Providers caring for patients with cirrhosis, especially decompensated cirrhosis (ascites, variceal bleeding, hepatic encephalopathy), should initiate discussions regarding advance care planning and goals of care, and should consider referral to palliative care.

Key concepts

• Natural history of cirrhosis is unpredictable, with periods of stability and episodes of hepatic decompensation that can result in rapid decline and death
• Patients with cirrhosis may experience a health crisis or lose decision-making capacity before the health care team has talked with them about their goals of care and life-sustaining treatment
• The VA Life-Sustaining Treatment (LST) Decisions Initiative is a national quality improvement effort that promotes proactive goals of care conversations with high-risk patients about their values, goals, and preferences
• Palliative care provides patient- and family-centered care focused on anticipation, prevention, and treatment of suffering for anyone with life-limiting illness; palliative care should be part of the regular care of patients with cirrhosis; it should not be reserved only for patients with short life expectancy
• Hospice care is appropriate for patients with life expectancy of less than 6 months

Key recommendations

• Educate patients regarding complications of cirrhosis (See Cirrhosis. A Patient's Guide) and prognostic scores used to assess mortality in cirrhosis (MELD score, CTP class)
• It is crucial to have goals-of-care discussions, especially with high-risk patients with cirrhosis: patients who were recently hospitalized for cirrhosis complications, with other comorbidities impacting their survival, or patients with decompensated cirrhosis who are not eligible for liver transplantation
• Consider using LST resources to improve your skills discussing goals of care in general or specifically in patients with cirrhosis (Brisebois et al)
• Document discussions of advance care planning and goals of care in the patient's health record; VA uses a standardized LST progress note template and durable LST orders, also Form 10-0137 for advance directive

References

Advance care planning (ACP) for specialists managing cirrhosis: a focus on patient-centered care. Brisebois A, Ismond KP, Carbonneau M, et al. Hepatology. 2018 May;67(5):2025-2040.

Palliative care for patients with end-stage liver disease: an overview. Rakowski MO, Volk ML. Clin Liver Dis. 2015 Jul;28(6)1:19-21.