Palliative Care in End-Stage Liver Disease

End-stage liver disease (ESLD) is the final result of various pathophysiological disturbances that underlie chronic liver diseases. ESLD is associated with significant physical and emotional distress as a result of known complication such as ascites, spontaneous bacterial peritonitis, electrolyte abnormalities, hepatic encephalopathy (also known as portosytemic encephalopathy), esophageal varices, pruritus, hepatorenal syndrome, and hepatocellular cancer. This chapter discusses the key issues related to ESLD, including pain (opioid and non-opioid pharmacological management), symptom management (e.g., cholestatic pruritus, hepatic encephalopathy), and prognosis. Drug selection and dosing is based upon the severity of liver disease (compensated vs. decompensated cirrhosis) and if there is coexisting renal failure. Decompensated cirrhosis is characterized by the presence of dramatic and life-threatening complications such as variceal hemorrhage, ascites, spontaneous bacterial peritonitis, or hepatic encephalopathy. Prognosis is highly variable, and once decompensation occurs, mortality rates are high. The Child-Pugh classification and MELD are two commonly used predictive models.