From the Guidelines
Palliative care evaluation for patients with end-stage liver disease (ESLD) should be provided based on needs assessment, delivered concurrently with curative or life-prolonging treatments, and tailored to the stage of disease, as recommended by the American Gastroenterological Association 1.
Key Components of Palliative Care Evaluation
The evaluation should focus on:
- Symptom management, including pain, pruritus, ascites, encephalopathy, fatigue, muscle cramps, and sleep disturbances
- Psychosocial support, including assessment for depression, anxiety, and existential distress
- Advance care planning, including discussions on goals of care, treatment preferences, surrogate decision-makers, and hospice considerations
- Quality of life assessment, including nutritional evaluation and functional assessment using tools like the Palliative Performance Scale
Symptom Management
Pain management may require careful medication selection, often using acetaminophen (up to 2 grams daily) while avoiding NSAIDs and monitoring opioids closely due to altered metabolism in liver failure 1. Pruritus can be addressed with antihistamines like hydroxyzine (10-25mg every 6 hours), cholestyramine (4g 1-2 times daily), or sertraline (50-100mg daily).
Advance Care Planning
Advance care planning discussions should address goals of care, treatment preferences, surrogate decision-makers, and hospice considerations when appropriate, as recommended by the American Association for the Study of Liver Diseases (AASLD) 1. Patients with orders to withhold or withdraw life-sustaining treatment should have them followed, and palliative care or hospice should be offered to patients expected to survive <6 months 1.
Palliative Care Quality Metrics
Palliative care quality metrics that should be considered in patients with ESLD include:
- Offering palliative care or hospice to patients expected to survive <6 months
- Documenting goals of care for medical therapy
- Identifying a surrogate decision-maker within 48 hours of hospital admission
- Discussing goals of care before initiation of mechanical ventilation or pacemaker placement 1
Collaboration and Communication
Palliative care specialists and hepatologists should work collaboratively to achieve the desired goals of care for each patient, and any member of a patient's care team can offer primary palliative care with advanced care planning and symptom management 1.
From the Research
Key Components of Palliative Care Evaluation for End-Stage Liver Disease (ESLD)
The key components of a palliative care evaluation for patients with ESLD include:
- An interdisciplinary approach to care, involving a team of healthcare professionals from various disciplines 2, 3
- Early palliative care intervention, which has been shown to improve symptom control and mood in patients with ESLD 4, 5
- Discussion of goals of care with patients and their family members, including advance care planning and symptom management 6, 3
- Symptom management, including the assessment and treatment of physical and psychological symptoms such as pain, fatigue, and depression 4, 5, 3
- Psychosocial support, including support for patients and their family members to cope with the emotional and psychological impacts of ESLD 2, 3
Benefits of Palliative Care Evaluation for ESLD
The benefits of palliative care evaluation for ESLD include:
- Improved symptom control and quality of life for patients with ESLD 4, 5
- Improved mood and reduced depression in patients with ESLD 4
- Increased patient and family satisfaction with care 5, 6
- Improved goal concordant care and reduced healthcare utilization 5
- Better outcomes for patients with ESLD, including improved itching, well-being, appetite, anxiety, fatigue, and depression 3
Challenges and Future Directions
Despite the benefits of palliative care evaluation for ESLD, there are challenges to its implementation, including: