should recognise the possibility that disease heterogeneity may limit the utility of these models for individual prognostication; they may be more useful for population level health planning.

Inequity in end-of-life care for patients with chronic liver disease in England

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.

Palliative Care and End-of-Life Outcomes in Patients Considered for Liver Transplantation: A Single-Center Experience in the US Midwest

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.

Liver Transplantation: Protocol for Recipient Selection, Evaluation, and Assessment

Liver transplantation (LT) is the definitive therapy for patients with end-stage liver disease, acute liver failure, acute-on-chronic liver failure, hepatocellular carcinoma, and metabolic liver diseases. The acceptance of LT in Asia has been gradually increasing and so is the expertise to perform LT. Preparing a patient with cirrhosis for LT is the most important aspect of a successful LT. The preparation for LT begins with the first index decompensation for a patient with cirrhosis. Patients planned for LT should undergo a thorough screening for infections, and a complete cardiac, pulmonology, and psychosocial evaluation pre-LT. In this review, we discuss the indications and contraindications of LT and the evaluation and assessment of patients with liver disease planned for LT.

Palliative Care in Kidney and Liver Diseases

The role of palliative care is to recognize patients with advanced illnesses who are at risk for poor outcomes and to alleviate their pain and suffering. Patients with both kidney and liver disease are a very vulnerable population due to the unique pathophysiologic relationship these two organs share, which often leads to an abbreviated life expectancy and a significant symptom burden. These patients face many challenges in their care. This article discusses the importance of prognostication for early palliative care referrals as well as the management of the two most common complaints patients with kidney and liver disease face: pain and ascites.

A Pilot Study of a Palliative Care Service Embedded in a Hepatology Clinic at a Large Public Hospital

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.

Understanding Prognosis: Discrepancy in Prognosis Estimates Between Patients With Cirrhosis and their Hepatologists

BACKGROUND & AIMS

Patients require a clear understanding of their prognosis to make informed decisions about their care. The aim of this study was to compare the perceptions of prognosis and transplant candidacy between patients with cirrhosis and their hepatologists.

METHODS

Patients with cirrhosis and their hepatologists were prospectively recruited at an urban liver transplant center. Patients and hepatologists were asked about transplant candidacy and about how many years patients would live with and without a liver transplant. Agreement between patients and hepatologists was assessed with the weighted kappa statistic. Associations between patient/hepatologists' prognostic estimates and those predicted by patients' Model for End-Stage Liver Disease-Sodium (MELD-Na) score were estimated using the Pearson correlation coefficient.

RESULTS

Seventy patients and 6 hepatologists were enrolled in the study. Patients were predominantly male (61.4%) and white (68.6%), with a mean MELD-Na score of 19 ± 9. There was no-slight agreement between patients and hepatologists regarding survival without and with a liver transplant (κ = 0.1 and 0.2, respectively), with patients more optimistic than their hepatologists. There was greater agreement between patients and hepatologists about transplant candidacy (κ = 0.6). There was a negligible association between MELD-Na and patient estimates (r = -0.24, P = .05) but a moderate association between MELD-Na and hepatologist estimates (r = -0.51, P < .001), with higher MELD-Na scores associated with lower predicted survival.

CONCLUSIONS

Patients with cirrhosis are more optimistic and less accurate in their predictions of survival compared with hepatologists, although they are more realistic about their transplant candidacy. Aligning patient and provider expectations may increase the likelihood that patients receive value-concordant care.

Feasibility of a Palliative Care Intervention within Routine Care of Hepatocellular Carcinoma: A Pilot Randomized Controlled Trial

Background: Patients with hepatocellular cancer (HCC) are at risk for poor quality of life (QoL) and high symptom burden, coupled with limited treatment options. Palliative care (PC) can play an important role in reducing the suffering of this population, but remains underutilized. Aim: To demonstrate feasibility of an outpatient PC intervention within HCC care. Methods: This is a pilot randomized controlled trial conducted at an academic center. All stages of HCC patients (except Barcelona Clinic Liver Cancer stage D) with a scheduled hepatology appointment were eligible. Patients were randomized to receive PC intervention or usual care (control arm). In the PC arm, patients received PC from a PC provider at enrollment and at three months from the baseline visit, in addition to continued standard of care. Control arm received only standard care. All patients completed FACT-Hep (Functional Assessment of Cancer Therapy-Hepatobiliary Cancer) and modified Edmonton Symptom Assessment Scale at baseline and at three-month visit. Descriptive statistics were utilized to summarize questionnaires, and change in QoL and symptoms from baseline to three months were compared between the two study groups. Results: Of the 109 approached, 57 patients (52.3%) consented to enroll, and 52 (91%) completed the study. QoL and symptom burden assessments demonstrated impaired QoL and high symptom burden in both arms of the study. At least 50% of enrolled patients in each arm had some degree of fatigue, pain, sleep disturbance, and appetite loss, at baseline. Post-intervention, symptom burden and QoL improved in the intervention arm and remained same or worsened in the control group. All FACT-Hep scores decreased numerically among controls and increased numerically among patients in the PC intervention group. Conclusion: Outpatient PC intervention within routine HCC care is feasible, and can potentially improve QoL and symptoms.

