Table 2

Achievable changes

Early, open discussions around prognosis and advance care planning
Advanced liver disease MDT
  • Encourage discussion of patients with unstable disease.

  • Clarify optimal medical management, discuss emergency treatment plans and establish reasonable ceilings of care.

  • Ensure clear, consistent communication between primary and secondary care as well as patients and carers.

Prognostic scoring
  • Use SPICT or Bristol Screening Tool to identify patients with ESLD who may benefit from SPC input.38 39

Hepatic encephalopathy
  • Education of patients and carers about recognition, avoidance and management of HE.

  • Encourage patients and carers to adjust laxative doses themselves to control symptoms and reduce hospital admissions.

  • Proactive use of rifaximin – second episode of HE.

Ascites
  • Access to day case paracentesis service.

  • Consider use of LTAD or alfapump

  • Pragmatic approach to diuretic use at EOL.

Malnutrition
  • Early referral to dietitian.

  • Education of patients and carers on good nutrition in liver disease – encourage bedtime snack.

  • Use liver frailty index (https://liverfrailtyindex.ucsf.edu/).

Pain management
Financial assistance
  • Provide information about local services and charities that can assist patients with applications for financial assistance.

Carer support
  • Early referral to carer support services, for example, respite care.

  • Support to access financial assistance if eligible.

  • CLD, chronic liver disease; EOL, end of life; ESLD, end-stage liver disease; HE, hepatic encephalopathy; LTAD, long-term abdominal drain; SPC, specialist palliative care; SPICT, Supportive and Palliative Care Indicators Tool.