Table 2.

Achievable changes

Early, open discussions around prognosis and advance care planning	Discuss disease progression, potential complications and management options early with patients and carers.41 Provide patients and carers with opportunities to express preferences around future place and type of care. British Liver Trust’s ‘Thinking Ahead’ leaflet is available to support discussions (https://www.britishlivertrust.org.uk/liver-information/thinking-ahead-planning-for-your-future-when-you-have-advanced-liver-disease/).
Advanced liver disease MDT	Encourage discussion of patients with unstable disease. Clarify optimal medical management, discuss emergency treatment plans and establish reasonable ceilings of care. Ensure clear, consistent communication between primary and secondary care as well as patients and carers.
Prognostic scoring	Use SPICT or Bristol Screening Tool to identify patients with ESLD who may benefit from SPC input.38 39
Hepatic encephalopathy	Education of patients and carers about recognition, avoidance and management of HE. Encourage patients and carers to adjust laxative doses themselves to control symptoms and reduce hospital admissions. Proactive use of rifaximin – second episode of HE.
Ascites	Access to day case paracentesis service. Consider use of LTAD or alfapump Pragmatic approach to diuretic use at EOL.
Malnutrition	Early referral to dietitian. Education of patients and carers on good nutrition in liver disease – encourage bedtime snack. Use liver frailty index (https://liverfrailtyindex.ucsf.edu/).
Pain management	Assess for pain and advise patients, carers and GPs on safe analgesic use in advanced CLD. Use BASL guidelines for prescribing in advanced CLD (https://www.basl.org.uk/index.cfm/content/page/cid/33).
Financial assistance	Provide information about local services and charities that can assist patients with applications for financial assistance.
Carer support	Early referral to carer support services, for example, respite care. Support to access financial assistance if eligible.

CLD, chronic liver disease; EOL, end of life; ESLD, end-stage liver disease; HE, hepatic encephalopathy; LTAD, long-term abdominal drain; SPC, specialist palliative care; SPICT, Supportive and Palliative Care Indicators Tool.