From the Guidelines
Hospice care should be considered for patients with liver cirrhosis and ascites when they have a poor prognosis, typically with a life expectancy of six months or less, and meet certain criteria such as significant functional decline, severe malnutrition, or refractory ascites. For a patient who is hardly eating and spends most of the day lying down despite stable labs and no encephalopathy, hospice may be appropriate if they meet these criteria. The patient's nutritional status and activity level suggest progressive decline, which is concerning even with stable laboratory values. Consider consulting with a hepatologist or palliative care specialist to evaluate the patient's prognosis more accurately, as recommended by the British Society of Gastroenterology and the British Association for the Study of the Liver 1. A goals-of-care discussion with the patient and family is essential to understand their preferences regarding end-of-life care, and to determine the best course of action for symptom management and quality of life. Some key indicators of poor prognosis in patients with liver cirrhosis and ascites include:
- A MELD-Na score above 20
- Child-Pugh class C cirrhosis
- Refractory ascites despite maximum diuretic therapy
- Hepatorenal syndrome
- Recurrent variceal bleeding
- Severe malnutrition with muscle wasting
- Significant functional decline The National Comprehensive Cancer Network clinical guidelines support the incorporation of palliative care into the treatment of cancer at time of diagnosis regardless of stage, and hospice care is appropriate for those whose life expectancy is less than six months 1. The "surprise question" can be a useful tool to recognize patients who would benefit most from palliative care measures, by asking the primary care physician if they would be surprised if the patient dies within a defined short time interval 1. Ultimately, the decision to pursue hospice care should balance medical indicators of poor prognosis with the patient's overall functional decline and personal wishes, with the goal of providing symptom management, emotional support, and improved quality of life when curative treatments are no longer beneficial or desired.
From the Research
Decision for Hospice Care
The decision to opt for hospice care for patients with liver cirrhosis and ascites is complex and depends on various factors, including the patient's overall health, quality of life, and prognosis.
- The patient's current condition, with stable labs and no encephalopathy, but hardly eating, sleeping, or laying in the couch all day, suggests a poor quality of life.
- According to 2, hospice care is considered when a patient has a prognosis of 6 months or less, and the focus is on providing comprehensive comfort care and support for the patient and their family.
Treatment of Ascites
The treatment of ascites in patients with liver cirrhosis is crucial in improving their quality of life and reducing mortality.
- Studies 3, 4, and 5 suggest that diuretics, such as spironolactone and furosemide, are effective in treating ascites, with spironolactone being the first-line treatment.
- The combination of diuretics and octreotide may also improve portal and systemic hemodynamics, as shown in 6.
Prognosis and Quality of Life
The development of ascites is associated with significant mortality and a poor quality of life, as stated in 3.
- The patient's current condition, with a poor quality of life and stable labs, may indicate a need for a discussion about hospice care, as their prognosis may be limited.
- However, the decision to opt for hospice care should be based on a comprehensive assessment of the patient's overall health, prognosis, and goals of care, as emphasized in 2.