A Review of Clinical Signs and Symptoms of Imminent End-of-Life in Individuals With Advanced Illness

Background: World population is not only aging but suffering from serious chronic illnesses, requiring an increasing need for end-of-life care. However, studies show that many healthcare providers involved in the care of dying patients sometimes express challenges in knowing when to stop non-beneficial investigations and futile treatments that tend to prolong undue suffering for the dying person. Objective: To evaluate the clinical signs and symptoms that show end-of-life is imminent in individuals with advanced illness. Design: Narrative review. Methods: Computerized databases, including PubMed, Embase, Medline,CINAHL, PsycInfo, and Google Scholar were searched from 1992 to 2022 for relevant original papers written in or translated into English language that investigated clinical signs and symptoms of imminent death in individuals with advanced illness. Results: 185 articles identified were carefully reviewed and only those that met the inclusion criteria were included for review. Conclusion: While it is often difficult to predict the timing of death, the ability of healthcare providers to recognize the clinical signs and symptoms of imminent death in terminally-ill individuals may lead to earlier anticipation of care needs and better planning to provide care that is tailored to individual's needs, and ultimately results in better end-of-life care, as well as a better bereavement adjustment experience for the families.

Symptom Frequency and Distress Underestimated in Decompensated Cirrhosis

BACKGROUND

Studies assessing multiple symptoms and the distress of these symptoms in decompensated cirrhosis are lacking.

AIMS

The aims of this study were to assess symptom prevalence and distress among patients with decompensated cirrhosis and to describe medical management of the most prevalent symptoms.

METHODS

Patients were recruited from hepatology clinics within two health-care systems. Eligibility criteria included a model for end-stage liver disease (MELD-Na) score ≥15. Patients completed the Condensed Memorial Symptom Assessment Scale and Patient Health Questionnaire. Comparative statistics were used to analyze the cross-sectional survey data.

RESULTS

Of the sample (n = 146), most patients were Child-Turcotte-Pugh (CTP) class B (49.7%) and C (46.2%). Mean age was 56.5 years, 65.1% were male, and 88.4% were white. Average MELD-Na score was 19.1 ± 4.5. The most prevalent symptoms were lack of energy and feeling drowsy while the most distressing were lack of energy and difficulty sleeping. Only 24 patients (16.4%) were treated for their difficulty sleeping with sleep medication. Importantly, those prescribed sleep medications had similar distress (3.9 ± 1.2 vs. 3.5 ± 1.2, p = 0.229) compared with patients not prescribed sleep medications. Opioids were prescribed to 57 (39.0%) patients; antidepressants to 34 (23.3%). Forty patients (27.4%) who reported moderate or greater depression were not prescribed an antidepressant.

CONCLUSIONS

The study highlights the multiple symptoms and distress experienced by patients with decompensated cirrhosis, and the need for improved medical management by health-care providers through enhanced awareness and attention to these complex symptoms. Future research should focus on improvements in symptom management.

Predicting 1-year mortality among patients with decompensated cirrhosis: results of a multicentre evaluation of the Bristol Prognostic Score

Objective

Chronic liver disease continues to be a significant cause of morbidity and mortality yet remains challenging to prognosticate. This has been one of the barriers to implementing palliative care, particularly at an early stage. The Bristol Prognostic Score (BPS) was developed to identify patients with life expectancy less than 12 months and to act as a trigger for referral to palliative care services. This study retrospectively evaluated the BPS in a cohort of patients admitted to three Scottish hospitals.

Method

Routinely collated healthcare data were used to obtain demographics, BPS and analyse 1-year mortality for patients with decompensated liver disease admitted to three gastroenterology units over two 90-day periods. Statistical analysis was undertaken to assess performance of BPS in predicting mortality.

Results

276 patients were included in the final analysis. Participants tended to be late middle-aged men, socioeconomically deprived and have alcohol-related liver disease. A similar proportion was BPS+ve (>3) in this study compared with the original Bristol cohort though had more hospital admissions, higher ongoing alcohol use and poorer performance status. BPS performed poorer in this non-Bristol group with sensitivity 54.9% (72.2% in original study), specificity 58% (83.8%) and positive predictive value (PPV) 43.4% (81.3%).

Conclusion

BPS was unable to accurately predict mortality in this Scottish cohort. This highlights the ongoing challenge of prognostication in patients with chronic liver disease, furthering the call for more work in this field.

