Review article: towards a considered and ethical approach to organ support in critically‐ill patients with cirrhosis

• Published in: Alimentary pharmacology & therapeutics 2013-01, Vol.37 (2), p.174-182
• Main Authors: Berry, P. A., Thomson, S. J., Rahman, T. M., Ala, A.
• Format: Article
• Language: English
• Subjects: Alcohol Drinking - adverse effects; Alcoholism - complications; Attitude of Health Personnel; Biological and medical sciences; Critical Care - ethics; Critical Care - standards; Digestive system; Gastroenterology. Liver. Pancreas. Abdomen; Humans; Intensive Care Units - ethics; Intensive Care Units - standards; Liver Cirrhosis - therapy; Liver. Biliary tract. Portal circulation. Exocrine pancreas; Medical sciences; Multiple Organ Failure - therapy; Other diseases. Semiology; Pharmacology. Drug treatments; Severity of Illness Index; Survival Analysis
• ISSN: 0269-2813; 1365-2036
• DOI: 10.1111/apt.12133

Summary Background Increasing numbers of patients are being admitted to hospital with decompensated chronic liver disease in the UK. A significant proportion will develop complicating extra‐hepatic organ dysfunction, but the selection of those who should be admitted to intensive care is complex and challenging. Alcohol‐related liver disease also presents complex ethical dilemmas. Aim To review recent survival analyses and explore differences in secondary and tertiary care; to highlight strengths and weaknesses of prognostic models, therapeutic advances and shifts in prognostic expectation. We also aim to explore the ethical challenges presented by addiction and self‐injury in an area of limited resource. Methods We searched PubMed for articles discussing ‘cirrhosis’, ‘prognosis’, ‘critical illness’, ‘organ failure’, ‘renal failure’, ‘alcohol’, ‘ethics’ and ‘addiction’. We also explored particular ethical dilemmas encountered by the authors and colleagues. Results Prognosis has improved in many cirrhotic complications and historically poor outcomes in tertiary care may reflect a more complex patient cohort. Previously ‘untreatable’ complications are now being managed successfully. Estimates of survival are more accurate after a 48‐h period of supportive care. Physicians are not best placed to make judgments with regard to deservingness, moral responsibility, rationing and access to organ support in cases of acute deterioration related to alcoholism, and the case for denying support must be made on purely medical grounds. Conclusions An early, aggressive approach to organ support is justified. Further discussions between hepatologists and critical care physicians are required to determine acceptable burden‐to‐benefit ratios for prolonged intensive care support in young alcoholic patients.