Ethical approach to organ support in critically-ill patients with cirrhosis

A study in the latest issue of the Alimentary Pharmacology & Therapeutics considers an ethical approach to organ support in critically-ill patients with cirrhosis.

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.

Dr Berry and colleagues from the United Kindgom reviewed the 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. 

The researchers explored the ethical challenges presented by addiction and self- injury in an area of limited resource.

Previously ‘untreatable’ complications are now being managed successfully

Alimentary Pharmacology & Therapeutics

The researchers also searched PubMed for articles discussing ‘cirrhosis’, ‘prognosis’, ‘critical illness’, ‘organ failure’, ‘renal failure’, ‘alcohol’, ‘ethics’ and ‘addiction’.

The team explored particular ethical dilemmas encountered by colleagues.
 
With the findings and outcomes of the study, the prognosis has improved in many cirrhotic complications.

Historically poor outcomes in tertiary care may reflect a more complex patient cohort.

The team observed that previously ‘untreatable’ complications are now being managed successfully.

The doctor's found that estimates of survival are more accurate after a 48-hour 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.
 
Dr Berry's team concludes, "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."