Presented at Royal Free Hepatology course May 2017, this lecture examines the evolving evidence and ethical challenges relating to treatment escalation in cirrhosis patients.

1. Medical ethics and ceilings
of care in hepatology
Philip Berry
Consultant Hepatologist
Guy’s and St Thomas’ NHS
Foundation Trust
@philaberrywww.illusionsofautonomy.worpdress.com

2. Outline
At the bedside: nihilism vs opportunity
A look at bias
The problem with prognosis
Defining futility
Choice and fate
Finding an ethical path

3. At the bedside: nihilism vs
opportunity

4. How many times have
they been told to stop?
This is end-stage disease,
the prognosis is awful
They’re not a transplant
candidate anyway
I have a responsibility to
use health resources
sensibly
I used to try hard in these
cases, but I’ve seen what
happens too many times
now...
They’re so young… they
have a lot of life to live yet
There are children
This is the first severe
presentation
It might be reversible
They’re not alcoholic by
choice
Has anyone actually tried
to treat the addiction?
I am not a gatekeeper, I’m
a doctor

5. Verrill et al, Addiction 2009

7. ‘Good Medical Practice’
“The investigations or treatment you provide or arrange
must be based [ ] on your clinical judgement about
the likely effectiveness of the treatment options.
“You must not refuse or delay treatment because you
believe that a patient's actions have contributed to
their condition...”

8. Indiscriminate,
‘give everyone
a chance, full
organ
support…’
Cirrhosis and
ICU don’t
mix, look at
the data…
Heroic ‘saves’
Pushing the therapeutic envelope
Higher total burden of care
Higher cost
Poor relationship with ICU?
Failure to engage early in EoL discussions?
Lost opportunities in reversible cases
No-one is going to argue; matches expectation of
cirrhosis
...but when you do go to ICU, they listen
Diagnosing dying: a self-fulfilling prophecy
Infectious nihilism

9. Indiscriminate,
‘give everyone
a chance, full
organ
support…’
Cirrhosis and
ICU don’t
mix, look at
the data…
Heroic ‘saves’
Pushing the therapeutic envelope
Higher total burden of care
Higher cost
Poor relationship with ICU?
Failure to engage early in EoL discussions?
Lost opportunities in reversible cases
No-one is going to argue; matches expectation of
cirrhosis
...but when you do go to ICU, they listen
Diagnosing dying: a self-fulfilling prophecy
Infectious nihilism
Case-by-case decision making
Discriminating ‘end stage’ vs ACLF
Early expectation management (families and colleagues)
Evidenced based advocacy
Realistic limits

10. Genius...

11. And saint?

12. A look at bias
Neuberger et al, BMJ 1998

14. Liver case

15. Opening question

16. ‘League table’ of advocacy
Mean
advocacy
score

17. Breakdown of advocacy scores for ALD case
No. of
respondents
Advocacy score selected

18. Ceilings

19. Reasons for not escalating Ceilings of care
% respondents % respondents
Ceilings

20. Rationing considerations

21. Rationing considerations
?

22. Jalan et al, J Hep 2014
The problem with prognosis

23. Carvellas & Bagshaw, Current
Opinion in Critical Care 2012

24. CLIF-ACLF score

25. 150 µmol/l
160 mmol/l

27. N=128 patients, mortality 54%
Cholongitas et al, J Gastro Hep 2008

28. Score Admission ROC 48hr ROC
CPS 0.75 0.78
MELD 0.78 0.86
APACHE II 0.75 0.78
SOFA 0.81 0.88
FOS 0.79 0.85
Cholongitas et al, J Gastro Hep 2008

30. TAZ PRED

31. Defining futility

32. Thomson et al, Aliment
Pharmacol Ther 2010

33. Survival stratified according to ACLF
grade at day 3-7
Gustot et al, Hepatology 2015

34. “The best time point to define the clinical course of ACLF was
between the third and seventh day after ACLF diagnosis (d3-7
ACLF).
“Together, these findings suggest [ ] that assessment at day 7
could help to make decisions regarding subsequent
management: continuation and potential LT, or
discontinuation owing to futility.”

35. • “…organ support should be offered to
those with pre-morbid MELD <15, but
questioned if MELD is >30 and there is
>/= 3 organ failure...”

36. “…exceptionally high degrees of confidence
in mortality risk are a prerequisite, and our
assessment suggests that mortality may not
be as reliably predicted as described… more
complex algorithms may be required in
determining optimal time limitation.”
McPhail et al, Hepatology 2016

37. Choice and fate
Dependence/injury
• Gender (F > M)
• Genes (aldehyde dehydrogenase 2, PNPLA3, TM6SF2
and MBOAT7)
• Cofactors (iron, α1-AT)
• Social factors
– Abuse
– Parental example
Ball, Addiction 2008
Stickel/Moreno et al, J Hep 2016

38. Choice and fate

40. Seeking help: moral responsibility
There is ample time during an alcoholic's life to
comprehend the damage that drink does
The decision to continue drinking must involve a
personal acceptance that they will become ill
Most will be offered an opportunity to engage with
addiction services
Moss, JAMA 1991
Glannon, Medicine & Philosophy 1998
Those who do, but for whom attempts to break the
addiction fail, might be regarded in a more positive
light when they become ill.

41. Finding an ethical path

42.  Prognosis at or shortly after admission may not be accurate
 Experience counts, but judgments concerning addiction must
translate to utility calculations
 Rationing healthcare on the ‘shop floor’ is not likely to be just
 Agreement is needed as to what defines futility, and what
constitutes a clinical response to therapy