Managing symptoms and complications associated with chronic liver disease in palliative care

Patients with advanced chronic liver disease experience many symptoms common to other advanced conditions (eg pain, breathlessness, anxiety, depression, muscle cramps, fatigue, anorexia, nausea and vomiting), along with specific symptoms and complications associated with advanced chronic liver disease (eg itch, ascites, portal vein thrombosis, hepatic encephalopathy); see also Cirrhosis and its complications: overview.

Management of chronic liver disease in patients with palliative care needs depends on potential benefits and burdens of treatment, and the patient’s prognosis, preferences (including preferred care setting) and goals of care—see Principles of symptom management in palliative care. When using a drug to treat patients with chronic liver disease, consider whether the dosage needs modification, or whether an alternative drug is required.

For management of pain, see Principles of managing pain in palliative care and the considerations outlined in the Pain and Analgesia guidelines. Distension-related abdominal pain can be managed symptomatically and often requires a multimodal approach.

For management of breathlessness, see Breathlessness in palliative care. Breathlessness is usually caused by presence of ascites. For management of malignant ascites in patients with palliative care needs, see Malignant ascites in palliative care. For management of nonmalignant ascites, see the Liver disorder guidelines. Complications such as portal vein thrombosis can worsen ascites or abdominal pain—see the Liver disorders guidelines for management of portal vein thrombosis.

For management of anxiety and depression, see Emotional, psychological and behavioural symptoms in palliative care. For patients with cirrhosis, exclude uncontrolled hepatic encephalopathy and if drug therapy is required, carefully consider possible adverse effects when selecting a drug. If a benzodiazepine is used for anxiety, oxazepam is the preferred drug, starting with a low dose.

For management of muscle cramps, see Muscle cramps in palliative care. Vitamin E may not be beneficial for cramps in decompensated cirrhosisKalia, 2022.

For management of fatigue, see Fatigue in palliative care.

For management of nausea, vomiting and anorexia, see Nausea and vomiting in palliative care and Anorexia, weight loss and cachexia in palliative care—draining ascites may improve these symptoms.

For management of cholestatic itch, see Cholestatic itch in palliative care.

Hepatic encephalopathy is a form of delirium—for management, see Hepatic encephalopathy in the Liver disorders guideline. Alcohol withdrawal–related delirium can occur during an episode of hepatic encephalopathy when a patient stops drinking because they are comatose—see Alcohol withdrawal in the Addiction guidelines for management. For patients in the last days of life or with refractory encephalopathy, consider using a psychotropic for delirium. Impaired liver metabolism and renal excretion can cause accumulation of some drugs; if a psychotropic is used, consider if dose reduction is required to minimise sedation. Sedation may be mistaken for deteriorating encephalopathy.