End-stage liver disease: Critical care escalation or palliative care

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End-stage liver disease:
critical care escalation or palliative care
E
nd-stage liver disease is a terminal
diagnosis, for which transplantation
is the only cure, an option possible
in a minority. Patients present with
complications requiring escalated
care, including variceal haemorrhage, sepsis,
hepatorenal syndrome or encephalopathy.
Each time a decision must be made whether
to intervene or accept the complication as a
terminal event. Unless the patient has made an
advance decision, the default is to preserve life.
A 64-year-old patient with non-alcoholic
steatohepatitis-related cirrhosis presented
with recurrent ascites. Cardiovascular risk
precluded transplantation. Life expectancy
was felt to be 3–6 months. Paracentesis-
induced renal dysfunction (likely hepatorenal
syndrome) had previously been treated
successfully on the ward. On this occasion,
the creatinine level rapidly rose to 399 umol/
litre. Without guided uid management or
renal replacement therapy in a critical care
environment, a fatal outcome appeared likely.
Case for critical care escalation
Data demonstrate improved short-term
outcomes through early recognition
and treatment of acute precipitants in
critical care (Sauneuf et al, 2013). Despite
numerous proposed prognostic scores, there
is no standardized scoring system to predict
outcomes, making it dicult to deny critical
care based on available models. Literature
supports initial unrestricted critical care
escalation with re-calculation of prognostic
scores at 48–72 hours to inform further
therapeutic options (McPhail et al, 2015).
Dr Sreelakshmi Kotha, Senior Hepatology
Clinical Fellow, Department of
Gastroenterology, St Thomas’ Hospital,
Guy’s & St Thomas’ NHS Foundation Trust,
London
Dr Philip Berry, Consultant Hepatologist,
Department of Gastroenterology, St
Thomas’ Hospital, Guy’s & St Thomas’ NHS
Foundation Trust, London SE1 7EH
Correspondence to: Dr P Berry
(philip.berry@gstt.nhs.uk)
Hepatorenal syndrome is usually fatal
within 2 weeks without treatment. It is
diagnosed in the absence of structural
kidney disease, hypovolaemia or nephrotoxic
inuences, and is characterized by pre-existing
portal hypertension with ascites, low urine
sodium concentrations and poor response
to uid challenges. Early identication and
guided uid management with albumin and
vasoconstrictors is the best treatment in the
non-transplant group (Fede et al, 2012).
In the absence of advance decision making
with patient and family, conversion to a
palliative approach during the onset of a severe
deterioration can come as a shock. Patients
are acutely vulnerable, often with impaired
mental capacity as a result of encephalopathy.
Case for ward-based care
and palliation
When hepatorenal syndrome develops in
end-stage liver disease (transplant excluded),
transfer to critical care is usually clinically
futile. Uncertainty around the clinical course
in end-stage liver disease is a major barrier to
anticipatory planning of palliation. Poonja et
al (2014) found that just 11% of patients who
had been declined a transplant were referred
to palliative care services and only 28% of
these had orders to limit resuscitation while
48% had subsequent critical care admission.
Use of resources is an important
consideration, although it should not
inuence individual cases. e mean cost of
hospitalization in the last year of life in patients
with cirrhosis was £18 500, with the ‘mean
cost of the terminal admission’ £9615 (Gola
et al, 2015), compared to £4500 for patients
whose terminal admission was in a hospice.
Outcome of current case
Discussion with the patient and family
included prognosis, and escalating to critical
care or changing focus to palliative care, with
an expedited, supported discharge to home
(preferred place of care if dying). ey rmly
believed that if more could be done, it should.
e patient was transferred to critical care
and invasive circulatory monitoring started.
Over 72 hours the patient’s renal function
improved. She was discharged 3 weeks later,
following an advance decision that care would
not be escalated beyond the ward during future
admissions. ere were three more arranged
admissions for paracentesis, but on the third
occasion her condition rapidly deteriorated
and she died peacefully in hospital.
Conclusions
Data suggest unrestricted critical care
management should take place in the initial
48 hours with re-assessment in this cohort
of patients, but this should not preclude
discussions about prognosis and should
provide an opportunity to introduce palliative
care and to make advance decisions regarding
end-of-life care. In patients with end-stage liver
disease deemed unsuitable for transplantation,
the goal of care should be to address quality of
life and symptom management and focus on
support for both patient and family. BJHM
Fede G, D’Amico G, Arvaniti V et al. Renal failure
and cirrhosis: a systematic review of mortality and
prognosis. J Hepatol. 2012 Apr;56(4):810–818.
https://doi.org/10.1016/j.jhep.2011.10.016
Gola A, Davis S, Greenslade L et al. Economic
analysis of costs for patients with end stage liver
disease over the last year of life. BMJ Support
Palliat. 2015;5:110. https://doi.org/10.1136/
bmjspcare-2014-000838.23
McPhail MJW, Shawcross DL, Abeles RD et al.
Increased survival for patients with cirrhosis and
organ failure in liver intensive care and validation
of the chronic liver failure–sequential organ failure
scoring system. Clin Gastroenterol Hepatol.
2015 Jul;13(7):1353–1360.e8. https://doi.
org/10.1016/j.cgh.2014.08.041
Poonja Z, Brisebois A, van Zanten SV, Tandon
P, Meeberg G, Karvellas CJ. Patients with
cirrhosis and denied liver transplants rarely
receive adequate palliative care or appropriate
management. Clin Gastroenterol Hepatol. 2014
Apr;12(4):692–698. https://doi.org/10.1016/j.
cgh.2013.08.027
Sauneuf B, Champigneulle B, Soummer A et al.
Increased survival of cirrhotic patients with septic
shock. Crit Care. 2013;17(2):R78. https://doi.
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Anaesthetic and critical care dilemmas are
coordinated by Dr Rob Anker, Anaesthetic
Registrar (ST6), Royal Marsden Hospital, London
and Dr Prashanth Nandhabalan, Specialist
Registrar in Anaesthesia and Intensive Care, King’s
College Hospital NHS Foundation Trust, London
658 British Journal of Hospital Medicine, November 2018, Vol 79, No 11
Anaesthetic and Critical Care Dilemma
© 2018 MA Healthcare Ltd
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