The Critically Ill Alcoholic – A
Daily Challenge
PERSONAL INTRODUCTION
A DIFFICULT CASE
MEDICAL AND ETHICAL FACTORS
DISCUSSION & QUESTIONS
Your speaker – Dr Philip Berry
 University of Bristol (qual. 1996)
 Roehampton, Kingston, St Thomas’, Sydney (ICU)
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SW Thames gastroenterology rotation
MD at Kings College Hospital - Institute of Liver Studies
Hepatology - Royal Free Hospital, University College Hospital
Appointed FPH November 2010
Interests
 Decompensated cirrhosis and prognosis
 Critical illness, interface with ICU
 Advanced endoscopy
 Medical ethics
 General gastroenterology
MW, 55 years old, known ALD
2010
VB, Ascites,
recovered
MW, 55 years old, known ALD
2010
VB, Ascites,
recovered
2012
Jaundice
Ascites
Confusion
MW, 55 years old, known ALD
2010
VB, Ascites,
recovered
2012
Jaundice
Ascites
Confusion
O/E
Icteric++
Fever
Large
abdomen
Aterixis
MW, 55 years old, known ALD
2010
VB, Ascites,
recovered
2012
Jaundice
Ascites
Confusion
O/E
Icteric++
Fever
Large
abdomen
Aterixis
Ix
Bili 346 µmol/L
INR 2.8
Hb 10.4 g/dL
Creat 280 µmol/L
Further Ix
Tap – 460
PMN/ml
MW, 55 years old, known ALD
2010
VB, Ascites,
recovered
2012
Jaundice
Ascites
Confusion
O/E
Icteric++
Fever
Large
abdomen
Aterixis
Ix
Bili 346 µmol/L
INR 2.8
Hb 10.4 g/dL
Creat 280 µmol/L
Further Ix
Tap – 460
PMN/ml
Tx
CVC
Tazocin
Albumin
Terlipressin
ADU
MW, 55 years old, known ALD
Later that night:
Semi-comatose
Hypotensive
Oligoanuric
ABG – acidosis
Hypoxic
ICU – full organ
support
ADU/HDU ceiling of care
Ward – palliative
care
MW, 55 years old, known ALD
Later that night:
Semi-comatose
Hypotensive
Oligoanuric
ABG – acidosis
Hypoxic
ICU – full organ
support
ADU/HDU ceiling of care
Ward – palliative
care
Should he be admitted to ITU?
Is it appropriate?
 Considerations:
 He will definitely die without organ support - Fact
 What is the chance of short term survival on ICU?
 What is the longer term outlook?
 What is the duration of therapy that will be required?
 Cost? – should we be asking ourselves this?
 Does he deserve another ‘throw of the dice’? – should we be
asking this?
National burden of decompensated CLD
 In the UK, between 1990 and 2003, admissions for chronic
liver disease (CLD) rose by 71% in males and 43% in
females.
 These changes were largely driven by alcohol related liver
disease (ARLD) with rates more than doubling in all age
groups.
 There has been a five-fold increase in progression to
cirrhosis in 35-55 year olds over the last 10 years.
 Between 1996 and 2005 the percentage of ICU admissions
in England and Wales with ARLD rose from 0.65% to 1.35%,
the estimated number of bed days rising from 3100 to over
10000.
Single rising cause of death
The National Plan for
Liver Services UK
2009
A Time to Act: Improving
Liver Health and
Outcomes in Liver
Disease
Experience of ALD at FPH
 66 patients with decompensated cirrhosis leading to
154 admissions over 12 months
ALD
HCV
HBV
ALD
ALD/Fluclox
HFE/ALD
NASH
PSC
First
presentation
Ongoing
alcohol use
Abstinence
Experience of ALD at FPH
In-hospital mortality:
Ward - 5%
HDU - 14%
ICU - 36%
LEVEL of CARE
ICU
HDU
Ward
0
5
10
15
20
25
30
35
40
Length of Stay and Mortality
90 day mortality:
Ward - 8%
HDU - 21%
ICU - 50%
50
45
40
35
30
25
Ward
20
HDU
ICU
15
10
ICU
5
HDU
0
LOS (d)
Ward
In-hospital
mortality
(%)
90 day
mortality
(%)
Therapeutic nihilism
 100 cirrhotic patients requiring mechanical ventilation.
