Palliative Care and Hospice Interventions in Decompensated Cirrhosis and Hepatocellular Carcinoma: A Rapid Review of Literature.

BACKGROUND: Patients with decompensated cirrhosis (DC) and/or hepatocellular carcinoma (HCC) have a high symptom burden and mortality and may benefit from palliative care (PC) and hospice interventions. OBJECTIVE: Our aim was to search published literature to determine the impact of PC and hospice interventions for patients with DC/HCC. METHODS: We searched electronic databases for adults with DC/HCC who received PC, using a rapid review methodology. Data were extracted for study design, participant and intervention characteristics, and three main groups of outcomes: healthcare resource utilization (HRU), end-of-life care (EOLC), and patient-reported outcomes. RESULTS: Of 2466 results, eight were included in final results. There were six retrospective cohort studies, one prospective cohort, and one quality improvement study. Five of eight studies had a high risk of bias and seven studied patients with HCC. A majority found a reduction in HRU (total cost of hospitalization, number of emergency department visits, hospital, and critical care admissions). Some studies found an impact on EOLC, including location of death (less likely to die in the hospital) and resuscitation (less likely to have resuscitation). One study evaluated survival and found hospice had no impact and another showed improvement of symptom burden. CONCLUSION: Studies included suggest that PC and hospice interventions in patients with DC/HCC reduce HRU, impact EOLC, and improve symptoms. Given the few number of studies, heterogeneity of interventions and outcomes, and high risk of bias, further high-quality research is needed on PC and hospice interventions with a greater focus on DC.

Challenges and successes in non-operative management of high-grade malignant bowel obstruction.

Malignant bowel obstruction (MBO) occurs in between 3% and 15% of patients with cancer, and portends a poor mean survival of four weeks for patients who are not able to undergo operative intervention. Surgical interventions may be fraught with complications since these patients typically have compromised nutritional status and progressive metastatic disease burden, with tumor type and degree of aggressiveness affecting outcomes. MBO is a dynamic and difficult process to treat, with adequate pain control being limited by unpredictable enteral absorption and need for prolonged parenteral analgesia (given limited enteral access) with its inherent risks. To explore these difficulties, we report the case of a 43-year-old patient who presented with multi-level MBO from metastatic rectal carcinoma, and explore the challenges and successes of symptom management in a non-operative MBO.