PALLIATIVE CARE IN END-STAGE LIVER DISEASE
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1 PALLIATIVE CARE IN END-STAGE LIVER DISEASE Ken S. Ota, DO Family Medicine Banner Good Samaritan Medical Center Learning Objectives: Describe the common bio-psycho-social issues in end-stage liver disease (ESLD). Discuss the trajectory of functional decline in patients with ESLD. Coordinate palliative treatments for common physical symptoms experienced by patients with ESLD Communicate the role of palliative care in ESLD. DISCLOSURE OF COMMERCIAL SUPPORT Ken S. Ota, DO does not have a significant financial interest or other relationship with manufacturer(s) of commercial product(s) and /or provider(s) of commercial services discussed in this presentation. the. 1
2 Palliative Care in End-Stage Liver Disease Ken S. Ota, DO Transitional Care Medicine Banner Good Samaritan Medical Center Phoenix, AZ WHY? Not eligible for transplant, too sick for life. What is Palliative Care? an approach that improves the quality of life of patients and their families facing the problem associated with lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. W.H.O. Defintiion of Palliative Care. the. 2
3 Objectives Describe the common bio-psycho-social issues in patients with ESLD Discuss the trajectory of functional decline in ESLD Coordinate palliative treatments for common physical symptoms in ESLD Communicate the role of palliative care in ESLD Not Enough Donor Livers Schiff s Diseases of the Liver. 11 th Edition MELD Score for prognosis the. 3
4 End-Stage Liver Disease Cirrhosis with Renal Dysfunction and Hyponatremia Hansen L, et al Background 5.5 million Americans with chronic liver disease Various etiologies: infectious, autoimmune, metabolic ~30,000 deaths annually Transplant listed patients > Liver donors Asymptomatic for years $4 billion healthcare costs 37% readmit to hospital within 1 month Biological Issues Ascites Bleeding due to Portal Hypertension Spontaneous Bacterial Peritonitis Hepatic Encephalopathy Malnutrition Renal Dysfunction Hepatocellular Carcinoma Pruritus Pain the. 4
5 Ascites Sodium restriction Diuretics (i.e. spironolactone/furosemide) Therapeutic Paracentesis Transjugular intrahepatic portosystemic shunt (Deltenre P, et al. 2005, Meta-analysis) Peritoneal tunneled catheter (Tapping CR, et al. 2012, observational study) Hepatic Encephalopathy Protein restricted diet not advisable (Hansen L, et al. 2010) Non-absorbable dissacharide (lactulose) (Sharma BC, et al. 2009, RCT) Non-absorbable antibiotic (rifaximin) + lactulose synergy (Loguercio C, et al. 2003, RCT) Lactulose enema at home (Saito T, et al. 2002) Pain Acetaminophen (1.5 g to 2 g/day, Bubalo J 2009) Avoid NSAIDs Non-pharmacologic therapy (CBT, gentle massage, reflexology) Prevent/Treat Constipation Groninger H, et al the. 5
6 Observational retrospective study of ESLD patients Poonja et al Social Issues Bajaj et al Patients with cirrhosis lack self-management of disease knowledge. (Volk et al. 2013) Many patients with ESLD/Cirrhosis feel stigmatized. (Vaughn-Sandler et al. 2014) Psychological Issues Poonja et al Illness-related fear in ESLD is prevalent. (Stewart KE et al. 2013) the. 6
7 the. 7
8 Summary Summary on caring for patients with ESLD Bio-Psycho-Social Care Disease trajectory can be unpredictable Palliative care is appropriate at any stage of a life-threatening illness Keep lines of communication open and prepare for the worst the moral test how [we] treat those who are in the shadows of life the. 8
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