Palliative Care and Symptom-Based Management in Decompensated Cirrhosis

Patient Guideline Summary

Publication Date: January 31, 2022

Last Updated: March 3, 2023

Objective

This patient summary means to discuss key recommendations from the American Association for the Study of Liver Diseases (AASLD) for palliative care and symptom-based management in decompensated cirrhosis. It is limited to adults 18 years of age and older and should not be used as a reference for children.

Overview

Hospice care focuses exclusively on comfort and includes only persons with a life expectancy measured in months.

Palliative care can include disease-directed or even curative treatments.
- It includes all aspects of life – spiritual, cultural, social, psychological, ethical, medical, and end-of-life planning.
- Consequently, everyone has the ability to contribute.

This patient summary focuses on palliative care for decompensated cirrhosis.

Treatment

Palliative care, begun as soon as the need is identified and followed through, can result in greater consensus between patients and clinicians about the goals of care, reduce symptom burden and unwanted life-sustaining treatment, improve mental health and quality of life, provide earlier provision of comfort-focused care, and reduced hospital readmission.
- It can also reduce non-professional caregivers’ symptoms.

Advance care planning, an integral part of palliative care, is an ongoing assessment of a patient’s care preferences, goals, and values as end-of-life approaches.
- Topics to be covered include finances, legal documents such as trusts, wills, and powers of attorney, and pastoral/spiritual counseling.
The language used in all conversations with the patient should be clearly understood, hence free of technical terms and concepts.
Attention to the wide array of symptoms that accompany late-stage disease must be continuous and can involve a range of modalities like physical therapy and behavioral modification in addition to medications.
- Causes of symptoms should be carefully identified.
- Multimodal pain management is highly effective.
  - NSAIDs should be avoided in patients with cirrhosis.
  - Opioids should be reserved for inadequate response to less harmful pain medications.
- The reduction of ascites may alleviate abdominal symptoms.
- Difficulty breathing may respond to oxygen, a fan, drainage of hydrothorax, opioids, and medications for anxiety.
- Brain dysfunction (hepatic encephalopathy) may cause intermittent or continuous fatigue or disturbances in sleep, mood, wakefulness, and cognition. Medical and behavioral treatments are available.
- Muscle cramps may respond to medications or supplemental potassium, magnesium, and zinc.
- Itching is a common problem best treated topically. Alternatives include cholestyramine, low-dose naltrexone, rifaximin (in anicteric patients [those not jaundiced]), and sertraline.
- Sexual dysfunction, depression, and anxiety are also common and may require mental health professionals.
- Nausea and vomiting occur in many patients with cirrhosis for multiple reasons. After a thorough search for treatable causes, ondansetron may be used.

Planning for hospice care for patients nearing death can be facilitated by standardized scoring systems.
- Model for End-Stage Liver Disease (MELD)
- Child-Pugh-Turcotte scores

It is important that caregivers are also cared for, particularly non-professionals who bear the daily burdens of dying loved ones.

Abbreviations

AASLD: American Association For The Study Of Liver Diseases
MELD: Model For End-stage Liver Disease

Source Citation

Rogal SS, Hansen L, Patel A, Ufere NN, Verma M, Woodrell CD, Kanwal F. AASLD Practice Guidance: Palliative care and symptom-based management in decompensated cirrhosis. Hepatology. 2022 Feb 1. doi: 10.1002/hep.32378. Epub ahead of print. PMID: 35103995.

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.