Health-Related Quality of Life and Its Contributors According to a Preference-Based Generic Instrument in Cirrhosis

It is essential to determine contributors around impairment in health-related quality of life (HRQoL) in patients with cirrhosis aiming at improving health care and therapeutic strategy. Studies simultaneously incorporating disease severity based on biochemical parameters and other physical/psychological effects (i.e., sleep disturbance and frailty) are heterogeneous and the subject of the present study. We analyzed and compared HRQoL, using the EuroQol Group 5 Dimension (EQ-5D) questionnaire and the utility index retrieved, in patients with cirrhosis and across groups stratified by sleep disturbance or frailty phenotype. Sleep disturbance and frailty were determined by the Pittsburgh Sleep Quality Index (PSQI) and Frailty Index, respectively. Multiple linear regression was implemented to clarify contributors of poor HRQoL. In this cohort of 227 patients with mean age of 61.7 years and 47.2% male, more than half of the study population represented impairment in HRQoL in at least one domain, according to EQ-5D. Furthermore, sleep disturbance and frailty have proved to be independently associated with poor HRQoL in two separate regression models, whereas conventional scoring systems such as Child-Pugh classification and Model for End-Stage Liver Disease are not closely relevant. Intriguingly, not all health domains within EQ-5D correlated well with PSQI and Frailty Index, with the exception of usual activities. Pain and anxiety/depression were the most frequently affected HRQoL domains even in patients without sleep disturbance or frailty. Conclusion: Impaired HRQoL is prevalent in patients with decompensated cirrhosis. Sleep disturbance and frailty are independently associated with poor HRQoL. It is imperative to timely intervene with these symptoms and deliver tailored health care.

Overview of Complications in Cirrhosis

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.

Predictors of do-not-resuscitate order utilization in decompensated cirrhosis hospitalized patients: A nationwide inpatient cohort study

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.

Frailty is strongly associated with self-reported symptom burden among patients with cirrhosis

OBJECTIVES

Although patients with cirrhosis often experience debilitating symptoms, few are referred for palliative care. Frailty is increasingly incorporated in liver transplantation evaluation and has been associated with symptom burden in other populations. We hypothesized that frail patients with cirrhosis are highly symptomatic and thus are likely to benefit from palliative care.

METHODS

Patients with cirrhosis undergoing outpatient liver transplantation evaluation completed the Liver Frailty Index (grip strength, chair stands and balance) and a composite of validated measures including the Edmonton Symptom Assessment Scale, distress and quality of life (QOL) measures.

RESULTS

Of 233 patients (median age 61 years, 43% women), 22% were robust, 59% prefrail and 19% frail. Overall, 38% of patients reported ≥1 severe symptoms based on preestablished Edmonton Symptom Assessment Scale criteria. Higher frailty categories were associated with increased prevalence of pain, dyspnea, fatigue, nausea, poor appetite, drowsiness, depression and poor well-being (test for trend, all P < 0.05). Frail patients were also more likely to report psychological distress and poor QOL (all P < 0.01). In univariate analysis, each 0.5 increase in liver frailty index was associated with 44% increased odds of experiencing ≥1 severe symptoms [95% confidence interval (CI), 1.2-1.7, P < 0.001], which persisted (odds ratio, 1.3, 95% CI, 1.0-1.6, P = 0.004) even after adjusting for Model for End Stage Liver Disease-Sodium, ascites, hepatic encephalopathy and age.

CONCLUSION

In patients with cirrhosis, frailty is strongly associated with physical/psychological symptoms, including pain and depression and poor QOL. Frail patients with cirrhosis may benefit from palliative care co-management to address symptoms and improve QOL.

Advance Care Planning and Goals of Care Discussions in Advanced Liver Disease

PURPOSE OF REVIEW

Advance care planning (ACP) has been shown to improve multiple outcomes in patients with serious illnesses; however, patients with advanced liver disease, or cirrhosis, rarely receive timely ACP. The purpose of this review is to evaluate the current state of ACP for patients with advanced liver disease and to provide practical guidance for integrating early ACP into routine outpatient hepatology care.

RECENT FINDINGS

Due to multiple patient-, physician-, and systems-level barriers, patients with advanced liver disease have low rates of timely ACP engagement. Early identification and preparation of a surrogate decision-maker, enhancing clinician ACP communication skills, use of patient-centered educational tools, optimizing outpatient processes for ACP documentation, and early referral to specialty palliative care may help to improve current deficits in ACP for this population.

SUMMARY

Provision of early ACP to patients with advanced liver disease may better ensure that patients receive medical care that is consistent with their goals and values.

AGA Clinical Practice Update on Palliative Care Management in Cirrhosis: Expert Review

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.

Top Ten Tips Palliative Care Clinicians Should Know About End-Stage Liver Disease

End-stage liver disease (ESLD) is an increasingly prevalent condition with high morbidity and mortality, especially for those ineligible for liver transplantation. Patients with ESLD, along with their family caregivers, have significant needs related to their quality of life, and there is increasing attention being paid to integration of palliative care (PC) principles into routine care throughout the disease spectrum. To provide upstream care for these patients and their family caregivers, it is essential for PC providers to understand their complex psychosocial and physical needs and to be aware of the unique challenges around medical decision making and end-of-life care for this patient population. This article, written by a team of liver and PC experts, shares 10 high-yield tips to help PC clinicians provide better care for patients with advanced liver disease.

