Palliative Care Case Presentation CNS Fiona Smith

Transcript:Palliative Care Case Presentation CNS Fiona Smith:
Palliative Care Case Presentation CNS Fiona Smith and Dr Yvonne Cartwright DH NASH cirrhosis with portal hypertension diagnosed 2011 2014-2018 - 6 monthly cirrhosis surveillance. Stable Evidence of decompensation 2018 – found to have moderate ascites on scan and bilateral leg oedema- started Spironolactone, Ciprofloxacin and had monthly review from this point Age 73, Type 2 diabetes mellitus, Ischaemic heart disease, COPD September 2018- discussion with Hepatology CNS that liver disease would deteriorate, in-dwelling drain inserted and referred to ESC Weekly paracentesis from September 2018-May 2019 including one day before his death At ESC appointment- commenced antidepressant for low mood, supported to claim PIP, encouraged to update will and referred to Community Palliative Care Support reviewed in Advanced Liver Disease MDT April 2019; all in place Died May 2019 – without readmission to an Acute Trust Palliative Care in End-stage Liver Disease (ESLD) Mortality rate from chronic liver disease in the UK is rising rapidly Patients with advanced disease have a symptom burden comparable to cancer and other life-limiting conditions Liver disease strongly associated with significant social, psychological and financial hardships for patients and carers; early MDT involvement helpful The unpredictable trajectory of the disease makes prognostication difficult 70% of patients with Advanced Liver Disease die in hospital Specialist Palliative Care input for patients with HCC and ESLD has been shown to encourage advance care planning, reduce in-hospital deaths and reduce healthcare costs Hepatologist Perceptions Palliative Care more suitable for those with cancer than without Feel they should have initial conversations about ACP Are unclear about the referral criteria for Specialist Palliative Care May be uncertain about appropriate medications for symptom control May believe that Palliative Care is synonymous with End of Life care Feel that Palliative Care involvement is inappropriate for patients still being considered for transplantation Role of the Hepatologist Recognition of decompensated cirrhosis and early consideration of appropriate treatment options Is liver transplantation a feasible consideration or clearly precluded? If so, transplant assessment, but bringing transplant into discussion enables discussion about prognosis. Palliative Care can be involved in parallel with being on Transplant w/l. If not early discussion about stage of disease and prognosis This leads to Planning of management of decompensation events offer of earlier Palliative Care input -> timely referral to Specialist Palliative care either hospital or community based (both may be appropriate) Timely conversations about treatment escalation plans (including CPR), admission criteria (if appropriate),