AGA clinical practice guideline update: Palliative care management in patients with cirrhosis

Palliative Care (PC) is an approach to care that focuses on improving the quality-of-life of patients and their caregivers who are facing life-limiting illnesses.1 In order to meet the needs of the increasingly prevalent cirrhosis population, it is important that all clinicians are able to work together to deliver PC as a standard of care.1 To date, there are limited guidelines or guidance statements to direct clinicians in the area of PC and cirrhosis.1 A newly published clinical practice guideline by the American Gastroenterological Association (AGA) has provided the latest evidence-based review of the ten Best Practice Advice (BPA) statements which address key issues pertaining to PC in patients with cirrhosis.1

Patients with cirrhosis have a life-limiting chronic illness with a median survival ranging from 2 years in decompensated disease to 12 years in compensated disease.2 Cirrhosis is associated with a high burden of physical and psychological symptoms even in the compensated state, and the quality-of-life of patients with worsening disease parallels to those with advanced cancer.3,4 Despite the severity of cirrhosis, rates of advance care planning (ACP) and goals of care directives remain low.1 Symptom management is also suboptimally addressed, and specialty PC and hospice referrals occur infrequently and late in the course of the disease.5

Currently, there are limited guidelines or guidance statements to direct clinicians in the area of PC and cirrhosis.1 The AGA clinical practice guideline update thereby proposed 10 best practices to help clinicians fill this gap. Dr. Tandon, Associate Professor in the Department of Medicine, Division of Gastroenterology at the University of Alberta, and associates reviewed and summarized available data pertinent to the provision of PC in patients with cirrhosis to generate specific advice in addressing the key aspects of clinical management.1

The ten BPA statements are summarized as follows:1

  1. Care with PC principles should be provided to any patients with advanced serious chronic illness or life-limiting illness such as cirrhosis, irrespective of the transplant candidacy. This care should be based on needs assessment instead of prognosis alone, aiming to deliver concurrently with curative or life-prolonging treatments tailored to the stage of disease
  2. Care inclusive of PC principles may be delivered by healthcare providers from any specialties within any healthcare settings
  3. Providers caring for persons with cirrhosis should assess for the presence and severity of symptoms within physical, psychological, social, and spiritual domains related to their liver disease, its treatment and prognosis
  4. Across the spectrum of cirrhosis, excellence in communication is integral to high quality advance care planning, goals of care conversations, and the cultivation of prognostic awareness with patients and caregivers
  5. Routine care for patients with cirrhosis, and particularly for those with decompensated disease, should include assessment of caregiver support and screening for caregiver needs.
  6. Prognosis should be evaluated by gastroenterology/hepatology providers during routine care visits and at sentinel events
  7. Goals of care discussions in patients with cirrhosis should be repeated at sentinel events including hospital or intensive care admission, before the initiation of life supporting therapies, before surgery, on new onset of cirrhosis-related complications, and after determination of transplant eligibility
  8. Because lack of time is one of the major barriers to administering PC, healthcare providers should consider how they can optimize efficiencies in PC delivery
  9. Dedicated specialist PC services are often a limited resource. As such, healthcare providers should work together with local specialist PC teams to establish clear triggers and pathways for referral
  10. Healthcare providers caring for patients with cirrhosis should provide timely referral to hospice for patients who have comfort-oriented goals and prognosis of 6 months or less

Overall, the new guideline provided extensive coverage and recommendations on the clinical management of patients with cirrhosis in PC.1 With its adoption, clinicians can be better equipped in the management of relevant patients with the ultimate goal of providing a better quality-of-life to cirrhotic patients and their caregivers.1

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