Palliative Care Interventions in End-Stage Liver Disease: A Rapid Review
Of the 400,000 patients with end-stage liver disease (ESLD) in the United States, approximately 2% of patients are transplanted, with the remainder of the population dying from liver disease. These patients have a high level of symptom burden and may benefit from palliative care intervention. Our objective was to review the current evidence for palliative care provider intervention in patients with end-stage liver disease and do this with an effective and time-efficient methodology, the rapid review.
We reviewed six databases (PubMed, EMBASE, CINAHL, PsychInfo, ClinicalTrials.gov, Cochrane) for adults with ESLD and hepatocellular carcinoma (HCC) who received palliative care, with a rapid review methodology. We included patients with hepatocellular carcinoma (HCC) since most patients with HCC also have liver cirrhosis and often have similar symptoms. We excluded pharmacological and procedural interventions and focused on what the role of a specialty palliative care provider is, including: communication regarding patient values, prognosis, understanding, in combination with symptom management and end-of-life care with multidisciplinary support. Data were extracted for study design, participant and intervention characteristics, and three main groups of outcomes: patient-centered outcomes (symptoms, quality-of-life, etc.), quality-of-death outcomes (receiving end-of-life care, advanced directives, concordance of actual care with wishes, etc.), and healthcare resource utilization (visits and admissions to emergency room and hospital, lengths of stay, costs of treatment, etc.).
Database search resulted in 2460 studies. After removing duplicates and exclusion criteria applied, 19 studies were included in final results. There were 2 randomized controlled trials and 17 non-randomized studies. From the 19 studies, 63% (12), were focused on HCC and 37% (7) on non-malignant ESLD. Interventions included: 31% (6) inpatient palliative care consultation, 21% (4) outpatient hospice, 16% (3) inpatient hospice, 16% (3) outpatient palliative care delivery, and others (combination of inpatient and outpatient hospice, and communication with unspecified location). Six of the studies showed improvement in patient-centered outcomes. Most of the studies looking at healthcare resource utilization showed reduction in cost, fewer procedures, ER visits, hospitalizations. All of the studies looking at quality of death outcomes showed an improvement. Two studies showed no difference in survival and one showed an improvement in survival in HCC compared to patients who did not have hospice.
There is a paucity of high quality research regarding palliative care interventions in ESLD and HCC, and existing evidence shows improvement in quality-of-death, patient-centered, and healthcare utilization outcomes. A rapid review methodology is a great tool for trainees, practicing clinicians, or policy-makers to quickly synthesize a summary of evidence on a topic.
- Sandhya Mudumbi, MD
- Clinical Instructor, Postdoctoral Fellow
- University of Alabama at Birmingham
- 1960 6th avenue south
- Birmingham, AL 35209
- Alayne D. Markland
- Brendan Mcguire
- Catherine H. Smith
- Cynthia J. Brown
- Nicholas Hoppman