Too little, too late: Palliation and end-stage liver disease

Palliative Care Referral Patterns and Outcomes for Patients with End-Stage Liver Disease at an Academic Liver Transplant Center

Background: Patients with end-stage liver disease (ESLD) have complex needs and may benefit from palliative care (PC), which is often underutilized or delayed. Objectives: To characterize patients with ESLD who received inpatient PC consultation and to explore differences in characteristics between those who received PC consultation before (pre-Pall) or after (post-Pall) PC participation at weekly liver transplant (LT) Patient Selection Committee (PSC) meetings. Design: Single-center retrospective cohort study. Setting/Subjects: Hospitalized patients with ESLD who received inpatient PC consultation between February 2017 and February 2019 at an academic LT center in the United States. Measurements: PC referral reasons and timing, code status, hospice referrals, discharge location, and mortality. Results: Two hundred five patients were included. The primary reason for PC was goals of care (88.8%; n = 182). Most (86.8%; n = 178) were Full Code at hospital admission, while 81% (n = 166) were do-not-resuscitate at discharge. Nearly one quarter (22.9%; n = 47) sought life-prolonging care at discharge, while 41.5% (n = 85) were discharged with hospice, and 34.1% (n = 70) died before discharge. By the end of the study, 85.9% (n = 176) were confirmed as deceased. Median time from PC to hospice referral was 12 days [95% confidence interval [CI]: 8-23]. Median time from PC consult to death was 13 days [95% CI: 9-17] and from hospice referral to death was 7 days [95% CI: 4-13]. There were no statistically significant differences between the pre- and post-Pall groups related to PC referral patterns or outcomes. Conclusions: Most PC contacts occurred near end of life, and many led to comfort-focused care. Late referrals may be due to reliance on inpatient consults during acute illness. PC presence at PSC meetings represents an important step in collaboration with LT teams but did not lead to direct impact on PC referral patterns or outcomes.

Supportive and palliative care needs in advanced non-malignant liver disease: systematic review

Advanced cirrhosis confers a significant symptom burden and has a 50% 2-year mortality rate in those with decompensated disease. There is increasing demand for supportive and palliative care (SAPC) for these patients, yet no consensus on the best model of delivery. It is necessary to identify the needs of such patients and their carers, and evaluate whether they are being met.A literature search was conducted using key words pertaining to adult patients with liver cirrhosis and their SAPC needs. Study quality was assessed and findings grouped by theme. 51 full texts were selected for inclusion, 8 qualitative studies, 33 quantitative studies, 7 systematic reviews, 2 mixed methods studies and 1 Delphi methods. Key findings were grouped into three main themes: SAPC needs, access to SAPC and models of care.Patients with cirrhosis have significant psychological and physical symptom burden with many unmet needs. These data failed to identify the best service model of care. The impact of specialist palliative care (SPC) referral was limited by small numbers and late referrals. With the majority of studies conducted in the USA, it is unclear how well these findings translate to other healthcare systems. Comparison between hepatology led services and SPC was limited by inconsistent outcome measures and prevented pooling of data sets. These data also had limited evaluation of patient-reported outcome measures. We propose the development of a core outcome set to ensure consistent and meaningful evaluation of the SAPC needs of patients with advanced non-malignant liver cirrhosis.

Improving palliative and supportive care in advanced cirrhosis: the HepatoCare model of integrated collaborative care

BACKGROUND

Patients with advanced cirrhosis experience an unpredictable disease trajectory but are infrequently referred to palliative care (PC) services and rarely undertake advance care planning (ACP).

AIM

We assessed whether a novel model of care increased provision of meaningful PC in advanced cirrhosis compared with standard of care (SOC).

METHODS

Thirty consecutive hepatology clinic outpatients with advanced cirrhosis, meeting one or more cirrhosis-related PC referral criteria, consented to treatment in the HepatoCare clinic (PC physician, specialist liver nurse, pharmacist) in parallel with usual specialist hepatology care. A control cohort of 30 consecutive outpatients with advanced cirrhosis undergoing SOC treatment was retrospectively identified for comparison. The primary outcome was provision of meaningful PC using HepatoCare versus SOC. Additional clinical outcomes were assessed over 12 months or until death and significant differences were identified.

RESULTS

The intervention and control cohorts had similarly advanced cirrhosis (mean Child-Pugh scores 8.7 vs 8.2, P = 0.46; mean model for end-stage liver disease scores 14.4 vs 14.6, P = 0.88) but a lower 12-month mortality rate (33% HepatoCare vs 67% SOC; P = 0.02). The intervention cohort experienced higher uptake of formal ACP (100% vs 25% for the control cohort) and outpatient PC referral (100% vs 40%), and were more likely to die at home or in a PC bed/hospice (80% vs 30%). The majority of the HepatoCare cohort (81%) had medications safely deprescribed and experienced fewer unplanned admission days (470 vs 794).

CONCLUSIONS

HepatoCare is a novel multidisciplinary model of care that integrates effective PC and specialist hepatology management to improve outcomes in advanced cirrhosis.

What is known about the care and support provided for an ageing population with lived experience of chronic viral hepatitis as they near end-of-life: A scoping review

Ageing with a chronic hepatitis B (HBV) or hepatitis C (HCV) infection is an emerging public health priority. For people living with chronic viral hepatitis, their disease progression into old age is both underpinned by their existing blood borne virus and the potential emergence of other infectious and non-infectious conditions. These twinned pathways bring additional challenges to the care and support for people as they near end of life. This scoping review sought to examine what is known about the experiences of the end-of-life phase of an increasing population ageing with HBV and HCV in studies conducted in high-income settings and published in peer reviewed literature (2010-2021). In interpreting this literature, we found that challenges in determining the end-of life phase for people with lived experience of HBV or HCV are exacerbated by the conflation of aetiologies into a singular diagnosis of end-stage liver disease. Studies overwhelmingly reported the clinical aspects of end-of-life care (i.e. prognosis assessment and symptom management) with less attention paid to educative aspects (i.e. advance care directives and surrogate decision makers, discussion of treatment options and determining goals of care). Psychosocial interventions (i.e. quality of life beyond symptom management, including emotional/spiritual support and family and bereavement support) received limited attention in the literature, though there was some recognition that psychosocial interventions should be part of end-of-life care provision. Given the focus on the prominent disease presentation of liver cirrhosis and/or end-stage liver disease, the social and cultural dimensions of these infections have received less attention in the literature on end-of-life in the context of chronic viral hepatitis.