The final stages of liver failure represent a progressive decline in the liver’s ability to perform its many functions, leading to widespread systemic changes. This period, often termed end-stage liver disease, brings about significant physical and neurological symptoms as the body’s detoxification and regulatory systems fail. Understanding this decline allows for informed decisions centered on comfort, dignity, and preparation during the last days of life. Certain patterns of physical and mental change are expected as the body nears its final shut down.
Physical Signs of Decline
As the liver stops producing and processing essential substances, the body experiences major visible changes. Jaundice, the yellowing of the skin and the whites of the eyes, typically worsens due to the liver’s inability to clear bilirubin from the bloodstream. This buildup of bile products can cause severe, unrelenting itchiness, known as pruritus.
Fluid retention is another prominent physical manifestation, often presenting as massive abdominal swelling called ascites, and edema in the limbs. Ascites occurs because the failing liver cannot synthesize enough albumin, a protein that helps keep fluid within blood vessels, and because of increased pressure in the portal vein system. The pressure from this fluid can cause significant discomfort and shortness of breath as it pushes against the diaphragm.
The body’s inability to synthesize clotting factors increases the risk of bleeding and bruising easily, a condition called coagulopathy. This impairment means even minor trauma can lead to noticeable bruising, and internal bleeding, such as from enlarged veins in the esophagus (varices), remains a concern. Accompanying these changes is profound fatigue, weakness, and a loss of appetite, reflecting the systemic exhaustion of a body no longer able to metabolize nutrients efficiently.
Cognitive and Neurological Changes
The most distinguishing neurological change in end-stage liver failure is hepatic encephalopathy (HE), a syndrome of brain dysfunction caused by the accumulation of toxins in the bloodstream. The failing liver can no longer effectively convert neurotoxins, such as ammonia, into harmless urea for excretion, allowing them to cross the blood-brain barrier. The presence of these toxins causes swelling and impairment of brain cells.
Initial signs of HE can be subtle, including mild confusion, forgetfulness, personality changes, or a reversal of sleep patterns, causing wakefulness at night and drowsiness during the day. As the disease progresses, symptoms become more pronounced, leading to disorientation, slurred speech, and an inability to perform basic tasks. A common physical sign is asterixis, a characteristic flapping tremor of the hands when the arms are outstretched.
A key feature of hepatic encephalopathy is its fluctuating nature, with periods of lucidity interspersed with confusion, often triggered by events like infection or gastrointestinal bleeding. In the final stages, this cognitive decline can progress rapidly through stages of stupor and agitation before culminating in deep unresponsiveness, known as a hepatic coma. This loss of consciousness results from the brain being overwhelmed by toxic metabolic waste products.
Prioritizing Comfort and Symptom Management
In the final days of liver failure, the focus of care shifts entirely from life-prolonging treatments to maximizing comfort and quality of life through palliative care. Hospice teams specialize in managing the intense symptom burden associated with end-stage disease. Medications are carefully chosen, acknowledging the liver’s reduced ability to metabolize drugs, which can lead to unpredictable side effects.
Pain management is a primary concern, even though the liver itself is often not a source of severe pain; discomfort frequently arises from the pressure of ascites, muscle cramping, or other complications. Symptoms of hepatic encephalopathy are managed with treatments like the laxative lactulose, which reduces ammonia absorption in the gut, and specific antibiotics that decrease the gut bacteria that produce ammonia. These interventions preserve comfort and a degree of awareness for as long as possible.
Managing severe itching (pruritus) is a priority, often requiring specialized medications to provide relief. Palliative care also addresses psychological symptoms like anxiety and restlessness, which can be heightened by the neurological changes of HE. Medications are used proactively to calm agitation and ensure the person remains peaceful.
The Final Hours
The final 24 to 48 hours of life are marked by a distinctive set of physiological changes as the body’s systems shut down irreversibly. Circulation slows dramatically, causing the skin of the extremities to cool and develop a mottled, purplish discoloration as blood flow is prioritized for the core organs. Mottling often begins in the feet and legs before moving upward.
Breathing patterns change noticeably as the body loses its ability to regulate respiratory function. A common pattern is Cheyne-Stokes respiration, characterized by cycles of progressively deeper and faster breathing followed by periods of shallow breathing or temporary cessation of breath. The person may also develop noisy breathing, sometimes called a “death rattle,” caused by secretions in the throat that they can no longer cough up or swallow.
Urine output decreases significantly as the kidneys cease to function, often due to damage from preceding liver failure. Responsiveness diminishes profoundly, with the person spending most of their time in a deep sleep or coma, no longer responding to verbal or tactile stimuli. The presence and gentle touch of loved ones are the most important form of support, providing comfort through the final stages of life.