A scoping review to identify and map the multidimensional domains of pain in adults with advanced liver disease

Background: Pain is a significant problem in adults living with advanced liver disease, having limited guidance available for its clinical management. While pain is considered a multidimensional experience, there have been limited reviews of the pain literature in advanced liver disease conducted with a multidimensional framework. Aims: The goal of this scoping review was to identify and map the multidimensional domains of pain in adults with advanced liver disease using the biopsychosocial model. Methods: We used Arksey and O'Malley's scoping framework. A search was conducted in MEDLINE, Embase, AMED, and CINAHL databases and the gray literature using specific eligibility criteria (1990-2019). Citation selection and data extraction were performed by two independent reviewers and in duplicate. Results: Of the 43 studies that met inclusion criteria, 51% were from North America and 93% utilized quantitative methods. The combined studies reported on 168,110 participants with ages ranging between 23 to 87 years. Only 9% reported an objective scoring system for liver disease severity. Few studies reported pain classification (9%) and intensity (16%). Pain prevalence ranged between 18% and 100%, with pain locations including joint, abdomen, back, head/neck, and upper/lower extremities. We identified and mapped 115 pain factors to the biopsychosocial model: physical (81%), psychological (65%), and sociocultural (5%). Only 9% measured pain using validated multidimensional tools. Pharmacological intervention (92%) prevailed among pain treatments. Conclusions: Pain is not well understood in patients with advanced liver disease, having limited multidimensional pain assessment and treatment approaches. There is a need to systematically examine the multidimensional nature of pain in this population.

Advance Care Planning Preferences and Readiness in Cirrhosis: A Prospective Assessment of Patient Perceptions and Knowledge

Background: In 2014, the province of Alberta launched a campaign to promote public awareness of advance care planning (ACP) and its associated two-part documentation-a Goals of care designation (GCD, a medical order written by a health care practitioner detailing wishes for care) and a personal directive (PD, a document naming a surrogate decision maker). Notably, unlike the GCD, the PD can be self-initiated independent of a health practitioner. Objective: Two years after the campaign, we aimed to assess knowledge and recall of participation in ACP among cirrhosis patients. Design/Setting: Consecutive adult cirrhosis patients attending one of two specialty cirrhosis clinics in Edmonton, Alberta, were surveyed. Results: Ninety-seven patients were included. Mean model for end-stage liver disease was 12. Although 97% of patients indicated it was extremely important to know the reality of their illness, only 53% understood that cirrhosis would affect their future quality of life. Thirty-three percent of patients had completed a PD and 14% had completed a GCD. Seventy-eight percent of patients believed a GCD was important to them and 85% preferred to complete it in an outpatient clinic setting. Only a minority of patients who had taken the initiative to complete a PD in the community also had a GCD. Conclusions: Despite efforts to raise awareness of and educate Albertans about ACP, <20% of cirrhosis patients have a completed GCD. Additional strategic prioritization is required in both patients and providers to ensure that health practitioner-facilitated ACP is carried out as standard-of-care in all patients with cirrhosis.

Palliative care in liver disease: what does good look like?

The mortality rate from chronic liver disease in the UK is rising rapidly, and patients with advanced disease have a symptom burden comparable to or higher than that experienced in other life-limiting illnesses. While evidence is limited, there is growing recognition that care of patients with advanced disease needs to improve. Many factors limit widespread provision of good palliative care to these patients, including the unpredictable trajectory of chronic liver disease, the misconception that palliative care and end-of-life care are synonymous, lack of confidence in prescribing and lack of time and resources. Healthcare professionals managing these patients need to develop the skills to ensure effective delivery of core palliative care, with referral to specialist palliative care services reserved for those with complex needs. Core palliative care is best delivered by the hepatology team in parallel with active disease management. This includes ensuring that discussions about disease trajectory and advance care planning occur alongside active management of disease complications. Liver disease is strongly associated with significant social, psychological and financial hardships for patients and their carers; strategies that involve the wider multidisciplinary team at an early stage in the disease trajectory help ensure proactive management of such issues. This review summarises the evidence supporting palliative care for patients with advanced chronic liver disease, presents examples of current best practice and provides pragmatic suggestions for how palliative and disease-modifying care can be run in parallel, such that patients do not miss opportunities for interventions that improve their quality of life.

Physicians' Perspectives on Palliative Care for Patients With End-Stage Liver Disease: A National Survey Study

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.

Current Knowledge, Barriers to Implementation, and Future Directions in Palliative Care for End-Stage Liver Disease

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.

Symptom prevalence and quality of life of patients with end-stage liver disease: A systematic review and meta-analysis

BACKGROUND:

End-stage liver disease is a common cause of morbidity and mortality worldwide, yet little is known about its symptomatology and impact on health-related quality of life.

AIM:

To describe symptom prevalence and health-related quality of life of patients with end-stage liver disease to improve care.

