AB100. SOH24AB_160. A case of acute on chronic liver failure in a young patient: ethical considerations

Background: Acute chronic liver failure (ACLF) is associated with the presence of decompensation, organ failure and a significant mortality in excess of 30% at 28 days. This condition occurs in relatively young patients and is frequently alcohol-related. While current recommendations maintain that escalation of care should be actively pursued in patients who present acutely and “whose background functional status is good”, escalation to higher care in this cohort presents significant clinical and ethical considerations. Reluctance to admit these patients to a high dependency unit/intensive care unit (HDU/ICU) may stem from predefined poor prognosis and the futility of extensive resuscitative measures. We present the case of a 37-year-old woman with established chronic liver disease (CLD) secondary to alcohol presenting with ACLF.

Methods: The patient was brought to emergency department (ED) with a 1day history of worsening confusion. She was hepatic encephalopathic (HE), tensely ascitic, coagulopathic and had an anuric acute kidney injury (AKI) suggestive of hepatorenal syndrome. Infection was the suspected precipitant for this acute decompensation. History was significant for type 1 diabetes mellitus (T1DM) and an ICU admission 5 months prior for HE and AKI requiring dialysis. After discharge, it was recorded that the patient was not for readmission to ICU or for extensive resuscitative measures including intubation or cardiopulmonary resuscitation (CPR). despite counselling by Consultant Intensivist regarding their family member’s poor prognosis given her advanced disease state, emphasising that extreme measures to prolong life were not in the patient’s best interests, the family chose not to accept medical advice citing her relatively young age, 6-month abstinence from alcohol and her young children as reasons to continue life-sustaining measures.

Results: In accordance with the family’s wishes, the patient was ultimately readmitted to the ICU. An ascitic tap was performed under ultrasound guidance which helped to negate the need for immediate intubation, however, she remained critically unwell. This allowed time for a second family meeting with 2 different specialists. As the family gained an understanding of the medical consensus, agreement was reached that the patient would not be for CPR or intubation in the event of further deterioration.

Conclusions: A poor prognosis does not preclude a patient from intensive care if they/their representative is unaccepting of medical advice. This case emphasises the ethical considerations and importance of frank disclosure during family meetings in the context of critical illness. Involving additional specialists can assist the process.

Keywords: Intensive care; anaesthesiology; chronic liver disease; acute liver failure; ethics