Abstract and Introduction
Abstract
In the United States, end-stage liver disease (ESLD) is the 12th leading cause of death and the 7th leading cause of death in people between the ages of 25 and 64 years. Complications of ESLD such as ascites, variceal hemorrhage, hepatic encephalopathy, and renal impairment primarily account for these deaths. Patients with ESLD require increasingly complex medical support and manifest a spectrum of complications and symptoms that have significant impact on both survival and quality of life.
Introduction
Because of the possibility of liver transplantation, patients with ESLD are more likely to receive aggressive care despite constant declining poor health. In current practice, discussions and referrals to palliative or hospice care are not done until the hope of recovery is diminished, which is often in the last weeks of life. There is little literature on the appropriate palliative care approach for those with ESLD. The purpose of this article is to summarize the transitions often experienced by patients with ESLD as they approach end-of-life, compare and contrast these transitions to other life limiting illnesses, and review current palliative care strategies recommended for ESLD.
Cirrhosis is a final common endpoint in patients with chronic progressive liver disease from a variety of etiologies. Patients who have abnormalities of liver synthetic and excretory function and who develop ascites, variceal hemorrhage, hepatic encephalopathy, or renal impairment are considered to have end-stage liver disease (ESLD). Liver transplantation is a valid treatment option for ESLD; however, with increased waiting times for organ transplantation, approximately 17% of listed patients die annually while waiting for transplantation, and many other patients with ESLD are not candidates for liver transplantation. Patients with ESLD are generally managed in the community and face a variety of symptoms and disease-related complications, which affect survival and health-related quality of life.
The purpose of this article is to discuss the symptom burden of patients with ESLD, describe how symptoms affect the transitions patients experience as they near the end-of-life (EOL), compare and contrast these transitions to other life limiting illnesses, and review current palliative care strategies recommended for ESLD. Palliative care for patients with ESLD is often poor, in part because of inadequate communication between patients and their providers, lack of criteria to help clinicians determine which patients would benefit from EOL conversations, and the lack of clear understanding of the contribution of common psychosocial issues and their effects on successful implementation of palliative care strategies. Further research is needed in these areas to improve EOL care for these patients.