DESIGN:

Systematic review.

DATA SOURCES:

We searched eight electronic databases from January 1980 to June 2018 for studies investigating symptom prevalence or health-related quality of life of adult patients with end-stage liver disease. No language restrictions were applied. Meta-analyses were performed where appropriate.

RESULTS:

We included 80 studies: 35 assessing symptom prevalence, 41 assessing health-related quality of life, and 4 both. The instruments assessing symptoms varied across studies. The most frequently reported symptoms were as follows: pain (prevalence range 30%–79%), breathlessness (20%–88%), muscle cramps (56%–68%), sleep disturbance (insomnia 26%–77%, daytime sleepiness 29.5%–71%), and psychological symptoms (depression 4.5%–64%, anxiety 14%–45%). Erectile dysfunction was prevalent (53%–93%) in men. The health-related quality of life of patients with end-stage liver disease was significantly impaired when compared to healthy controls or patients with chronic liver disease. Compared with compensated cirrhosis, decompensation led to significant worsening of both components of the 36-Item Short Form Survey although to a larger degree for the Physical Component Summary score (decrease from average 6.4 (95% confidence interval: 4.0–8.8); p < 0.001) than for the Mental Component Summary score (4.5 (95% confidence interval: 2.4–6.6); p < 0.001).

CONCLUSION:

The symptom prevalence of patients with end-stage liver disease resembled that of patients with other advanced conditions. Given the diversity of symptoms and significantly impaired health-related quality of life, multidisciplinary approach and timely intervention are crucial.

Palliative Care and Hospice Interventions in Decompensated Cirrhosis and Hepatocellular Carcinoma: A Rapid Review of Literature

BACKGROUND

Patients with decompensated cirrhosis (DC) and/or hepatocellular carcinoma (HCC) have a high symptom burden and mortality and may benefit from palliative care (PC) and hospice interventions.

OBJECTIVE

Our aim was to search published literature to determine the impact of PC and hospice interventions for patients with DC/HCC.

METHODS

We searched electronic databases for adults with DC/HCC who received PC, using a rapid review methodology. Data were extracted for study design, participant and intervention characteristics, and three main groups of outcomes: healthcare resource utilization (HRU), end-of-life care (EOLC), and patient-reported outcomes.

RESULTS

Of 2466 results, eight were included in final results. There were six retrospective cohort studies, one prospective cohort, and one quality improvement study. Five of eight studies had a high risk of bias and seven studied patients with HCC. A majority found a reduction in HRU (total cost of hospitalization, number of emergency department visits, hospital, and critical care admissions). Some studies found an impact on EOLC, including location of death (less likely to die in the hospital) and resuscitation (less likely to have resuscitation). One study evaluated survival and found hospice had no impact and another showed improvement of symptom burden.

CONCLUSION

Studies included suggest that PC and hospice interventions in patients with DC/HCC reduce HRU, impact EOLC, and improve symptoms. Given the few number of studies, heterogeneity of interventions and outcomes, and high risk of bias, further high-quality research is needed on PC and hospice interventions with a greater focus on DC.

Patient Views on Advance Care Planning in Cirrhosis: A Qualitative Analysis

AIM

To investigate patient experiences and perceptions of advance care planning (ACP) process in cirrhosis.

METHODS

Purposive sampling was used to identify and recruit participants (N = 17) from discrete patient groups: compensated with no prior decompensation, decompensated and not yet listed for transplant, transplant wait listed, medical contraindications for transplant, and low socioeconomic status. Review and discussion of local ACP videos, documents, and experiences with ACP occurred in two individual interviews and four focus groups. Data were analyzed using inductive content analysis including iterative processes of open coding, categorization, and abstraction.

RESULTS

Three overarching categories emerged: (1) lack of understanding about disease trajectories and ACP processes, (2) roles of alternate decision makers, and (3) preferences for receiving ACP information. Most patients desired advanced care-planning conversations before the onset of decompensation (specifically hepatic encephalopathy) with a care provider with whom they had a trusting, preexisting relationship. Involvement of the alternate decision makers was of critical importance to participants, as was the use of direct, easy to understand patient education tools that address practical issues.

CONCLUSION

Our findings support the need for early advance care planning in the outpatient setting. Outpatient clinicians may play a key role in facilitating these discussions.

Advance care planning (ACP) for specialists managing cirrhosis: A focus on patient-centered care

Advance care planning (ACP) and goals of care designation (GCD) are being integrated into modern health care. In cirrhosis, uptake and adoption of these practices have been limited with physicians citing many perceived barriers and limitations. Recognizing the many tangible benefits of ACP and GCD processes in patients with life-limiting chronic diseases, the onus is on health practitioners to initiate and direct these conversations with their patients and surrogates. Drawing upon the literature and our experiences in palliative care and cirrhosis, we provide an actionable framework that can be readily implemented into a busy clinical setting by a practitioner. Conversation starters, visual aids, educational resources (for patients and practitioners), and videos of mock physician-patient scenarios are presented and discussed. Importantly, we have customized each of these tools to meet the unique health care needs of patients with cirrhosis. The inherent flexibility of our approach to ACP discussions and GCD can be further modified to accommodate practitioner preferences.

