Skip to main content
SpringerLink
Log in

Integrating Palliative Principles into Cirrhosis Care: The Effect of Hepatic Encephalopathy

  • Chapter
  • First Online:
Diagnosis and Management of Hepatic Encephalopathy

  • 740 Accesses

Abstract

The integration of palliative principles into the management of patients with cirrhosis is a vital, yet often overlooked, component of cirrhosis care. With a focus on symptom control and advance care planning (ACP) discussions, the integration of care using palliative care principles enhances health-related quality of life, decreases healthcare utilization, and improves patient and family satisfaction. The routine use of palliative principles has the potential to optimize effective and comprehensive management of all patients with cirrhosis. These principles have particular relevance in patients with hepatic encephalopathy (HE), with several points of intersection. Most notably, (i) HE itself is perhaps the most debilitating symptom of cirrhosis, requiring early detection and intensive symptom management; (ii) medications given to control other cirrhosis-associated symptoms, such as pain killers, anxiolytics, neuroleptics, benzodiazepines, and antidepressants, may precipitate HE, necessitating dose reduction or avoidance; (iii) the cognitive impairment that defines HE complicates ACP and is a major reason supporting early ACP discussions; and (iv) HE increases caregiver burnout. This chapter outlines the role of integrating palliative principles into cirrhosis care and more specifically the care of patients with HE. We provide an overview of medication management considering the risk for HE and finally we discuss brief strategies for supporting caregivers of patients with cirrhosis, vital members of the healthcare team who are often underappreciated and overworked, at the expense of their own well-being.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 59.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 79.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. World Health Organization Definition of Palliative Care. Retrieved from http://www.who.int/cancer/palliative/definition/en/. Accessed on March 19, 2018.

  2. Brisebois AJ, Tandon P. Working with palliative care services. Clin Liver Dis. 2015;6:37–40.

    Article  Google Scholar 

  3. Sudore RL, Fried TR. Redefining the “planning” in advance care planning: preparing for end-of-life decision making. Ann Intern Med. 2010;153:256–61.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Cohen LM, Moss AH, Weisbord SD, et al. Renal palliative care. J Palliat Med. 2006;9:977–92.

    Article  PubMed  Google Scholar 

  5. Schwarz ER, Baraghoush A, Morrissey RP, et al. Pilot study of palliative care consultation in patients with advanced heart failure referred for cardiac transplantation. J Palliat Med. 2012;15:12–5.

    Article  PubMed  Google Scholar 

  6. Singer AE, Goebel JR, Kim YS, et al. Populations and interventions for palliative and end-of-life care: a systematic review. J Palliat Med. 2016;19:995–1008.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Lamba S, Murphy P, McVicker S, et al. Changing end-of-life care practice for liver transplant service patients: structured palliative care intervention in the surgical intensive care unit. J Pain Symptom Manag. 2012;44:508–19.

    Article  Google Scholar 

  8. Cordoba J, Flavia M, Jacas C, et al. Quality of life and cognitive function in hepatitis C at different stages of liver disease. J Hepatol. 2003;39:231–8.

    Article  PubMed  Google Scholar 

  9. Poonja Z, Brisebois A, van Zanten SV, et al. Patients with cirrhosis and denied liver transplants rarely receive adequate palliative care or appropriate management. Clin Gastroenterol Hepatol. 2014;12:692–8.

    Article  PubMed  Google Scholar 

  10. Kathpalia P, Smith A, Lai JC. Underutilization of palliative care services in the liver transplant population. World J Transplant. 2016;6:594–8.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Larson AM. Palliative care for patients with end-stage liver disease. Curr Gastroenterol Rep. 2015;17:440.

    Article  PubMed  Google Scholar 

  12. D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol. 2006;44:217–31.

    Article  PubMed  Google Scholar 

  13. Jalan R, Gines P, Olson JC, et al. Acute-on chronic liver failure. J Hepatol. 2012;57:1336–48.

    Article  PubMed  Google Scholar 

  14. Abrams GA, Concato J, Fallon MB. Muscle cramps in patients with cirrhosis. Am J Gastroenterol. 1996;91:1363–6.

    PubMed  CAS  Google Scholar 

  15. Muir AJ. Understanding the complexities of cirrhosis. Clin Ther. 2015;37:1822–36.

    Article  PubMed  CAS  Google Scholar 

  16. James J, Liou IW. Comprehensive care of patients with chronic liver disease. Med Clin North Am. 2015;99:913–33.

    Article  PubMed  Google Scholar 

  17. McPherson S, Lucey MR, Moriarty KJ. Decompensated alcohol related liver disease: acute management. BMJ. 2016;352:i124.

    Article  PubMed  CAS  Google Scholar 

  18. Larson AM, Curtis JR. Integrating palliative care for liver transplant candidates: “too well for transplant, too sick for life”. JAMA. 2006;295:2168–76.

    Article  PubMed  CAS  Google Scholar 

  19. Potosek J, Curry M, Buss M, et al. Integration of palliative care in end-stage liver disease and liver transplantation. J Palliat Med. 2014;17:1271–7.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Vilstrup H, Amodio P, Bajaj J, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014;60:715–35.

    Article  PubMed  Google Scholar 

  21. Roth K, Lynn J, Zhong Z, et al. Dying with end stage liver disease with cirrhosis: insights from SUPPORT. Study to understand prognoses and preferences for outcomes and risks of treatment. J Am Geriatr Soc. 2000;48:S122–30.

    Article  PubMed  CAS  Google Scholar 

  22. Schomerus H, Hamster W. Quality of life in cirrhotics with minimal hepatic encephalopathy. Metab Brain Dis. 2001;16:37–41.

    Article  PubMed  CAS  Google Scholar 

  23. Shaw J, Bajaj JS. Covert hepatic encephalopathy: can my patient drive? J Clin Gastroenterol. 2017;51:118–26.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Agrawal S, Umapathy S, Dhiman RK. Minimal hepatic encephalopathy impairs quality of life. J Clin Exp Hepatol. 2015;5:S42–8.

    Article  PubMed  Google Scholar 

  25. Bass NM, Mullen KD, Sanyal A, et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med. 2010;362:1071–81.

    Article  CAS  PubMed  Google Scholar 

  26. Arguedas MR, DeLawrence TG, BM MG. Influence of hepatic encephalopathy on health-related quality of life in patients with cirrhosis. Dig Dis Sci. 2003;48:1622–6.

    Article  PubMed  Google Scholar 

  27. McMahan RD, Knight SJ, Fried TR, et al. Advance care planning beyond advance directives: perspectives from patients and surrogates. J Pain Symptom Manag. 2013;46:355–65.

    Article  Google Scholar 

  28. Lum HD, Sudore RL, Bekelman DB. Advance care planning in the elderly. Med Clin North Am. 2015;99:391–403.

    Article  PubMed  Google Scholar 

  29. Jackson VA, Jacobsen J, Greer JA, et al. The cultivation of prognostic awareness through the provision of early palliative care in the ambulatory setting: a communication guide. J Palliat Med. 2013;16:894–900.

    Article  PubMed  Google Scholar 

  30. van Vliet LM, Lindenberger E, van Weert JC. Communication with older, seriously ill patients. Clin Geriatr Med. 2015;31:219–30.

    Article  PubMed  Google Scholar 

  31. Clark K, Lam LT, Agar M, et al. The impact of opioids, anticholinergic medications and disease progression on the prescription of laxatives in hospitalized palliative care patients: a retrospective analysis. Palliat Med. 2010;24:410–8.

    Article  PubMed  CAS  Google Scholar 

  32. Good P, Richard R, Syrmis W, et al. Medically assisted hydration for adult palliative care patients. Cochrane Database Syst Rev. 2014;(4):Cd006273.

    Google Scholar 

  33. Garg RK. Anesthetic considerations in patients with hepatic failure. Int Anesthesiol Clin. 2005;43:45–63.

    Article  PubMed  Google Scholar 

  34. Hokka M, Kaakinen P, Polkki T. A systematic review: non-pharmacological interventions in treating pain in patients with advanced cancer. J Adv Nurs. 2014;70:1954–69.

    Article  PubMed  Google Scholar 

  35. Forrest JA, Adriaenssens P, Finlayson ND, et al. Paracetamol metabolism in chronic liver disease. Eur J Clin Pharmacol. 1979;15:427–31.

    Article  CAS  PubMed  Google Scholar 

  36. Rhee C, Broadbent AM. Palliation and liver failure: palliative medications dosage guidelines. J Palliat Med. 2007;10:677–85.

    Article  PubMed  Google Scholar 

  37. Imani F, Motavaf M, Safari S, et al. The therapeutic use of analgesics in patients with liver cirrhosis: a literature review and evidence-based recommendations. Hepat Mon. 2014;14:e23539.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Amarapurkar DN. Prescribing medications in patients with decompensated liver cirrhosis. Int J Hepatol. 2011;2011:519526.

    PubMed  PubMed Central  Google Scholar 

  39. Dwyer JP, Jayasekera C, Nicoll A. Analgesia for the cirrhotic patient: a literature review and recommendations. J Gastroenterol Hepatol. 2014;29:1356–60.

    Article  CAS  PubMed  Google Scholar 

  40. Soleimanpour H, Safari S, Shahsavari Nia K, et al. Opioid drugs in patients with liver disease: a systematic review. Hepat Mon. 2016;16:e32636.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  41. Khademi H, Kamangar F, Brennan P, et al. Opioid therapy and its side effects: a review. Arch Iran Med. 2016;19:870–6.

    PubMed  Google Scholar 

  42. Verbeeck RK. Pharmacokinetics and dosage adjustment in patients with hepatic dysfunction. Eur J Clin Pharmacol. 2008;64:1147–61.

    Article  PubMed  CAS  Google Scholar 

  43. Chandok N, Watt KD. Pain management in the cirrhotic patient: the clinical challenge. Mayo Clin Proc. 2010;85:451–8.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Tegeder I, Lotsch J, Geisslinger G. Pharmacokinetics of opioids in liver disease. Clin Pharmacokinet. 1999;37:17–40.

    Article  PubMed  CAS  Google Scholar 

  45. Haberer JP, Schoeffler P, Couderc E, et al. Fentanyl pharmacokinetics in anaesthetized patients with cirrhosis. Br J Anaesth. 1982;54:1267–70.

    Article  PubMed  CAS  Google Scholar 

  46. Navapurkar VU, Archer S, Gupta SK, et al. Metabolism of remifentanil during liver transplantation. Br J Anaesth. 1998;81(6):881.

    Article  PubMed  CAS  Google Scholar 

  47. Crotty B, Watson KJ, Desmond PV, et al. Hepatic extraction of morphine is impaired in cirrhosis. Eur J Clin Pharmacol. 1989;36:501–6.

    Article  PubMed  CAS  Google Scholar 

  48. Hasselstrom J, Eriksson S, Persson A, et al. The metabolism and bioavailability of morphine in patients with severe liver cirrhosis. Br J Clin Pharmacol. 1990;29:289–97.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  49. Kotb HI, el-Kabsh MY, Emara SE, et al. Pharmacokinetics of controlled release morphine (MST) in patients with liver cirrhosis. Br J Anaesth. 1997;79(6):804.

    Article  PubMed  CAS  Google Scholar 

  50. Durnin C, Hind ID, Ghani SP, et al. Pharmacokinetics of oral immediate-release hydromorphone (Dilaudid IR) in subjects with moderate hepatic impairment. Proc West Pharmacol Soc. 2001;44:83–4.

    PubMed  CAS  Google Scholar 

  51. Tallgren M, Olkkola KT, Seppala T, et al. Pharmacokinetics and ventilatory effects of oxycodone before and after liver transplantation. Clin Pharmacol Ther. 1997;61:655–61.

    Article  PubMed  CAS  Google Scholar 

  52. Bosilkovska M, Walder B, Besson M, et al. Analgesics in patients with hepatic impairment: pharmacology and clinical implications. Drugs. 2012;72:1645–69.

