PERT Program

Tip of the Month: September 2005


CARING FOR PATIENTS WITH ADVANCED LIVER DISEASE¹


This month's tip focuses on caring for patients with liver failure. Although less than 2 percent of nursing home deaths are caused by liver failure², the number of nursing home patients with advanced liver disease is likely to increase in the coming years.

The liver is the largest organ in the human body, comprising approximately one-fiftieth of the total adult body weight. It is located in the right upper quadrant extending from the diaphragm to the nipple line and has a fibrous capsule covering. The liver receives approximately 25% of the cardiac output, or nearly 1500 ml of blood per minute.

Each year, over 23,000 people die in the United States from liver disease, making it the 10th leading cause of death. The primary cause of liver disease in the United States is chronic alcohol abuse, followed closely by Hepatitis C virus. The symptoms of liver disease are similar in most patients, regardless of the cause. Chronic liver disease is characterized by a progressive, irreversible decline in liver function. The term chronic liver disease is often used synonymously with the terms cirrhosis, liver failure, or end-stage liver disease. All of these terms are correct in that they refer to liver disease that is chronic and life-limiting. Chronic liver disease is a terminal illness for which the only curative treatment is liver transplantation. Cirrhosis occurs with all types of chronic liver disease regardless of the cause. It is an irreversible inflammatory process that causes disruption to the structures and functions of the liver. Cirrhosis eventually causes multiple clinical problems, of which three major ones are described below.

Portal Hypertension. All forms of cirrhosis eventually cause portal hypertension. The changes in liver structure caused by cirrhosis impair blood flow and increase blood pressure within the liver. The increased pressure within the liver's circulatory system causes blood vessels in the lower esophagus to enlarge. These enlarged vessels, called varices, have a tendency to rupture and bleed. When this occurs, the bleeding is often life-threatening. Patients with cirrhosis secondary to alcohol have the greatest risk of bleeding.

All treatment for portal hypertension is palliative. Goals of care are based on patient preference, prognosis, and the benefits and burdens of providing or not providing a treatment. At all times, the goal of treatment for portal hypertension is to prevent bleeding through reduction of portal pressure. In approximately 20–50% of patients, use of a non-selective β-blocker, such as propranolol, reduces portal pressure via splanchnic vaso-constriction and reduction of cardiac output. Some patients may elect transfer to a hospital, in which case the goals are control of bleeding, hemodynamic stability, prevention of infection and hepatic encephalopathy, and correction of associated clotting abnormalities. Other more aggressive treatments that may be considered include: sclerotherapy and banding, surgical creation of portal-systemic shunts, and TIPS (transjugular intrahepatic portosystemic shunt). It is likely that none of the above treatments will be effective in decreasing portal hypertension and the associated complications for patients at the end of their disease. A comprehensive nursing assessment of patients with hepatic failure should always include the risk of esophageal bleeding. Patients with a history of gastrointestinal hemorrhage are at a greater risk. Staff should also assess for signs and symptoms of anemia, which would include assessing for melena. Patients at risk of variceal rupture and their families will need ongoing education. Teaching tailored to the patients, families, and staff should include what to expect, what actions to take in the event of a rupture, and whom to call for assistance.

Ascites is the presence of free fluid within the peritoneal cavity. It is one of the most common complications of cirrhosis. Patients with ascites report a poor quality of life, and are at an increased risk for infections and renal failure. In patients with liver failure, ascites is due to portal hypertension and the shunting of blood to the systemic circulation. As with other symptoms associated with liver failure, ascites can range from mild to severe. It may present suddenly or over the course of months. The prognosis associated with a slow onset is worse because the causative factors are more likely to be irreversible.

Common symptoms associated with ascites include weight gain, an increased abdominal girth, and the presence of dullness and a fluid wave with palpation. Dyspnea is the primary reason patients with ascites seek medical care. Findings include increased respiratory rate, shortness of breath with exertion, sleeping in a semi-Fowler position, and some peripheral edema.