CONCLUSION

In our clinics, this assemblage of "best practice tools" has been well received by patients and surrogates enabling us to increase the number of outpatients with cirrhosis who have actively contributed to their GCD before acute health events and are supported by well-informed surrogates. (Hepatology 2018;67:2025-2040).

The incompatibility of healthcare services and end-of-life needs in advanced liver disease: A qualitative interview study of patients and bereaved carers

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.

Palliative care for people with advanced liver disease: A feasibility trial of a supportive care liver nurse specialist

BACKGROUND

Liver disease is an increasing cause of death worldwide but palliative care is largely absent for these patients.

AIM

We conducted a feasibility trial of a complex intervention delivered by a supportive care liver nurse specialist to improve care coordination, anticipatory care planning and quality of life for people with advanced liver disease and their carers.

DESIGN

Patients received a 6-month intervention (alongside usual care) from a specially trained liver nurse specialist. The nurse supported patients/carers to live as well as possible with the condition and acted as a resource to facilitate care by community professionals. A mixed-method evaluation was conducted. Case note analysis and questionnaires examined resource use, care planning processes and quality-of-life outcomes over time. Interviews with patients, carers and professionals explored acceptability, effectiveness, feasibility and the intervention.

SETTING/PARTICIPANTS

Patients with advanced liver disease who had an unplanned hospital admission with decompensated cirrhosis were recruited from an inpatient liver unit. The intervention was delivered to patients once they had returned home.

RESULTS

We recruited 47 patients, 27 family carers and 13 case-linked professionals. The intervention was acceptable to all participants. They welcomed access to additional expert advice, support and continuity of care. The intervention greatly increased the number of electronic summary care plans shared by primary care and hospitals. The Palliative care Outcome Scale and EuroQol-5D-5L questionnaire were suitable outcome measurement tools.

CONCLUSION

This nurse-led intervention proved acceptable and feasible. We have refined the recruitment processes and outcome measures for a future randomised controlled trial.

Demographics, Resource Utilization, and Outcomes of Elderly Patients With Chronic Liver Disease Receiving Hospice Care in the United States

OBJECTIVES

Hospice offers non-curative symptomatic management to improve patients' quality of life, satisfaction, and resource utilization. Hospice enrollment among patients with chronic liver disease (CLD) is not well studied. The aim of tis tudy is to examine the characteristics of Medicare enrollees with CLD, who were discharged to hospice.

METHODS

Medicare patients discharged to hospice between 2010 and 2014 were identified in Medicare Inpatient and Hospice Files. CLDs and other co-morbidities were identified by International Classification of Diseases-ninth revision codes. Generalized linear model was used to estimate regression coefficients with P-values. Logistic regression was used to calculate odds ratios and 95% confidence intervals.

RESULTS

A total of 2,179 CLD patients and 34,986 controls without CLD met the inclusion criteria. Non-alcoholic fatty liver disease, alcoholic liver disease, and hepatitis C virus (HCV) were the most frequent cause of CLD. CLD patients were younger (70 vs. 83 years), more likely to be male (57.7 vs. 39.3%), had longer hospital stay (length of stay, LOS) (19.4 vs. 13.0 days), higher annual charges ($175,000 vs. $109,000), higher 30-day re-hospitalization rates (51.6 vs. 34.2%), and shorter hospice LOS (13.7 vs. 17.7 days) than controls (all P<0.001). Presence of HCV and congestive heart failure were the strongest contributors to increased total annual costs (34% and 31% higher, P<0.001), increased total annual LOS (26% and 43% higher, P<0.001), and increased 30-day readmission risk (2.20 and 2.19 times, respectively).

CONCLUSIONS

Patients with CLD have longer and costly hospitalizations before hospice enrollment as compared with patients without CLD. It was highly likely that these patients were enrolled relatively late, which could potentially lead to less benefit from hospice.

Symptom Domain Groups of the Patient-Reported Outcomes Measurement Information System Tools Independently Predict Hospitalizations and Re-hospitalizations in Cirrhosis

BACKGROUND

Patient-Reported Outcomes Measurement Information System (PROMIS) tools can identify health-related quality of life (HRQOL) domains that could differentially affect disease progression. Cirrhotics are highly prone to hospitalizations and re-hospitalizations, but the current clinical prognostic models may be insufficient, and thus studying the contribution of individual HRQOL domains could improve prognostication.

AIM

Analyze the impact of individual HRQOL PROMIS domains in predicting time to all non-elective hospitalizations and re-hospitalizations in cirrhosis.