    Article  PubMed  CAS  Google Scholar 

  53. Shull HJ, Wilkinson GR, Johnson R, et al. Normal disposition of oxazepam in acute viral hepatitis and cirrhosis. Ann Intern Med. 1976;84:420–5.

    Article  PubMed  CAS  Google Scholar 

  54. Kraus JW, Desmond PV, Marshall JP, et al. Effects of aging and liver disease on disposition of lorazepam. Clin Pharmacol Ther. 1978;24:411–9.

    Article  PubMed  CAS  Google Scholar 

  55. Ghabrial H, Desmond PV, Watson KJ, et al. The effects of age and chronic liver disease on the elimination of temazepam. Eur J Clin Pharmacol. 1986;30:93–7.

    Article  PubMed  CAS  Google Scholar 

  56. Haussinger D, Schliess F. Pathogenetic mechanisms of hepatic encephalopathy. Gut. 2008;57:1156–65.

    Article  PubMed  CAS  Google Scholar 

  57. Prabhakar S, Management BR. Management of agitation and convulsions in hepatic encephalopathy. Indian J Gastroenterol. 2003;22(Suppl 2):S54–8.

    PubMed  Google Scholar 

  58. Lewis J, Stine J. Prescribing medications in patients with cirrhosis–a practical guide. Aliment Pharmacol Ther. 2013;37:1132–56.

    Article  PubMed  CAS  Google Scholar 

  59. Holliday SM, Benfield P. Venlafaxine. A review of its pharmacology and therapeutic potential in depression. Drugs. 1995;49:280–94.

    Article  PubMed  CAS  Google Scholar 

  60. Suri A, Reddy S, Gonzales C, et al. Duloxetine pharmacokinetics in cirrhotics compared with healthy subjects. Int J Clin Pharmacol Ther. 2005;43:78–84.

    Article  PubMed  CAS  Google Scholar 

  61. Hrdina PD, Lapierre YD, Koranyi EK. Altered amitriptyline kinetics in a depressed patient with porto-caval anastomosis. Can J Psychiatr. 1985;30:111–3.

    Article  CAS  Google Scholar 

  62. Mullish BH, Kabir MS, Thursz MR, et al. Review article: depression and the use of antidepressants in patients with chronic liver disease or liver transplantation. Aliment Pharmacol Ther. 2014;40:880–92.

    Article  PubMed  CAS  Google Scholar 

  63. Joffe P, Larsen FS, Pedersen V, et al. Single-dose pharmacokinetics of citalopram in patients with moderate renal insufficiency or hepatic cirrhosis compared with healthy subjects. Eur J Clin Pharmacol. 1998;54:237–42.

    Article  PubMed  CAS  Google Scholar 

  64. Demolis JL, Angebaud P, Grange JD, et al. Influence of liver cirrhosis on sertraline pharmacokinetics. Br J Clin Pharmacol. 1996;42:394–7.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  65. Spahr L, Coeytaux A, Giostra E, et al. Histamine H1 blocker hydroxyzine improves sleep in patients with cirrhosis and minimal hepatic encephalopathy: a randomized controlled pilot trial. Am J Gastroenterol. 2007;102:744–53.

    Article  PubMed  CAS  Google Scholar 

  66. Montagnese S, De Pittà C, De Rui M, et al. Sleep-wake abnormalities in patients with cirrhosis. Hepatology. 2014;59:705–12.

    Article  PubMed  Google Scholar 

  67. Verbeeck RK, Patwardhan RV, Villeneuve JP, et al. Furosemide disposition in cirrhosis. Clin Pharmacol Ther. 1982;31:719–25.

    Article  PubMed  CAS  Google Scholar 

  68. Abshagen U, Rennekamp H, Luszpinski G. Disposition kinetics of spironolactone in hepatic failure after single doses and prolonged treatment. Eur J Clin Pharmacol. 1977;11:169–76.

    Article  PubMed  CAS  Google Scholar 

  69. Oliveira L, Ferreira MO, Rola A, et al. Deprescription in advanced cancer patients referred to palliative care. J Pain Palliat Care Pharmacother. 2016;30:201–5.

