Improving palliative and supportive care in advanced cirrhosis: The HepatoCare model of integrated collaborative care

Improving palliative and supportive care in advanced cirrhosis: The HepatoCare model of integrated collaborative care

An article written by Alison Kearney, Department of Palliative and Supportive Care, Royal Brisbane and Women's Hospital

Patients with decompensated liver disease have an unpredictable prognosis and a high symptom burden but are rarely offered palliative care in a timely fashion. Dominant symptoms include poor appetite, fatigue, nausea, pain, itch, anxiety and insomnia. They are less likely to have participated in advance care planning, compared with other patient populations with similarly advanced disease, which often leads to persistence of aggressive and invasive medical treatments in their final admissions. Unfortunately, their place of death is usually an acute care setting.

To address these issues, a new service (known as ‘HepatoCare’) was introduced as a pilot initiative at the Royal Brisbane and Women’s Hospital in 2017. This was established as a multidisciplinary out-patient clinic staffed by a senior pharmacist, a specialist hepatology nurse and a palliative care physician. Referral guidelines were developed, based on published palliative care referral criteria, to identify patients with advanced cirrhosis who are at high risk of death and who are likely to benefit from the introduction of palliative care support. Importantly, these patients continued to attend their regular hepatology appointments in parallel with this new service, providing flexibility when patients deteriorate or their goals of care change. The hepatology nurse acts as a case manager for HepatoCare patients and exists as a single point of contact for patients and their families as they negotiate an uncertain disease trajectory.

Our recently published paper [1] reports on our experience with our initial pilot cohort of patients recruited to this novel model of care and compares outcomes with a historical control cohort of patients undergoing standard of care management. Each cohort comprised thirty consecutive patients with similarly advanced disease. The HepatoCare referral criteria were effective at recognising patients with high mortality, with 67% in  the control group and 33% of the intervention group dying within 12 months of follow-up. Traditional liver-related disease severity scores (such as the Child-Pugh and MELD Score) were not effective at distinguishing patients who died. Standard of care management saw 70% of control patients dying in an acute care setting in 70%, compared with only 20% of the Hepatocare cohort.

Advance care planning was formally addressed in 100% of HepatoCare patients compared with only 25% of the standard of care group.  Unplanned hospital admissions were substantially lower in the intervention group (470 vs 794 patient bed days used) with a significant reduction in inpatient length of stay related to non-liver-related admissions. The provision of meaningful palliative care, defined as palliative care input prior to the terminal admission, was only 40% in the control group but improved to in the HepatoCare group.

High levels of polypharmacy were noted in all patients at baseline. The HepatoCare intervention also involved a routine review of medications by a senior pharmacist and 81% of HepatoCare patients had medications safely deprescribed. Patients’ treatment regimens were optimised to address symptoms and medication lists were provided to patients, carers and local pharmacists and GPs.

The success of the HepatoCare program has seen it become embedded as the new standard of care at the Royal Brisbane and Women’s Hospital. The program has facilitated closer working relationships between the hepatology and palliative care departments. Hitherto neglected patients with cirrhosis enjoy the benefits of joint hepatology/palliative care ward rounds on a weekly basis, cirrhosis-specific analgesic advice as well as holistic support and more streamlined access to community-based resources. We encourage other hospital palliative care and hepatology services to embrace this model of care to improve outcomes for their patients with advanced cirrhosis.

Authors


Alison Kearney

Department of Palliative and Supportive Care

Royal Brisbane and Women's Hospital


 

 

Reference

  1. Kearney A, Tiwari N, Cullen O, Legg A, Arbi I, Douglas C, Leggett B, Fenech M, Mina J, Hoey P, Skoien R. Improving palliative and supportive care in advanced cirrhosis: The HepatoCare model of integrated collaborative care. Intern Med J. 2023 Nov;53(11):1963-1971.
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