METHODS

Outpatient cirrhotics were administered PROMIS computerized tools. The first non-elective hospitalization and subsequent re-hospitalizations after enrollment were recorded. Individual PROMIS domains significantly contributing toward these outcomes were generated using principal component analysis. Factor analysis revealed three major PROMIS domain groups: daily function (fatigue, physical function, social roles/activities and sleep issues), mood (anxiety, anger, and depression), and pain (pain behavior/impact) accounted for 77% of the variability. Cox proportional hazards regression modeling was used for these groups to evaluate time to first hospitalization and re-hospitalization.

RESULTS

A total of 286 patients [57 years, MELD 13, 67% men, 40% hepatic encephalopathy (HE)] were enrolled. Patients were followed at 6-month (mth) intervals for a median of 38 mths (IQR 22-47), during which 31% were hospitalized [median IQR mths 12.5 (3-27)] and 12% were re-hospitalized [10.5 mths (3-28)]. Time to first hospitalization was predicted by HE, HR 1.5 (CI 1.01-2.5, p = 0.04) and daily function PROMIS group HR 1.4 (CI 1.1-1.8, p = 0.01), independently. In contrast, the pain PROMIS group were predictive of the time to re-hospitalization HR 1.6 (CI 1.1-2.3, p = 0.03) as was HE, HR 2.1 (CI 1.1-4.3, p = 0.03).

CONCLUSIONS

Daily function and pain HRQOL domain groups using PROMIS tools independently predict hospitalizations and re-hospitalizations in cirrhotic patients.

Palliative Care Quality Indicators for Patients with End-Stage Liver Disease Due to Cirrhosis

BACKGROUND AND AIMS

There are guidelines for the medical management of cirrhosis and associated quality indicators (QIs), but QIs focusing on standards for palliative aspects of care are needed.

METHODS

We convened a 9-member, multidisciplinary expert panel and used RAND/UCLA modified Delphi methods to develop palliative care quality indicators for patients with cirrhosis. Experts were provided with a report based on a systematic review of the literature that contained evidence concerning the proposed candidate QIs. Panelists rated QIs prior to a planned meeting using a standard 9-point RAND appropriateness scale. These ratings guided discussion during a day-long phone conference meeting, and final ratings were then provided by panel members. Final QI scores were computed and QIs with a final median score of greater than or equal to 7, and no disagreement was included in the final set.

RESULTS

Among 28 candidate QIs, the panel rated 19 as valid measures of quality care. These 19 quality indicators cover care related to information and care planning (13) and supportive care (6).

CONCLUSIONS

These QIs are evidence-based process measures of care that may be useful to improve the quality of palliative care. Research is needed to better understand the quality of palliative care provided to patients with cirrhosis.

Managing uncertainty in advanced liver disease: a qualitative, multiperspective, serial interview study

OBJECTIVE

To understand the experiences and support needs of people with advanced liver disease and those of their lay and professional carers to inform improvements in the supportive and palliative care of this rapidly growing but currently neglected patient group.

DESIGN

Multiperspective, serial interviews. We conducted up to three qualitative in-depth interviews with each patient and lay carer over 12 months and single interviews with case-linked healthcare professionals. Data were analysed using grounded theory techniques.

PARTICIPANTS

Patients with advanced liver disease of diverse aetiologies recruited from an inpatient hepatology ward, and their lay carers and case-linked healthcare professionals nominated by the patients.

SETTING

Primary and secondary care in South-East Scotland.

RESULTS

37 participants (15 patients, 11 lay and 11 professional carers) completed 51 individual and 13 joint patient-carer interviews. Nine patients died during the study. Uncertainty dominated experiences throughout the course of the illness, across patients' considerable physical, psychological, social and existential needs and affected patients, lay carers and professionals. This related to the nature of the condition, the unpredictability of physical deterioration and prognosis, poor communication and information-sharing, and complexities of care. The pervasive uncertainty also shaped patients' and lay carers' strategies for coping and impeded care planning. While patients' acute medical care was usually well coordinated, their ongoing care lacked structure and focus.

CONCLUSIONS

Living, dying and caring in advanced liver disease is dominated by pervasive, enduring and universally shared uncertainty. In the face of high levels of multidimensional patient distress, professionals must acknowledge this uncertainty in constructive ways that value its contribution to the person's coping approach. Pervasive uncertainty makes anticipatory care planning in advanced liver disease challenging, but planning 'just in case' is vital to ensure that patients receive timely and appropriate supportive and palliative care alongside effective management of this unpredictable illness.

Rate and predictors of successful cardiopulmonary resuscitation in end-stage liver disease

BACKGROUND

Cardiopulmonary resuscitation (CPR) after cardiac arrest in terminally ill patients is controversial. End-stage liver disease (ESLD) patients are unique from other terminally ill as they are generally younger and may be candidates for curative liver transplantation, but multiple studies have suggested poor outcomes when these patients require CPR. Predictors of success of CPR in ESLD have not been fully investigated, limiting end-of-life discussions.

AIM

The aim of this study was to quantify the rate and predictors of successful CPR in ESLD.

