Article Text

other Versions

Download PDFPDF
Integration of palliative and supportive care in the management of advanced liver disease: development and evaluation of a prognostic screening tool and supportive care intervention
  1. Benjamin E Hudson1,2,
  2. Kelly Ameneshoa1,
  3. Anya Gopfert1,
  4. Rachael Goddard1,
  5. Karen Forbes2,3,
  6. Julia Verne4,
  7. Peter Collins1,
  8. Fiona Gordon1,
  9. Andrew J Portal1,
  10. Colette Reid3,
  11. C Anne McCune1
  1. 1Department of Hepatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
  2. 2School of Clinical Sciences, University of Bristol, Bristol, UK
  3. 3Department of Palliative Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
  4. 4Public Health England South Region, Bristol, UK
  1. Correspondence to Dr Benjamin Edward Hudson, Department of Hepatology, University Hospitals Bristol NHS Foundation Trust, Marlborough Street, Bristol BS1 3NU, UK; ben.hudson{at}


Background and objectives Patients with decompensated cirrhosis rarely receive palliative and supportive care interventions, which are routine in other life-limiting diseases. We aimed to design and evaluate a prognostic screening tool to routinely identify inpatients with decompensated cirrhosis at high risk of dying over the coming year, alongside the development of a supportive care intervention.

Design Clinical notes from consecutive patients admitted as an emergency to University Hospitals Bristol with a diagnosis of cirrhosis over two distinct 90-day periods were scrutinised retrospectively for the presence or absence of five evidence-based factors associated with poor prognosis. These were analysed against their ability to predict mortality at 1 year. ‘Plan-Do-Study-Act’ (PDSA) methodology was used to incorporate poor-prognosis screening into the routine assessment of patients admitted with cirrhosis, and develop a supportive care intervention.

Results 73 admissions were scrutinised (79.5% male, 63% alcohol-related liver disease, median age 54). The presence of three or more poor-prognosis criteria at admission predicted 1-year mortality with sensitivity, specificity and positive predictive value of 72.2%, 83.8% and 81.3%, respectively, and was used as a trigger for implementing the supportive care intervention. Following modification from six PDSA cycles, prognostic screening was integrated into the assessment of all patients admitted with decompensated cirrhosis, with the supportive care intervention (developed simultaneously) instigated for appropriate patients.

Conclusions We describe a model of care which identifies inpatients with cirrhosis at significant risk of dying over the coming year, and describe development of a supportive care intervention, which can be offered to suitable patients in parallel to ongoing active management.

View Full Text

Statistics from


  • Contributors BEH led data collection and analysis and drafted the manuscript, KA, AG and RG assisted with data collection and statistical analysis, JV scrutinised and edited the manuscript, PC, FG, AJP, CR and KF assisted in design and implementation of the intervention, CAM led design of the study and critically reviewed the manuscript.

  • Funding The study was funded by David Telling Charitable Foundation.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.