The primary goal of treatment for ascites is to reduce the clinical symptoms thereby increasing patient comfort. Treatment options which are based on prognosis and goals of care might include placing the patient on a sodium-restricted diet and administration of potassium-sparing diuretics such as spironolactone. In some patients, it may be necessary to use stronger diuretics such as furosemide (Lasix®) or ethacrynic acid (Edecrin®). More aggressive interventions that may require transfer to an acute care facility include paracentesis and intrahepatic portosystemic stent-shunts (TIPS). Depending on the patient's prognosis and goals of care, nursing interventions would include monitoring electrolytes for hyponatremia and hypokalemia.

Nursing indications for treatment include ascites that produces clinical symptoms, ascites where the underlying cause is unknown regardless of if symptoms are present, and tense ascites — ascites that causes severe pain and may lead to eversion and ulceration of an umbilical hernia. When treating ascites it is important to monitor for excessive fluid loss, which can cause renal failure and encephalopathy. As with all palliative treatments, assessment of goals of care, and the benefits and burdens of specific treatments are required.

Hepatic Encephalopathy is a reversible but complex syndrome characterized by disturbances of consciousness, personality, and intellect that occur in combination with altered neuromuscular activity and electroencephalographic (EEG) abnormalities. The exact cause of hepatic encephalopathy is not fully understood. The primary cause is related to the liver's inability to clear toxic substances such as ammonia. Common symptoms include drowsiness, reversal of day/night sleep patterns, confusion, and difficulty concentrating. Other common findings include the inability to draw concentric circles or five pointed stars, hyperactive tendon reflexes, and ultimately decerebrate posturing. Speech is often slow, slurred, and monotonous, and some patients may have fetor hepaticus (odd, sweet smell on the breath).

Treatment of hepatic encephalopathy follows a stepwise approach that is dependent on the clinical picture. The first step requires an attempt to identify the precipitating cause. Some common causes are gastrointestinal bleeding and the over-use of tranquillizers, sedatives, or analgesics. Other causes include increased dietary protein intake, alkalosis, bacterial infection, or hypokalemia.

The next step requires interventions to reduce the production and absorption of gut-mediated ammonia and other toxins. This is accomplished through the reduction and modification of dietary protein, altering enteric bacteria and the colonic environment, and facilitating colonic emptying. Changing the colonic environment occurs via the administration of antibiotics and lactulose.

Because the primary cause of liver failure in the United States is alcohol abuse and Hepatitis C virus associated with substance abuse, patients are often younger than those with other chronic illnesses. Patients with liver failure who require care in a skilled nursing facility often have unique needs, both physically and socially. Those with advanced end-stage liver disease may have multiple physical needs that cannot be met by family or friends in the home setting, thus necessitating the need for a skilled facility.

Patients residing in a nursing facility with a diagnosis of end-stage liver disease would most likely experience portal hypertension and its associated complications of ascites and hepatic encephalopathy described above. All care provided is palliative in nature as there is no cure for liver disease. Symptoms are managed in accordance with the patient and family goals, prognosis, and the benefits versus burdens of providing treatment. Due to the complex physical, social, emotional, and spiritual needs of these patients, treatment by an interdisciplinary team is highly recommended.



References

  1. Adapted from: Owens, D. (2005). Treatment of End Stage Non-Cancer Diagnoses - Hepatic Failure. (P. Coyne, Ed.). Dubuque, IA: Kendall/Hunt
  2. Aronow WS. (2000). Clinical causes of death of 2372 older persons in a nursing home during 15-year follow-up. J Am Med Dir Assoc. 1(3):95-6.


This month's tip was prepared by Darrell A. Owens, PhD, RN, CHPN, a Palliative Care Specialist at the University of Washington at Harborview Medical Center, Seattle, and a member of the Editorial Advisory Board, Journal of Hospice and Palliative Nursing.