P010 End of life care in patients with cirrhosis: a district general hospital perspective

Abstract

<h3></h3> End of life care (EOLC) refers to care given to patients with a prognosis of less than one year. Whilst cirrhosis-related death can be unforeseen, it typically concludes a prolonged declining clinical trajectory. Clinical encounters represent key opportunities for EOLC planning in this cohort, yet the limitations of current provision by gastroenterologists are increasingly recognised.¹ We reviewed our practice to identify areas for improvement. This retrospective cohort study identified patients who died from sequelae of cirrhosis between 1st January 2018–31st December 2019 and had at least one non-terminal cirrhosis-related admission in their last year of life. Electronic records were interrogated for evidence of prognostication assessment, transplant candidacy and gastroenterology input. Discussions regarding end-stage liver disease (ESLD), EOLC and palliative care referral were reviewed. 52 patients were identified for analysis. In their last year of life, patients averaged 1.7 cirrhosis-related admissions and 69.2% had at least one outpatient clinic. 61.5% had no prognostication score documented, including 58.3% (7/12) of Child-Pugh C patients. Interestingly, only 23.6% met &gt;2 poor-prognosis criteria prior to their terminal admission.¹ ESLD was discussed in a quarter of patients in advance of terminal admission, yet EOLC was subsequently broached in only 61.5% (8/13) of these cases. Just 33.3% of Child-Pugh C patients and 65.3% (17/26) of non-transplantable patients were counselled regarding ESLD. In terms of palliative care provision, 19.2% (10/52) received inpatient palliative care, though 80% of these referrals only occurred during their terminal admission. 62.5% of community palliative care referrals occurred in the context of a Continuing Healthcare Fast Track discharge. We have highlighted that more needs to be done to resolve the gaps in our patient pathway to ensure ESLD is recognised, patients are counselled appropriately and fitting EOLC is offered. Enhanced EOLC planning in this high-risk group is a priority, as currently palliative care input is mostly limited to a late stage in the patient journey. Validated prognostication tools can identify those with poorer prognoses yet, without a formal pathway to review this, patients with declining trajectories were not readily recognised. We plan to introduce an inpatient ‘discharge bundle’ to prompt enhanced follow up of ESLD patients. The goal is to achieve an optimised parallel care model, with earlier EOLC offered alongside ongoing active management in this cohort. <h3>Reference</h3> Hudson BE, Ameneshoa K, Gopfert A, <i>et al</i>. Integration of palliative and supportive care in the management of advanced liver disease: development and evaluation of a prognostic screening tool and supportive care intervention. <i>Frontline Gastroenterol</i> 2017;<b>8</b>(1):45–52.