[Complications of end-stage liver disease].

Case description Mrs Z. was a 63-year-old woman with chronic hepatitis C infection and end-stage liver disease (ESLD). She had had 2 hospital admissions in the past 6 months for complications related to her ESLD, most recently for spontaneous bacterial peritonitis (SBP). Mrs Z. also had a history of refractory ascites requiring paracentesis every 2 weeks and large esophageal varices that had not previously bled. Her current list of medications included 120 mg of oral furosemide once daily, 300 mg of oral spironolactone once daily, 40 mg of bisoprolol once daily, 400 mg of oral norfloxacin once daily, 0.5 mg of oral hydromorphone twice daily and every hour as needed for pain, and 1 senna tablet orally at bedtime. Mrs Z. lived at home with her daughter with support from her family physician and palliative home care nursing. Her Palliative Performance Scale (PPS) score was 40%, which meant she was mainly in bed, was unable to do most activities, and required much assistance with self-care.1 She understood that her illness was incurable and progressive and that her estimated survival was on the order of weeks to months. She wanted the focus of her care to be on comfort at home with no further investigations or interventions. Within 2 weeks of being home, Mrs Z. became increasingly somnolent and confused. She was now inconsistent in taking her medications as prescribed and was having difficulty coping.