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Perspectives on Care at the Close of Life | Clinician's Corner

Integrating Palliative Care for Liver Transplant Candidates:  “Too Well for Transplant, Too Sick for Life”

Anne M. Larson, MD; J. Randall Curtis, MD, MPH
JAMA. 2006;295(18):2168-2176. doi:10.1001/jama.295.18.2168.
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Chronic liver disease results in more than 1 million physician visits and more than 300 000 hospitalizations per year in the United States. More than 27 000 patients annually progress to end-stage liver disease (ESLD), liver failure, or death. Quiz Ref IDPatients with ESLD experience such complications as encephalopathy, malnutrition, muscle wasting, ascites, esophagogastric variceal hemorrhage, spontaneous bacterial peritonitis, fatigue, and depression. Despite significant improvements in palliation, patients' quality of life diminishes and their disease will often inexorably progress. Liver transplantation, a valid treatment option, increases life and reduces many symptoms. With the current shortage of organs, up to 10% to 15% of these patients die without receiving an organ. Many patients also are not candidates for transplantation due to comorbid illness. In addition, some patients receive a transplant but succumb to complications of the transplant itself. Such patients and families face the conundrum of a potentially treatable yet often fatal illness. Quiz Ref IDThrough the case of a 55-year-old woman with a life-long history of hepatitis B virus infection who is awaiting transplant, we discuss the transplant eligibility process and the struggle with maintaining hope for a cure in the face a life-threatening illness. In all of these circumstances, the health care team must combine elements of palliative care with life-sustaining therapy to maximize the patient's quality and quantity of life.

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Figure. Three-Month Mortality Based on Model for End-Stage Liver Disease Score
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The formula for the model for end-stage liver disease (MELD) score is MELD = 0.957 × Loge (creatinine mg/dL) + 0.378 × Loge (bilirubin mg/dL) + 1.120 × Loge (international normalized ratio) + 0.643. The final score should be multiplied by 10 and rounded to the nearest whole number. For laboratory values that are lower than 1.0, set to 1.0 for purposes of calculation of the MELD score. The maximum serum creatinine level considered is 4.0 mg/dL (353.6 μmol/L). If the patient has had dialysis twice within a week before calculation of the MELD score, the score should be calculated with a serum creatinine value of 4.0 mg/dL (353.6 μmol/L) no matter what the actual serum creatinine level is.

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