The Guide to Hepatic Disease in Hospice

Introduction

Hepatic disease is a broad term to describe diseases that affect the liver. When hepatic disease is chronic, it is often referred to as liver failure, cirrhosis or end stage liver disease.

Symptoms

• Jaundice
• Pruritus
• Pain
• Ascites
• Dyspnea

Types of Hepatic Disease

Hepatitis

Hepatitis is an inflammation of the liver and can lead to cirrhosis or liver cancer. Hepatitis can be caused by various viruses, toxins, autoimmune disorders or hereditary conditions.

Cirrhosis

Cirrhosis is the scarring and damage of liver cells. It can be caused by hepatitis, alcoholism or malnutrition.

Primary Hemochromatosis (hereditary hemochromatosis)

This is an inherited disease. Secondary hemochromatosis is caused by anemia and alcoholism. Either type can cause the body to absorb and store too much iron. If the disease is not treated, the liver, heart and pancreas can fail. Cancer of the Liver
Liver cancer can be a primary carcinoma or metastatic cancer that has spread to the liver.

What is the Prognosis?

As hepatic diseases progress, complications can include:

• gastric and esophageal varices
• bleeding
• increasing ascites
• hepatic encephalopathy

Palliative Care

Pharmacological and non-pharmacological interventions should focus on symptomatic relief, maintaining maximum function and optimal quality of life. Psychological and spiritual support is needed to assist patients and their families who often experience fear, anxiety and depression. Support groups (including online chat groups) are an excellent resource. To help patients and caregivers find a support group, contact your local American Liver Foundation.

Documentation

Document the following signs and symptoms:

• Laboratory indicators of impaired liver function
• Prothrombin time prolonged more than 5 seconds over control and serum albumin < 2.5 gm/dl
• Jaundice — note color change of skin and eyes
• Bilirubin stained urine
• Alcoholic stools without bile (light-colored and gray)
• Oliguria (400 ml/day or less) — document amount when possible
• Cirrhosis and ascites
• Ascites — refractory to sodium restriction and diuretics
• Fatigue
• Itching
• Right upper quadrant pai
• Recurrent variceal bleeding
• Peritonitis
• Encephalopathy refractory to protein restriction and lactulose
• Hepatorenal Syndrome (this is often indicative of survival of days to weeks). Include in documentation the presence of cirrhosis and ascites, elevated BUN and creatinine, oliguria (< 400 ml/day), and urine sodium concentration < 10 mEq/l

Significant Prognostic Indicators

• Muscle wasting with reduced strength and endurance
• Continued active alcoholism, i.e. > 80 g ethanol per day
• Hepatocellular carcinoma
• HbsAg positivity
• Hep C refractory to treatment
• Progressive malnutrition

Documentation Tips

Document all signs and symptoms affecting physical function including onset of disease and changes over time. Include information relating the psychosocial and spiritual needs and interventions which impact the overall quality of life.

References

Fallon, M. Palliative Medicine in non-malignant disease.. In: Doyle D, Hanks G, Cherny N, Calman K eds Oxford Textbook Palliative Medicine. 3rd ed. pp. 844 -845, Oxford University, 2005.

Grauer P, Shuster J & McCrate-Protus B. (2008). Palliative Care Consultant: A reference guide for palliative care 3RDed. Kendall/Hunt publishing Co.

Kinzbrunner B. Non-malignant terminal diseases: criteria for hospice admission. Hosp Update 3: 3-6, 1993.

Stuart B, et al. Medical Guidelines for Determining Prognosis in Selected Non- Cancer Diseases. Arlington, VA, National Hospice Organization, 1996.

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