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

Waterman, Brittany; S, Ramsey; Whitsett, Maureen; Patel, Arpan; Radcliff, Jacob A; Kotler, Drew; Winters, Adam C.; Woodrell, Christopher D.; Ufere, Nneka N.; Serper, Marina; Walling, Anne M.; Jones, Christopher A.; Kelly, Sean G.

doi:10.1089/jpm.2021.0097

Cited by 5 publications

(28 citation statements)

References 68 publications

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“…Yet this scale also answers the call to use markers such as ascites, encephalopathy, and frailty to provide a more nuanced clinical risk assessment for mortality. 11,19 Patients with a MELD-Na ≥ 21 and any level of functional dependence will meet the criteria for hospice discussion by the HELP scale which underscores the importance of functional status, even in the absence of major complications of portal hypertension for patients with a high MELD-Na score. The HELP scale also demonstrates that a MELD-Na ≥ 21 with only 1 listed complication of portal hypertension does not meet the threshold for opening a hospice discussion but the cumulative effect or two or more listed complications will generally meet the threshold of 28 and may serve as a trigger to providers to begin discussions regarding the utility of hospice referral.…”

Section: Discussionmentioning

confidence: 99%

“…17,18 Decompensated liver disease is characterized by a prolonged, undulating course that can make prognostication difficult. 19 Providers must ascertain the likelihood of six-month mortality as a condition of hospice referral and the prognostic uncertainty often leads to delayed hospice referrals for this patient population. 5,20 Acknowledgment of the underutilization of hospice at the EOL for decompensated cirrhosis is becoming increasingly recognized on a national level and has led to the publication of the first practice guidance for palliative care and symptom-based management in decompensated cirrhosis.…”

Section: Introductionmentioning

confidence: 99%

“…An important barrier to hospice referral, for both patients and providers, is a poor understanding of mortality risk due to the uncertainty of the disease course 17,18 . Decompensated liver disease is characterized by a prolonged, undulating course that can make prognostication difficult 19 . Providers must ascertain the likelihood of six‐month mortality as a condition of hospice referral and the prognostic uncertainty often leads to delayed hospice referrals for this patient population 5,20 …”

Section: Introductionmentioning

confidence: 99%

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Consider hospice in end‐stage liver disease prognostic scale to open discussions regarding six‐month mortality

2023

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Background and Aim Hospice is underutilized in the management of patients with end‐stage liver disease and may improve the patient experience at the end of life. This study aims to create a novel prognostic scale to accurately predict 6‐month mortality to more comprehensively facilitate hospice referral. Methods Sociodemographic, clinical, and laboratory variables associated with mortality from the United Network for Organ Sharing database were tested in univariate analysis followed by multivariate analyses with four predictor groups: Demographics, Diagnoses, Complexities, and Laboratory studies to develop the hospice in end‐stage liver disease prognostic scale (HELP) scale (70% sample, N = 13 516) followed with replication in a 30% (N = 5792) internal validation sample. Results Only the predictor groups of Complexities and Laboratory studies met the c‐statistic threshold of 0.70 for inclusion in the multivariate analyses. Backward elimination in the final logistic regression and validated weighted transformation procedure resulted in: HELP scale = (functional status × 11) + (ascites × 3) + (SBP × 3) + (HE × 4) + (dialysis × 5) + (TIPS × −3) + (albumin × −3) + (MELD‐Na ≥ 21 × 20). HELP scale had a strong predictive value for six‐month mortality with Area under the Receiver Operating Curve (AUROC) 0.816 and replicated in the validation sample. Conclusion HELP scale is a novel prognostic score utilizing the strength of model of end‐stage liver disease‐sodium (MELD‐Na), along with clinical factors, for a more nuanced assessment of six‐month mortality. This scale can provide an individualized approach in opening discussions of hospice referral and may be better accepted by patients and providers given its contextualization of important clinical factors.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Consider hospice in end‐stage liver disease prognostic scale to open discussions regarding six‐month mortality

2023

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“…Pain is a common and debilitating symptom in patients with cirrhosis. Patients may have pain syndromes outside of their liver disease or may experience pain or discomfort that is disease-related, such as abdominal pain associated with ascites [ 3 •]. Pain can be acute (12 weeks or less) or chronic and can be nociceptive, neuropathic, or musculoskeletal in origin.…”

Section: Generalized Symptoms With Liver-specific Considerationsmentioning

confidence: 99%

“…While much of the literature in palliative hepatology has focused on methods to measure patient quality of life, referral rates to palliative care, and caregiver burden, there remains a dearth of guidance on how we, as hepatologists, can better manage our patients’ symptoms. In addition to the high symptom burden in patients with cirrhosis, there are physiological changes associated with cirrhosis that impact the metabolism of many medications, thereby creating challenges in treatment [ 3 •].…”

Section: Introductionmentioning

confidence: 99%

Symptom Management in Patients with Cirrhosis: a Practical Guide

Kaplan

Rosenblatt

2022

Curr Treat Options Gastro

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Purpose of the review Though it is well known that cirrhosis is associated with significant morbidity and mortality, management of symptoms in cirrhosis can be difficult. This review serves to offer practical guidance in the management of liver-specific symptoms of cirrhosis as well as other symptoms with special hepatic considerations. Recent findings We discuss liver-specific symptoms and management, including ascites and refractory ascites, hepatic encephalopathy, pruritus, and muscle cramping. We also discuss the challenges of treating more generalized symptoms in cirrhosis, including pain, depression/anxiety, appetite, and fatigue. Medication management is, especially complex in this population given the altered metabolism of drugs, and we consider some strategies to approach this. Summary With the right tools, provided throughout this review, hepatologists should be well equipped to manage the nuanced liver-specific and generalized symptoms in patients with cirrhosis.

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Hospital Opioid Usage and Adverse Events in Patients With End-Stage Liver Disease

Johnson¹,

Golzarri‐Arroyo²,

Mahendraker³

et al. 2023

Journal of Pain and Symptom Management

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

Cited by 5 publications

References 68 publications

Consider hospice in end‐stage liver disease prognostic scale to open discussions regarding six‐month mortality

Consider hospice in end‐stage liver disease prognostic scale to open discussions regarding six‐month mortality

Symptom Management in Patients with Cirrhosis: a Practical Guide

Hospital Opioid Usage and Adverse Events in Patients With End-Stage Liver Disease

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