Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Hi all, I'm looking for some assistance for what my next steps are, as I'm just a grad student and not a medical professional.TLDR: 48/F with late stage liver failure and diabetes. Estimated 3-6 months to live. She suddenly is not lucid after stopping most treatment and starting an SSRI. I want to know if this sounds like encephalopathy, and if it does, can it be caused by these treatments?My mom (48/F/caucasian) is currently in the hospital for late stage liver failure. The current prognosis is that 10% is functioning, which is complicated by her diabetes. Last month she was in the hospital with 20% liver function, and had a second toe removed (the first was amputated in 2019).I brought her back in after my dad called complaining about how she can no longer stand, speak coherently, stop crying, and was in constant pain, which we were told was encephalopathy. Since she was removed from the ICU, a family member has been here for the entirety of visitation hours everyday to help her eat, get to the bathroom, etc, so we have witnessed this whole process. After a week or so of treatment with diuretics, she was lucid, starting walking, ate all of her food plus snacks, etc, though still in pain. She was able to verbalize that.Due to the IV teatments they were giving her, she accumulated 40 lbs of fluids in her legs and and abdomen, which they said couldn't drain due to her hemoglobin levels/blood pressure. It started weeping from her legs as a yellow liquid, and eventually she developed dozens of sores on her leg bandages and the legs swelled to 3x their regular size. She was in excruciating pain plus itching, which from what I've read to pretty standard. That all said, she was still able to verbalize this and was lucid.5 days ago, she was told by the hospitalist that there is nothing they can do, and instead of palliative care, she should now be in hospice care. She was incredibly upset by this, but was still lucid. At that time, the palliative care doctor prescribed her an SSRI (not sure which one, they would not tell me) and the hospitalist stopped all other treatment other than blood pressure medicine, insulin before meals, oxycodone upon request, and benedryl for itching upon request.The timeline since then is as follows:Friday, she started receiving the SSRI. She was still lucid, calling people, and complaining of pain.Saturday, she stopped eating, speaking, or drinking anything. She just lays in bed, and if you ask her a question she stares blankly at you. She will nod sometimes to questions. She ate very little, and only when urged to.Sunday, she was about the same. Barely ate and doesn't speak at all.Today, Monday 3/15: she is still the same, and hadn't had any sort of fluid since the previous family member left at 6p the day before and I arrived this morning. She has had no bowel movements in 24 hours. The palliative care representative prescribed ritalin to make her more alert, but it hasn't done anything. We are currently working on transferring her to a hospice care facility.She looks like someone on a heavy dose of oxycodone, but she hasn't had any in days. All she does is stare at us and occasionally eat a piece of candy when prompted. I asked the hospitalist what could cause this so suddenly, but he said there's nothing they can do, as it is not encephalopathy. He referred me to hospice and would give no other information.All of that long background is to say this: this doesn't look like how her encephalopathy manifested before (crying, pain, etc). Is it possible for it show up differently? The only new medication introduced last week was an SSRI, but since she only started it Friday, it seems weird that it would have an immediate effect like that, since I would think that it takes some time for it to get to the liver and metabolize (or not metabolize) and cause a rise in her toxin levels. I have also always been told that it takes weeks for SSRIs to be effective, but I don't know how that changes in cirrhosis patients. If this is not encephalopathy, but what is causing this sudden change?I want to make sure she is receiving proper care, as I'm not able to clean much from her doctors and she is not lucid. Thank you for any guidance on this situation!Here are the papers I read regarding this, in case that is important:2015, Issues in the endstage liver disease patient for which palliative care could be helpful2017, Psychotropic drugs and liver disease: A critical review of pharmacokinetics and liver toxicityNote:I don't know her current numbers, as they messed up her labs this morning and apparently don't redo them when that happens.. ### Response: I imagine this is one of the toughest times you and your family have ever had to go through. Please don't neglect yourselves whilst looking after your mother and seek appropriate support, particularly psychological, as necessary.I am a psychiatrist, so I will try to answer your query regarding the SSRI. I'm afraid my internal medicine knowledge isn't up to date enough to help with much else here.All SSRIs are hepatically metabolised. They can therefore accumulate over long periods of time, so they must be used cautiously in liver impairment, and SSRIs with long half lives should be avoided. Of the SSRI family, citalopram / escitalopram have the least known effect on hepatic enzymes and are typically the SSRI of choice. Some specialists may prefer paroxetine, due to it having the shortest half life. Whichever is chosen, the general rule is to start low and go slow. I trust your mother's doctors have stuck with this rule. In which case, I suspect there has not been enough time for the new SSRI to accumulate to sufficient levels to be responsible for her acute deterioration, particularly if her deterioration began after just one or two doses.However, even if the SSRI isn't doing any harm, we need to ask ourselves, is it doing her any good? In the state that you have described her to be in, especially since the deterioration, I would struggle to justify continuing the SSRI. At this stage, I would argue the potential harm outweighs the potential benefits. And who knows, I might be wrong about the SSRI not being responsible; if it gets discontinued and your mother starts perking up, then all the better.Sorry to hear about this awful situation, do take care..