    Article  PubMed  Google Scholar 

  70. Maltoni M, Scarpi E, Rosati M, et al. Palliative sedation in end-of-life care and survival: a systematic review. J Clin Oncol. 2012;30:1378–83.

    Article  PubMed  Google Scholar 

  71. Chari AV, Engberg J, Ray KN, et al. The opportunity costs of informal elder-care in the United States: new estimates from the American Time Use Survey. Health Serv Res. 2015;50:871–82.

    Article  PubMed  Google Scholar 

  72. Hollander MJ, Liu G, Chappell NL. Who cares and how much? The imputed economic contribution to the Canadian healthcare system of middle-aged and older unpaid caregivers providing care to the elderly. Healthc Q. 2009;12:42–9.

    Article  PubMed  Google Scholar 

  73. Smith CE, Piamjariyakul U, Yadrich DM, et al. Complex home care: part III—economic impact on family caregiver quality of life and patients’ clinical outcomes. Nurs Econ. 2010;28:393–9. 414

    PubMed  PubMed Central  Google Scholar 

  74. Adelman RD, Tmanova LL, Delgado D, et al. Caregiver burden: a clinical review. JAMA. 2014;311:1052–60.

    Article  PubMed  CAS  Google Scholar 

  75. Rakoski MO, McCammon RJ, Piette JD, et al. Burden of cirrhosis on older Americans and their families: analysis of the health and retirement study. Hepatology. 2012;55:184–91.

    Article  PubMed  Google Scholar 

  76. Golics CJ, Basra MK, Salek MS, et al. The impact of patients' chronic disease on family quality of life: an experience from 26 specialties. Int J Gen Med. 2013;6:787–98.

    Article  PubMed  PubMed Central  Google Scholar 

  77. Jeffs L, Dhalla I, Cardoso R, et al. The perspectives of patients, family members and healthcare professionals on readmissions: preventable or inevitable? J Interprof Care. 2014;28:507–12.

    Article  PubMed  Google Scholar 

  78. Cameron JI, Chu LM, Matte A, et al. One-year outcomes in caregivers of critically ill patients. N Engl J Med. 2016;374:1831–41.

    Article  PubMed  CAS  Google Scholar 

  79. Morimoto T, Schreiner AS, Asano H. Caregiver burden and health-related quality of life among Japanese stroke caregivers. Age Ageing. 2003;32:218–23.

    Article  PubMed  Google Scholar 

  80. Pinquart M, Sörensen S. Correlates of physical health of informal caregivers: a meta-analysis. J Gerontol Ser B Psychol Sci Soc Sci. 2007;62:P126–37.

    Article  Google Scholar 

  81. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the Caregiver Health Effects Study. JAMA. 1999;282:2215–9.

    Article  PubMed  CAS  Google Scholar 

  82. Bajaj JS, Wade JB, Gibson DP, et al. The multi-dimensional burden of cirrhosis and hepatic encephalopathy on patients and caregivers. Am J Gastroenterol. 2011;106:1646–53.

    Article  PubMed  PubMed Central  Google Scholar 

  83. Montagnese S, Amato E, Schiff S, et al. A patients’ and caregivers’ perspective on hepatic encephalopathy. Metab Brain Dis. 2012;27:567–72.

    Article  PubMed  CAS  Google Scholar 

  84. Cohen M, Katz D, Baruch Y. Stress among the family caregivers of liver transplant recipients. Prog Transplant. 2007;17:48–53.

    Article  PubMed  Google Scholar 

  85. Miyazaki ET, Dos Santos R Jr, Miyazaki MC, et al. Patients on the waiting list for liver transplantation: caregiver burden and stress. Liver Transpl. 2010;16:1164–8.

    Article  PubMed  Google Scholar 

  86. Rodrigue JR, Dimitri N, Reed A, et al. Quality of life and psychosocial functioning of spouse/partner caregivers before and after liver transplantation. Clin Transpl. 2011;25:239–47.

    Article  Google Scholar 

  87. Nguyen DL, Chao D, Ma G, et al. Quality of life and factors predictive of burden among primary caregivers of chronic liver disease patients. Ann Gastroenterol. 2015;28:124–9.