 Overall mortality rate was 89%
 100% among patients with septic shock and/or
superimposed acute hepatitis and/or severe cirrhosis
defined with clinical signs: jaundice and/or ascites and/or
spontaneous hepatic encephalopathy and/or severe
malnutrition (Goldfarb 1983)
Relative optimism!
 Secondary care data, which may reflect a less highly
selected cohort of patients with CLD, has demonstrated
ICU and hospital mortality rates of only 38% and 47%
respectively (Thomson et al, 2010)
Recent analysis of 16,000 admissions to ICU
O’Brien et al,
2012
Guidance
 “…organ support should be offered to
those with pre-morbid MELD <15, but
questioned if MELD is >30 and there is
>/= 3 organ failure...”
Guidance
 “…organ support should be offered to
those with pre-morbid MELD <15, but
questioned if MELD is >30 and there is
>/= 3 organ failure...”
MELD = 40
CVS
RS
Renal
Don’t judge too soon
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, 2008
Self-inflicted pathology
 ‘Good Medical Practice’: “The investigations or
treatment you provide or arrange must be based on the
assessment you and the patient make of their needs and
priorities, and 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...”.
Moral Responsibility
 ‘Recidivists’ cannot resist the urge to drink
 The power of the individual to resist cravings is equated, in the eyes of
some authors, to their degree of ‘moral responsibility’.
 There is ample time during an alcoholic’s life to receive advice and
comprehend the damage that it is doing; therefore the decision to
continue must involve a personal acceptance that the individual will
become ill. (Glannon, 1998)
Moral Responsibility
 There is a responsibility that individuals should actively seek help once
it becomes clear that alcohol addiction has developed and those who do
not must bear some responsibility for this failure.
 Those who do, but for whom attempts to break the addiction fail, might
be regarded in a more positive light. (Moss AH, 1991)
Is help available?
 NICE has only recently published guidelines for identifying,
treating and supporting alcohol addicted patients.
 The interventions suggested (pharmacological,
psychological and psychosocial) demand the provision of
many suitably trained staff.
 It is likely that many patients presenting now will have not
had the benefit of such structured therapy.
Factors beyond their power
 Gender
 Genes
 Cofactors
 Social factors
 Abuse
 Parental example
 ‘Gremlins’
Gremlins
Dir. Paul Watson, 2007
The cost
 -The impact of organ dysfunction in cirrhosis: survival at a
cost?- (Shawcross et al, 2012)
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Alcohol was the most common etiology (47%) and variceal bleeding (VB) the
most common reason for admission (35%).
Invasive ventilatory support was required in 74% of cases, vasopressors in
49%, and 50% required renal replacement therapy.
Forty-nine per cent of non-transplanted patients survived to ICU discharge.
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Median ICU cost per patient was €14,139.
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Futility & Rationing
 “medical futility signifies that a treatment offers no
therapeutic benefit to a patient…rationing specifically
acknowledges that a treatment does offer a benefit, and the
issue becomes how to distribute beneficial but limited
resources fairly.”
 “To clarify the distinction further: futility decisions are made
at the bedside of a specific patient, whereas rationing
decisions, involving categories of patients or treatments or
circumstances, inevitably should be made at a policy level in
order to assure just distribution of resources.” (Jecker NS,
Schneiderman LJ, 1992)
Public Opinion
Decision Time?
Decision Time?
o No snap decisions re. prognosis
o Reversible factors?
o Patient preference?
o Family view
o Recognise death wheh it is happening
o Negotiation with ICU:
• Don’t behave as if liver patients are
‘special’
• But if you don’t advocate for them
who will?
• Trial of therapy, 3-5 days
• Restrict haemofiltration
• Agreed withdrawal criteria
• Prepare the ground with family