METHODS

We performed a retrospective chart review of patients with ESLD who received CPR from 2/2002 to 12/2013 at a single institution. Pre-cardiac arrest variables were collected for analysis as predictors of survival. Our primary outcome was survival to hospital discharge.

RESULTS

Of the 38 patients who underwent CPR, six survived to hospital discharge. When comparing those who survived to discharge with those who did not, we found no significant difference in age (p = 0.34), gender (p = 0.85), presence of ascites (p = 0.67), location at time of arrest (p = 0.39), concurrent GI bleeding (p = 0.48), and multiple individual lab values. Significant predictors of not surviving to hospital discharge were a model for end-stage liver disease (MELD) ≥ 20 (OR 6.0, p = 0.044) and presentation with a non-shockable rhythm (PEA/asystole) (OR 29, p < 0.001).

CONCLUSION

ESLD patients requiring CPR have worse outcomes as their MELD score increases. CPR in ESLD when MELD is <20 or with a shockable rhythm has a greater likelihood of success.

Validation of the Persian version of COOP/WONCA functional health status charts in liver transplant candidates

CONTEXT

Health-related quality of life is a preferred outcome measure for patients with advanced liver disease. The functional health status charts developed by the Dartmouth Primary Care Cooperative Information Project (COOP)/World Organization of National Colleges, Academies and Academic Associations (WONCA) make up a generic instrument for assessing health-related quality of life.

OBJECTIVE

To translate and validate the Persian version of COOP/WONCA in liver transplant candidates and to assess the correlation of Child Pugh classification and Model of End Stage Liver Disease (MELD) score with quality of life.Setting-The Shiraz liver transplant center, the most active liver transplant center in the Middle East.

PARTICIPANTS

Consecutive adult outpatients waiting for their first liver transplant who attended follow-up visits in the pretransplant clinic.Main Outcome Measures-Patients completed COOP/WONCA along with the Short Form (SF)-36. Data on the underlying cause of cirrhosis, Child-Pugh classification, and MELD scores were collected from medical records.

RESULTS

A Persian version of the COOP/WONCA was accepted by liver transplant candidates and showed adequate reliability and validity. Similar domains in COOP/WONCA charts and the SF-36 were highly correlated, indicating that construct validity of the COOP/WONCA in relation to the SF-36 was good (77% of correlations were as expected). Moreover, the exploratory factor analysis could not extract 2 different quality-of-life factors. These findings provide sufficient evidence to conclude that the Persian versions of COOP/WONCA charts and the SF-36 measure the same constructs of health-related quality of life and can be used interchangeably. Four of the 6 COOP/WONCA charts did not allow discrimination between groups of patients according to Child Pugh classification, indicating poor known group validity.

Life-sustaining treatment decisions in the ICU for patients with ESLD: a prospective investigation

We conducted a prospective study in the ICU of life-sustaining treatment and comfort care decisions over time in patients with end-stage liver disease (ESLD) from the perspectives of patients, family members, and healthcare professionals. Six patients with ESLD, 19 family members, and 122 professionals participated. The overarching theme describing the decision-making process was "on the train." Four sub-themes positioned patients and family members as passengers with limited control, unable to fully understand the decision-making process. Findings suggest that including patients and family members in non-immediate life-saving decisions and verifying early on their understanding may help to improve the decision-making process.

Prevalence and outcome of cirrhosis patients admitted to UK intensive care: a comparison against dialysis-dependent chronic renal failure patients

PURPOSE

Patients with decompensated liver cirrhosis who are admitted to intensive care units (ICU) are perceived, within the UK, as having a particularly poor prognosis.

METHODS

We performed a descriptive analysis of cirrhosis patients admitted to general critical care units 1995-2008 compared to patients admitted with pre-existing chronic renal failure. Data were obtained from the Intensive Care National Audit and Research Centre Case Mix Programme Database incorporating 192 adult critical care units in England, Wales and Northern Ireland.

RESULTS

Cirrhosis accounted for 2.6 % (16,096 patients) of total admissions with mean age 52.5 years and male preponderance (~60 %). Hospital mortality was high (>55 %) although this improved 5 % in recent years, and median length of stay was short (2.5 days). Mortality in cirrhotics with severe sepsis requiring organ support was 65-90 %, compared to 33-39 % in those without. Conversely, patients with chronic renal failure had lower mortality (42 %) despite similar characteristics and higher acute physiology and chronic health evaluation (APACHE) II scores. The APACHE II score under-predicted mortality in cirrhotics.

CONCLUSIONS

Cirrhosis patients exhibit worse outcomes compared to pre-existing renal failure patients, despite similar characteristics. Survival worsens considerably with organ failure, especially with sepsis. They represent a small number of admissions, albeit increasing over recent years, and, in general, have a short ICU stay. Patients with single organ failure have acceptable survival rates and mortality has improved; although we have no data on those refused ICU admission potentially causing survival bias. Given the extremely high mortality in patients with multi-organ failure, support should be limited/withdrawn in such patients.

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

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.