The landscape of palliative care is shifting. Today, it is about enhancing the quality of life for patients and their families throughout the treatment journey, not just at the end. At the heart of this shift is the PEACE (Palliate End-stage and Advanced Cirrhotics Early) programme, an initiative by Sengkang General Hospital (SKH) that offers integrated, holistic care to patients suffering from advanced liver cirrhosis. It was developed in July 2024 to address the unmet need for supportive care alongside disease-specific management for these patients, who often experience a high symptom burden, frequent hospitalisations, and reduced quality of life.

THE CASE FOR PEACE

Advanced liver cirrhosis is the final stage of chronic liver disease, when the liver becomes severely scarred and can no longer function properly. It is a progressive and irreversible condition, often caused by chronic alcohol use, hepatitis, or non-alcoholic fatty liver disease.

Many patients with advanced liver cirrhosis face significant physical, psychosocial, and emotional challenges, yet often only receive palliative care too late, when treatment is no longer an option.

This late-stage approach typically leaves patients shouldering a heavy symptom burden and frequent hospitalisations, which impair their quality of life. The PEACE programme challenges this model by providing supportive care from the early stages of advanced cirrhosis, ensuring patients receive holistic care alongside their treatment.

Given the increasing rates of liver disease and the population’s ageing demographic, the burden of advanced liver cirrhosis is expected to rise, making early intervention and management, such as through the PEACE programme, increasingly important.

A case that highlighted the need for earlier palliation in liver cirrhosis involved a young patient suffering from liver cancer with complications such as water retention, bleeding and jaundice. Despite the advanced stage of his disease, he continued working as a driver to support his elderly mother. He rarely shared his feelings, and specialists focused on treating his liver tumour, bleeding, and acquiring a potential transplant. However, because he was young and active, no discussions about end-of-life preferences, legacy planning, and care for his mother were initiated.

Eventually, he suffered a terminal decompensating event and only received supportive care days before his death, revealing that he had been living with pain and anxiety. It was deeply saddening to learn that his quality of life had not been addressed earlier, despite the best efforts to treat his disease.

Another case involved an elderly woman who required frequent hospital admissions to drain fluid from her abdomen. She spent more time in the hospital than at home and dreaded every readmission. The fluid buildup caused her significant discomfort and breathlessness, leaving her with no choice but to return for drainage. She had a long-term drain inserted two years ago, but it was removed due to complications and lack of support at home. After a family discussion about her care goals, we persuaded them to try the drain again with the programme’s support, allowing us to troubleshoot any issues remotely. This allows us to provide her with care both in the clinic and in the comfort of her home.

THE CHOICE FOR PEACE

The PEACE programme comprises a multidisciplinary team of experts, led by liver specialists with palliative care training, as well as speciality and community nurses, physiotherapists, social workers, pharmacists, dietitians, and palliative medicine doctors. The programme takes a proactive approach in the following areas:

• Symptom control (addressing physical, psychological and emotional needs)
• Caregiver support (helping loved ones cope with the stresses of caregiving)
• Advance Care Planning (focused on each patient’s unique needs)
• Preventive health (vaccinations, frailty screenings, etc)
• Anticipatory planning (helping patients and families prepare for the future)
• Direct support services for real-time assistance
• Seamless transitions to home hospice or inpatient care, if necessary
• Bereavement support for families after the patient’s passing

Studies over the last 20 years from publications such as Journal of Hepatology and Palliative & Supportive Care show that early integration of palliative care significantly improves a patient’s quality of life by relieving symptoms, enhancing comfort, and reducing hospital admissions, which in turn lowers healthcare expenditures. The PEACE programme ensures palliative care patients with liver cirrhosis receive the right care at the right time no matter where they are in their journey.

Early intervention also fosters better communication and facilitates meaningful discussions on Advance Care plans and end- of-life wishes, ensuring treatment plans align with the patient’s preferences and values. By addressing physical, emotional, and spiritual needs, palliative care provides comprehensive support for both patients and families. It improves long-term health outcomes by managing complications and coordinating care, empowering patients to actively manage their condition. It also provides emotional support to caregivers, reducing stress, burnout, and emotional strain, while offering respite and guidance.

The PEACE programme plays an essential role in shifting the perception of palliative care from a “last resort” to a vital component of liver disease treatment, providing integrated support at every stage. It’s not just about treating the disease — it’s about caring for the patient.