    PubMed  PubMed Central  Google Scholar 

  88. Kunzler-Heule P, Beckmann S, Mahrer-Imhof R, et al. Being an informal caregiver for a relative with liver cirrhosis and overt hepatic encephalopathy: a phenomenological study. J Clin Nurs. 2016;25:2559–68.

    Article  PubMed  Google Scholar 

  89. Hasselkus BR, Murray BJ. Everyday occupation, well-being, and identity: the experience of caregivers in families with dementia. Am J Occup Ther. 2007;61:9–20.

    Article  PubMed  Google Scholar 

  90. Abernethy AP, Currow DC, Fazekas BS, et al. Specialized palliative care services are associated with improved short-and long-term caregiver outcomes. Support Care Cancer. 2008;16:585–97.

    Article  PubMed  Google Scholar 

  91. Madigan K, Egan P, Brennan D, et al. A randomised controlled trial of carer-focussed multi-family group psychoeducation in bipolar disorder. Eur Psychiatry. 2012;27(4):281.

    Article  PubMed  CAS  Google Scholar 

  92. Hepburn K, Lewis M, Tornatore J, et al. The Savvy Caregiver program: the demonstrated effectiveness of a transportable dementia caregiver psychoeducation program. J Gerontol Nurs. 2007;33:30–6.

    PubMed  Google Scholar 

  93. Grant JS, Elliott TR, Weaver M, et al. Telephone intervention with family caregivers of stroke survivors after rehabilitation. Stroke. 2002;33:2060–5.

    Article  PubMed  Google Scholar 

  94. Chien LY, Chu H, Guo JL, et al. Caregiver support groups in patients with dementia: a meta-analysis. Int J Geriatr Psychiatry. 2011;26:1089–98.

    Article  PubMed  Google Scholar 

  95. Bajaj JS, Ellwood M, Ainger T, et al. Mindfulness-based stress reduction therapy improves patient and caregiver-reported outcomes in cirrhosis. Clin Transl Gastroenterol. 2017;8:e108.

    Article  PubMed  PubMed Central  Google Scholar 

  96. Medici V, Rossaro L, Wegelin JA, et al. The utility of the model for end-stage liver disease score: a reliable guide for liver transplant candidacy and, for select patients, simultaneous hospice referral. Liver Transpl. 2008;14:1100–6.

    Article  PubMed  Google Scholar 

  97. Organization NHaPC. NHPCO’s facts and figures: hospice care in America; 2015.

    Google Scholar 

  98. Christakis NA, Escarce JJ. Survival of Medicare patients after enrollment in hospice programs. N Engl J Med. 1996;335:172–8.

    Article  PubMed  CAS  Google Scholar 

  99. Fukui N, Golabi P, Otgonsuren M, et al. Demographics, resource utilization, and outcomes of elderly patients with chronic liver disease receiving hospice care in the United States. Am J Gastroenterol. 2017;112:1700–8.

    Article  PubMed  Google Scholar 

Download references

Author information

Author notes

  1. Amanda Brisebois and Puneeta Tandon contributed equally to this work.

Authors and Affiliations

  1. Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada

    Michael Ney M.D.

  2. Division of Palliative Care and General Internal Medicine, University of Alberta, Edmonton, AB, Canada

    Amanda Brisebois

  3. Cirrhosis Care Clinic, Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada

    Puneeta Tandon

Authors
  1. Michael Ney M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Amanda Brisebois
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Puneeta Tandon
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Puneeta Tandon .

Editor information

Editors and Affiliations

  1. McGuire VA Medical Center, Virginia Commonwealth University, Richmond, Virginia, USA

    Jasmohan S. Bajaj

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG, part of Springer Nature

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Ney, M., Brisebois, A., Tandon, P. (2018). Integrating Palliative Principles into Cirrhosis Care: The Effect of Hepatic Encephalopathy. In: Bajaj, J. (eds) Diagnosis and Management of Hepatic Encephalopathy. Springer, Cham. https://doi.org/10.1007/978-3-319-76798-7_9

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-76798-7_9

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-76797-0

  • Online ISBN: 978-3-319-76798-7

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation