1
|
Johnson AW, Golzarri Arroyo L, Mahendraker N, Hosty J, Kroenke K. Hospital Opioid Usage and Adverse Events in Patients With End-Stage Liver Disease. J Pain Symptom Manage 2023; 65:326-334.e2. [PMID: 36496114 DOI: 10.1016/j.jpainsymman.2022.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/21/2022] [Accepted: 11/26/2022] [Indexed: 12/13/2022]
Abstract
CONTEXT Patients with end-stage liver disease (ESLD) commonly experience pain and other symptoms that result in a poor quality of life. Few studies have examined opioid usage, adverse events (AEs), and other outcomes in ESLD patients receiving opioid analgesia. OBJECTIVES This study aimed to compare outcomes in ESLD patients who received opioids to those who did not and to determine risk factors for AEs. METHODS This was a retrospective case-cohort study of 270 hospitalized patients with ESLD that used administrative and clinical data from the electronic medical record. RESULTS Two-thirds of patients with ESLD admitted during the study period received at least one opioid analgesic. Patients who received opioids presented with a greater number of liver related complications and higher rates of anxiety (32% vs. 17%, P= 0.007), had substantially worse initial and average pain scores (both P< 0.001), and received more palliative care consultations. The opioid group had somewhat more respiratory (22.2% vs. 11.1%, P= 0.02) and gastrointestinal (38.5% vs. 25.2%, P= 0.03) AEs, but no increase in CNS adverse events which included hepatic encephalopathy. Anxiety and disease severity (i.e., the number of liver related complications) but not opioid administration were risk factors for the number of AEs. CONCLUSION Opioid administration was not an independent risk factor for the number of AEs in hospitalized patients with ESLD, whereas anxiety and more liver-related complications increased AE risk. Our findings suggest that opioids have an appropriate and reasonably safe role in alleviation of pain in patients with ESLD.
Collapse
Affiliation(s)
- Amy W Johnson
- Division of General Internal Medicine and Geriatrics (A.W.J,N.M.,K.K.), Indianapolis.
| | - Lilian Golzarri Arroyo
- Department of Epidemiology and Biostatistics (L.G-A), School of Public Health, Bloomington
| | - Neetu Mahendraker
- Division of General Internal Medicine and Geriatrics (A.W.J,N.M.,K.K.), Indianapolis
| | - Jack Hosty
- Indiana University School of Medicine (J.H.), Indianapolis
| | - Kurt Kroenke
- Division of General Internal Medicine and Geriatrics (A.W.J,N.M.,K.K.), Indianapolis; Regenstrief Institute, Inc. (K.K.), Indianapolis, Indianapolis USA
| |
Collapse
|
2
|
Kim S, Lee K, Kim C, Choi J, Kim S. How Do We Start Palliative Care for Patients With End-Stage Liver Disease? Gastroenterol Nurs 2022; 45:101-112. [PMID: 34269708 PMCID: PMC8963522 DOI: 10.1097/sga.0000000000000611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/30/2021] [Indexed: 11/25/2022] Open
Abstract
Patients with end-stage liver disease undergo repetitive patterns of recovery and deterioration and are burdened with uncertainty. Although quality of life is low in patients with end-stage liver disease and their family members, few studies have been conducted to identify what palliative care should be provided for them. This integrative review aimed to explore palliative care for patients with end-stage liver disease, focusing on the components and outcome measurements for further research. After searching for studies on palliative care for end-stage liver disease published between 1995 and 2017, 12 studies that met the inclusion criteria were analyzed. The common components of palliative care for patients with liver disease were: (a) an interdisciplinary approach, (b) early palliative care, (c) discussion goals of care with patient and family members, (d) symptom management, and (e) psychosocial support. It was reported that patients who were provided palliative care had improved itching, well-being, appetite, anxiety, fatigue, and depression, increased the number of do-not-resuscitate orders, palliative care consultations, and decreased length of stay. These findings could guide the development of palliative care for end-stage liver disease patients.
Collapse
Affiliation(s)
- Sookyung Kim
- Correspondence to: Sanghee Kim, PhD, RN, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea ()
| | - Kyunghwa Lee
- Sookyung Kim, PhD, RN, is Postdoctoral Researcher, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
- Kyunghwa Lee, PhD, RN, is Assistant Professor, College of Nursing, Konyang University, Daejeon, Republic of Korea
- Changhwan Kim, MSN, RN, is Staff Nurse, Department of Critical Care Nursing, Samsung Medical Center, Seoul, Republic of Korea
- Jahyun Choi, MSN, RN, is Doctoral Student, Department of Nursing, Yonsei University Graduate School, Seoul, Republic of Korea
- Sanghee Kim, PhD, RN, is Associate Professor, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
| | - Changhwan Kim
- Sookyung Kim, PhD, RN, is Postdoctoral Researcher, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
- Kyunghwa Lee, PhD, RN, is Assistant Professor, College of Nursing, Konyang University, Daejeon, Republic of Korea
- Changhwan Kim, MSN, RN, is Staff Nurse, Department of Critical Care Nursing, Samsung Medical Center, Seoul, Republic of Korea
- Jahyun Choi, MSN, RN, is Doctoral Student, Department of Nursing, Yonsei University Graduate School, Seoul, Republic of Korea
- Sanghee Kim, PhD, RN, is Associate Professor, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
| | - Jahyun Choi
- Sookyung Kim, PhD, RN, is Postdoctoral Researcher, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
- Kyunghwa Lee, PhD, RN, is Assistant Professor, College of Nursing, Konyang University, Daejeon, Republic of Korea
- Changhwan Kim, MSN, RN, is Staff Nurse, Department of Critical Care Nursing, Samsung Medical Center, Seoul, Republic of Korea
- Jahyun Choi, MSN, RN, is Doctoral Student, Department of Nursing, Yonsei University Graduate School, Seoul, Republic of Korea
- Sanghee Kim, PhD, RN, is Associate Professor, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
| | - Sanghee Kim
- Sookyung Kim, PhD, RN, is Postdoctoral Researcher, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
- Kyunghwa Lee, PhD, RN, is Assistant Professor, College of Nursing, Konyang University, Daejeon, Republic of Korea
- Changhwan Kim, MSN, RN, is Staff Nurse, Department of Critical Care Nursing, Samsung Medical Center, Seoul, Republic of Korea
- Jahyun Choi, MSN, RN, is Doctoral Student, Department of Nursing, Yonsei University Graduate School, Seoul, Republic of Korea
- Sanghee Kim, PhD, RN, is Associate Professor, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
| |
Collapse
|
3
|
Bowers SP, Clare K, Hagerty L, McColl K, Smith E, Brown-Kerr A, Ahmed A, Finlay F, Dillon JF, Barclay S. Predicting 1-year mortality among patients with decompensated cirrhosis: results of a multicentre evaluation of the Bristol Prognostic Score. BMJ Open Gastroenterol 2022; 9:e000822. [PMID: 35318191 PMCID: PMC8943768 DOI: 10.1136/bmjgast-2021-000822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 03/01/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Chronic liver disease continues to be a significant cause of morbidity and mortality yet remains challenging to prognosticate. This has been one of the barriers to implementing palliative care, particularly at an early stage. The Bristol Prognostic Score (BPS) was developed to identify patients with life expectancy less than 12 months and to act as a trigger for referral to palliative care services. This study retrospectively evaluated the BPS in a cohort of patients admitted to three Scottish hospitals. METHOD Routinely collated healthcare data were used to obtain demographics, BPS and analyse 1-year mortality for patients with decompensated liver disease admitted to three gastroenterology units over two 90-day periods. Statistical analysis was undertaken to assess performance of BPS in predicting mortality. RESULTS 276 patients were included in the final analysis. Participants tended to be late middle-aged men, socioeconomically deprived and have alcohol-related liver disease. A similar proportion was BPS+ve (>3) in this study compared with the original Bristol cohort though had more hospital admissions, higher ongoing alcohol use and poorer performance status. BPS performed poorer in this non-Bristol group with sensitivity 54.9% (72.2% in original study), specificity 58% (83.8%) and positive predictive value (PPV) 43.4% (81.3%). CONCLUSION BPS was unable to accurately predict mortality in this Scottish cohort. This highlights the ongoing challenge of prognostication in patients with chronic liver disease, furthering the call for more work in this field.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Fiona Finlay
- Queen Elizabeth University Hospital, Glasgow, UK
| | | | | |
Collapse
|
4
|
Grønkjær LL, Lauridsen MM. Impact of liver disease on patients' quality of life: a mixed methods systematic review protocol. JBI Evid Synth 2021; 19:1412-1417. [PMID: 33323778 DOI: 10.11124/jbies-20-00185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The objective of this systematic review is to explore the impact of liver disease on patients' quality of life in an attempt to develop effective evidence-based recommendations and strategies useful for clinical practice and health care professionals. INTRODUCTION Liver diseases are common worldwide and a major cause of illness and death due to health problems and serious complications, which not only cause hospitalization and death, but also emotional distress, depression, and impaired quality of life. INCLUSION CRITERIA This review will consider qualitative and quantitative studies on patients with liver disease of different severity and type. The qualitative component of this review will consider all studies that describe patients' lived experience and perception of having liver disease. The quantitative component will include studies that explore the quality of life in patients with liver disease. METHODS CINAHL (EBSCO), Embase (Ovid), MEDLINE (Ovid), PsycINFO (Ovid), Scopus (Elsevier), and Web of Science (Ovid) will be searched for articles published in Danish and English without any restriction in terms of year of publication. Articles describing both qualitative and quantitative studies will be screened for inclusion, critically appraised for methodological quality, and have data extracted using JBI instruments for mixed methods systematic reviews. A convergent integrated approach to synthesis and integration will be used. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020173501.
Collapse
|
5
|
Koon-Yee Lee G, Chun-Ming Au P, Hoi-Yee Li G, Chan M, Li HL, Man-Yung Cheung B, Chi-Kei Wong I, Ho-Fun Lee V, Mok J, Hon-Kei Yip B, King-Yip Cheng K, Wu CH, Cheung CL. Sarcopenia and mortality in different clinical conditions: A meta-analysis. Osteoporos Sarcopenia 2021; 7:S19-S27. [PMID: 33997305 PMCID: PMC8088992 DOI: 10.1016/j.afos.2021.02.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/26/2020] [Accepted: 02/06/2021] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES Sarcopenia is recognized to be a health problem which is as serious as obesity, but its relevance to mortality is unclear. We conducted a meta-analysis of cohort studies on lean mass and mortality in populations with different health conditions. METHODS In this study, a systematic search of PubMed, Cochrane Library and Embase was performed for cohort studies published before Dec 20, 2017 which examined the relationship between lean mass and mortality. We included studies reporting lean mass measurement by dual-energy X-ray absorptiometry, bioimpedance analysis or computed tomography, as continuous (per standard deviation [SD] decrease) or binary variables (using sarcopenia cutoffs). We excluded studies which used muscle mass surrogates, anthropometric measurement of muscle, rate of change in muscle mass, and sarcopenia defined by composite criteria. The primary study outcome was all-cause mortality. Pooled hazard ratio estimates were calculated using a random effects model. RESULTS A total of 9602 articles were identified from the systematic search, and 188 studies with 98 468 participants from 34 countries were included in the meta-analysis. Of the 68 studies included in the present meta-analysis, the pooled HR was 1.36 and 1.74 for every SD decrease in lean mass and in people with low lean mass (cutoffs), respectively. Significant associations were also observed in elderly and all disease subgroups, irrespective of the measurement modalities. CONCLUSIONS Lower lean mass is robustly associated with increased mortality, regardless of health conditions and lean mass measurement modalities. This meta-analysis highlighted low lean mass as a key public health issue.
Collapse
Affiliation(s)
- Grace Koon-Yee Lee
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Pokfulam, Hong Kong
| | - Philip Chun-Ming Au
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Pokfulam, Hong Kong
| | - Gloria Hoi-Yee Li
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Pokfulam, Hong Kong
| | - Marcus Chan
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Hang-Long Li
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | | | - Ian Chi-Kei Wong
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Pokfulam, Hong Kong
| | - Victor Ho-Fun Lee
- Department of Clinical Oncology, The University of Hong Kong, Pokfulam, Hong Kong
| | - James Mok
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Benjamin Hon-Kei Yip
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kenneth King-Yip Cheng
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Chih-Hsing Wu
- Department of Family Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Institute of Geriatrics, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Lung Cheung
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Pokfulam, Hong Kong
| |
Collapse
|
6
|
Gray-Renfrew A, Kimbell B, Finucane A. Emotional experience of people with advanced liver disease: Secondary data analysis. Chronic Illn 2020; 16:284-295. [PMID: 30286621 DOI: 10.1177/1742395318803668] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Patients with advanced liver disease live mainly in the community with treatment of complications provided for in-hospital. The illness trajectory of advanced liver disease is uncertain and most do not have access to end of life care. Gaps in knowledge and understanding of the patient experience of this condition have been identified. METHODS Secondary analysis of 15 transcripts from in-depth interviews with people with advanced liver disease collected as part of a previous longitudinal study on the experience of liver disease. Transcripts were thematically analysed for emotional content. RESULTS Fear, anger, sadness and guilt clearly featured in the person's experience of advanced liver disease. Certain causal factors were identified as provoking these emotional responses, including shock of diagnosis, uncertainty concerning illness, lack of coordinated care, worrying symptoms and sudden death. Humour emerged as a coping mechanism. CONCLUSION People living with advanced liver disease experience distressing emotions. It is helpful for clinicians, nurses and other healthcare support staff to have an appreciation of the person's emotional concerns in order to provide holistic care typical of a palliative approach.
Collapse
Affiliation(s)
| | - Barbara Kimbell
- Primary Palliative Care Research Group, Centre for Population Health Sciences, University of Edinburgh, Scotland, UK
| | - Anne Finucane
- Marie Curie Hospice Edinburgh, Usher Institute, University of Edinburgh, Scotland, UK
| |
Collapse
|
7
|
Millson C, Considine A, Cramp ME, Holt A, Hubscher S, Hutchinson J, Jones K, Leithead J, Masson S, Menon K, Mirza D, Neuberger J, Prasad R, Pratt A, Prentice W, Shepherd L, Simpson K, Thorburn D, Westbrook R, Tripathi D. Adult liver transplantation: A UK clinical guideline - part 1: pre-operation. Frontline Gastroenterol 2020; 11:375-384. [PMID: 32879721 PMCID: PMC7447286 DOI: 10.1136/flgastro-2019-101215] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 02/04/2023] Open
Abstract
Liver transplantation is a highly successful treatment for all types of liver failure, some non-liver failure indications and liver cancer. Most referrals come from secondary care. This first part of a two-part guideline outlines who to refer, and how that referral should be made, including patient details and additional issues such as those relevant to alcohol and drug misuse. The process of liver transplant assessment involves the confirmation of the diagnosis and non-reversibility, an evaluation of comorbidities and exclusion of contraindications. Finally, those making it onto the waiting list require monitoring and optimising. Underpinning this process is a need for good communication between patient, their carers, secondary care and the liver transplant service, synchronised by the transplant coordinator. Managing expectation and balancing the uncertainty of organ availability against the inevitable progression of underlying liver disease requires sensitivity and honesty from all healthcare providers and the assessment of palliative care needs is an integral part of this process.
Collapse
Affiliation(s)
- Charles Millson
- Department of Hepatology, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Aisling Considine
- Pharmacy department, King's College Hospital NHS Foundation Trust, London, UK
| | - Matthew E Cramp
- South West Liver Unit, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Andrew Holt
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stefan Hubscher
- Department of Cellular Pathology, University of Birmingham, Birmingham, UK
| | - John Hutchinson
- Department of Hepatology, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Kate Jones
- Liver Transplantation Service, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Joanna Leithead
- Department of Hepatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Steven Masson
- Liver Unit, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Krish Menon
- Liver Transplantation & HPB Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Darius Mirza
- Liver Transplantation & HPB surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - James Neuberger
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Raj Prasad
- Liver Transplantation & HPB Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Anthony Pratt
- Pharmacy department, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Wendy Prentice
- Palliative Care Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Liz Shepherd
- Liver Transplantation Service, Royal Free London NHS Foundation Trust, London, UK
| | - Ken Simpson
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Doug Thorburn
- Department of Hepatology, Royal Free London NHS Foundation Trust, London, UK
| | - Rachel Westbrook
- Department of Hepatology, Royal Free London NHS Foundation Trust, London, UK
| | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birminghams, UK
| |
Collapse
|
8
|
Ufere NN, O'Riordan DL, Bischoff KE, Marks AK, Eneanya N, Chung RT, Jackson V, Pantilat SZ, El-Jawahri A. Outcomes of Palliative Care Consultations for Hospitalized Patients With Liver Disease. J Pain Symptom Manage 2019; 58:766-773. [PMID: 31326503 PMCID: PMC6823143 DOI: 10.1016/j.jpainsymman.2019.07.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/10/2019] [Accepted: 07/12/2019] [Indexed: 12/17/2022]
Abstract
CONTEXT Although palliative care (PC) has been shown to improve symptoms and end-of-life (EOL) care for patients with cancer, data are lacking on the patterns of use and outcomes of PC consultations for hospitalized patients with liver disease. OBJECTIVES We sought to characterize the patterns of use and outcomes of PC consultations for hospitalized patients with liver disease compared with patients with cancer. METHODS We conducted an observational study using data from the Palliative Care Quality Network (PCQN). The PCQN contains prospectively collected data on 135,197 hospitalized patients receiving PC consultations at 88 PCQN sites between January 2013 and December 2017. The PCQN data set includes patient demographics, processes of care, and patient-level clinical outcomes. RESULTS The cohort included 44,933 patients, of whom 4402 (9.8%) had liver disease and 40,531 (90.2%) had cancer. Patients with liver disease were younger (58.9 years vs. 65.2 years, P < 0.0001) and had higher in-hospital mortality (28% vs. 16.8%, P < 0.0001). Patients with liver disease were more likely to receive PC consultations to address goals of care (81.7% vs. 67.9%, P < 0.0001) as opposed to pain management (10.9% vs. 34.9%, P < 0.0001). Both groups had similar rates of symptom improvement and change in resuscitation preferences after PC consultation. CONCLUSION Hospitalized patients with liver disease were more likely to have a PC referral to address goals of care compared with those with cancer and were more likely to die in the hospital. Despite late PC consultations, patients with liver disease experienced improvement in symptoms and clarification of their goals of care, similar to those with cancer.
Collapse
Affiliation(s)
- Nneka N Ufere
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - David L O'Riordan
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Kara E Bischoff
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Angela K Marks
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Nwamaka Eneanya
- Palliative and Advanced Illness Research Center, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raymond T Chung
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Jackson
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Areej El-Jawahri
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
9
|
Woodland H, Hudson B, Forbes K, McCune A, Wright M. Palliative care in liver disease: what does good look like? Frontline Gastroenterol 2019; 11:218-227. [PMID: 32419913 PMCID: PMC7223359 DOI: 10.1136/flgastro-2019-101180] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/08/2019] [Accepted: 08/11/2019] [Indexed: 02/04/2023] Open
Abstract
The mortality rate from chronic liver disease in the UK is rising rapidly, and patients with advanced disease have a symptom burden comparable to or higher than that experienced in other life-limiting illnesses. While evidence is limited, there is growing recognition that care of patients with advanced disease needs to improve. Many factors limit widespread provision of good palliative care to these patients, including the unpredictable trajectory of chronic liver disease, the misconception that palliative care and end-of-life care are synonymous, lack of confidence in prescribing and lack of time and resources. Healthcare professionals managing these patients need to develop the skills to ensure effective delivery of core palliative care, with referral to specialist palliative care services reserved for those with complex needs. Core palliative care is best delivered by the hepatology team in parallel with active disease management. This includes ensuring that discussions about disease trajectory and advance care planning occur alongside active management of disease complications. Liver disease is strongly associated with significant social, psychological and financial hardships for patients and their carers; strategies that involve the wider multidisciplinary team at an early stage in the disease trajectory help ensure proactive management of such issues. This review summarises the evidence supporting palliative care for patients with advanced chronic liver disease, presents examples of current best practice and provides pragmatic suggestions for how palliative and disease-modifying care can be run in parallel, such that patients do not miss opportunities for interventions that improve their quality of life.
Collapse
Affiliation(s)
- Hazel Woodland
- Department of Hepatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Ben Hudson
- Department of Hepatology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Karen Forbes
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Anne McCune
- Department of Liver Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Mark Wright
- Department of Hepatology, University Hospital Southampton, Southampton, UK
| | | |
Collapse
|
10
|
Hansen L, Leo MC, Chang MF, Zucker BL, Sasaki A. Pain and Self-Care Behaviours in Adult Patients with End-Stage Liver Disease: A Longitudinal Description. J Palliat Care 2018. [DOI: 10.1177/082585971403000105] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
This prospective descriptive study investigated pain characteristics in 20 outpatients with end-stage liver disease (ESLD) who were approaching the end of life, described variability in pain between and within patients, and described the pharmacological and nonpharmacological pain management strategies used. The instruments we utilized were the Brief Pain Inventory (BPI) and the self-care behaviour (SCB) log for pain. Data were collected once a month over a six-month period. BPI severity of, and interference from pain mean scores ranged from 5.52 to 6.03 and 5.36 to 6.64, respectively. The top three pain-relieving behaviours reported by patients were “taking pain medication,” “taking a nap,” and “asking for help.” Pain medication intake differed between patients who were pursuing a liver transplant and those who were not eligible for one. If we are to effectively improve care for ESLD patients, it is essential that we understand the ways in which these patients experience pain and the pain management strategies they employ.
Collapse
Affiliation(s)
- Lissi Hansen
- L Hansen: (corresponding author): Oregon Health and Science University, School of Nursing, SN-ORD, 3455 S.W. U.S. Veterans Hospital Road, Portland, Oregon, USA 97239–2941
| | - Michael C. Leo
- MC Leo: Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - Michael F. Chang
- MF Chang, BL Zucker: Portland Veterans Affairs Medical Center, Portland, Oregon, USA
| | - Betsy L. Zucker
- MF Chang, BL Zucker: Portland Veterans Affairs Medical Center, Portland, Oregon, USA
| | - Anna Sasaki
- A Sasaki: Portland Veterans Affairs Medical Center and Oregon Health and Science University, Portland, Oregon, USA
| |
Collapse
|
11
|
Carvalho JR, Vasconcelos M, Marques da Costa P, Marinho RT, Fatela N, Raimundo M, Carvalhana S, Ramalho F, Cortez-Pinto H, Velosa J. Identifying palliative care needs in a Portuguese liver unit. Liver Int 2018; 38:1982-1987. [PMID: 29682885 DOI: 10.1111/liv.13865] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 04/12/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Chronic liver disease is a major worldwide cause of morbidity and mortality. Palliative care policies are not clearly established in chronic liver disease. The NECPAL CCOMS-ICO© (NECesidades PALiativas/Palliative Needs) is a tool to identify palliative care needs, including a section for liver disease. AIM The aim of this study was to identify palliative care needs in liver patients hospitalised in a tertiary referral Liver Unit. METHODS Single-centre prospective observational study. One hundred and twenty patients with cirrhosis were included and NECPAL questionnaire was applied to all patients in a 7-month period. RESULTS 84.2% of patients were considered as requiring palliative intervention; however, clinicians identified those needs only in 65.8% of the cases and caregivers in 6.7% of the cases; less than 8% of the patients were referred for palliative care consultation. An excessive use of healthcare resources (positive answer to question 3) was strongly associated with a positive need for palliative care (positive NECPAL): OR 7.305, CI 95% 2.54-20.995, P < .001). An excessive use of healthcare facilities has a sensitivity of 84.2% and a specificity of 42.1% for prediction of a positive NECPAL result (AUC 0.710, 95% CI 0.570-0.850, P = .004). CONCLUSIONS The NECPAL CCOMS-ICO© represents a feasible and easy-to-use tool to identify palliative care needs in patients with chronic liver disease.
Collapse
Affiliation(s)
- Joana Rita Carvalho
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - Mariana Vasconcelos
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - Pedro Marques da Costa
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - Rui Tato Marinho
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - Narcisa Fatela
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - Miguel Raimundo
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - Sofia Carvalhana
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - Fernando Ramalho
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - Helena Cortez-Pinto
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| | - José Velosa
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, University of Lisbon, Lisbon, Portugal
| |
Collapse
|
12
|
Affiliation(s)
- Lisa Caulley
- From the Ear, Nose, and Throat Department, Guy's and St. Thomas' Hospital, London; Department of Epidemiology, Erasmus University Medical Center, Rotterdam, Rotterdam, the Netherlands; and the Ottawa Hospital Research Institute, Ottawa, Canada
| |
Collapse
|
13
|
Vasco M, Paolillo R, Schiano C, Sommese L, Cuomo O, Napoli C. Compromised nutritional status in patients with end-stage liver disease: Role of gut microbiota. Hepatobiliary Pancreat Dis Int 2018; 17:290-300. [PMID: 30173786 DOI: 10.1016/j.hbpd.2018.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with end-stage liver disease (ESLD) have a compromised nutritional status because of the liver crucial role in regulating metabolic homeostasis and energy balance. DATA SOURCES A systematic review of literature based on extensive relevant articles published from 2001 to 2017 in English in PubMed database was performed by searching keywords such as liver disease, non-alcoholic liver disease, alcoholic liver disease, malnutrition, epigenetics, gut microbiota, and probiotics. RESULTS Liver transplantation would be one eligible therapy for ESLD patients, even if, the clinical outcome is negatively influenced by malnutrition and/or infections. The malnutrition is a condition of nutrient imbalance with a high incidence in ESLD patients. An accurate evaluation of nutritional status could be fundamental for reducing complications and prolonging the survival of ESLD patients including those undergoing liver transplantation. In addition, the interaction among nutrients, diet and genes via epigenetics has emerged as a potential target to reduce the morbidity and mortality in ESLD patients. The malnutrition induces changes in gut microbiota causing dysbiosis with a probable translocation of bacteria and/or pathogen-derived factors from the intestine to the liver. Gut microbiota contribute to the progression of chronic liver diseases as well as hepatocellular carcinoma. The administration of probiotics modulating gut microbiota could improve all chronic liver diseases. CONCLUSIONS This review provides an update on malnutrition status linked to epigenetics and the potential benefit of some probiotics on the management of ESLD patients. In support of this view and to reveal the constant and growing interest in this field, some clinical trials are reported.
Collapse
Affiliation(s)
- Maria Vasco
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Regional Reference Laboratory of Transplant Immunology, Department of Internal and Specialty Medicine, Azienda Ospedaliera Universitaria, Università degli Studi della Campania "Luigi Vanvitelli", Naples 80138, Italy
| | - Rossella Paolillo
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Regional Reference Laboratory of Transplant Immunology, Department of Internal and Specialty Medicine, Azienda Ospedaliera Universitaria, Università degli Studi della Campania "Luigi Vanvitelli", Naples 80138, Italy
| | | | - Linda Sommese
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Regional Reference Laboratory of Transplant Immunology, Department of Internal and Specialty Medicine, Azienda Ospedaliera Universitaria, Università degli Studi della Campania "Luigi Vanvitelli", Naples 80138, Italy; Department of Experimental Medicine, Università degli Studi della Campania "Luigi Vanvitelli", Naples 80138, Italy.
| | - Oreste Cuomo
- Department of Liver Transplant, AORN A. Cardarelli, Naples, Italy
| | - Claudio Napoli
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Regional Reference Laboratory of Transplant Immunology, Department of Internal and Specialty Medicine, Azienda Ospedaliera Universitaria, Università degli Studi della Campania "Luigi Vanvitelli", Naples 80138, Italy; IRCCS SDN, Naples, Italy; Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| |
Collapse
|
14
|
Brisebois A, Ismond KP, Carbonneau M, Kowalczewski J, Tandon P. Advance care planning (ACP) for specialists managing cirrhosis: A focus on patient-centered care. Hepatology 2018; 67:2025-2040. [PMID: 29251778 DOI: 10.1002/hep.29731] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/28/2017] [Accepted: 12/11/2017] [Indexed: 01/07/2023]
Abstract
UNLABELLED Advance care planning (ACP) and goals of care designation (GCD) are being integrated into modern health care. In cirrhosis, uptake and adoption of these practices have been limited with physicians citing many perceived barriers and limitations. Recognizing the many tangible benefits of ACP and GCD processes in patients with life-limiting chronic diseases, the onus is on health practitioners to initiate and direct these conversations with their patients and surrogates. Drawing upon the literature and our experiences in palliative care and cirrhosis, we provide an actionable framework that can be readily implemented into a busy clinical setting by a practitioner. Conversation starters, visual aids, educational resources (for patients and practitioners), and videos of mock physician-patient scenarios are presented and discussed. Importantly, we have customized each of these tools to meet the unique health care needs of patients with cirrhosis. The inherent flexibility of our approach to ACP discussions and GCD can be further modified to accommodate practitioner preferences. CONCLUSION In our clinics, this assemblage of "best practice tools" has been well received by patients and surrogates enabling us to increase the number of outpatients with cirrhosis who have actively contributed to their GCD before acute health events and are supported by well-informed surrogates. (Hepatology 2018;67:2025-2040).
Collapse
Affiliation(s)
- Amanda Brisebois
- Division of General Internal Medicine, Department of Medicine and Division of Palliative Care, Department of Oncology, University of Alberta, Edmonton, AB, Canada.,PPRISM Non-Cancer Palliative Care Clinic, Edmonton, AB, Canada
| | - Kathleen P Ismond
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,CEGIIR, University of Alberta, Edmonton, AB, Canada
| | - Michelle Carbonneau
- University of Alberta Hospital, Edmonton, AB, Canada.,Cirrhosis Care Clinic, Edmonton, AB, Canada
| | | | - Puneeta Tandon
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,CEGIIR, University of Alberta, Edmonton, AB, Canada.,Cirrhosis Care Clinic, Edmonton, AB, Canada
| |
Collapse
|
15
|
Kimbell B, Murray SA, Byrne H, Baird A, Hayes PC, MacGilchrist A, Finucane A, Brookes Young P, O’Carroll RE, Weir CJ, Kendall M, Boyd K. Palliative care for people with advanced liver disease: A feasibility trial of a supportive care liver nurse specialist. Palliat Med 2018; 32:919-929. [PMID: 29516776 PMCID: PMC5946657 DOI: 10.1177/0269216318760441] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Liver disease is an increasing cause of death worldwide but palliative care is largely absent for these patients. AIM We conducted a feasibility trial of a complex intervention delivered by a supportive care liver nurse specialist to improve care coordination, anticipatory care planning and quality of life for people with advanced liver disease and their carers. DESIGN Patients received a 6-month intervention (alongside usual care) from a specially trained liver nurse specialist. The nurse supported patients/carers to live as well as possible with the condition and acted as a resource to facilitate care by community professionals. A mixed-method evaluation was conducted. Case note analysis and questionnaires examined resource use, care planning processes and quality-of-life outcomes over time. Interviews with patients, carers and professionals explored acceptability, effectiveness, feasibility and the intervention. SETTING/PARTICIPANTS Patients with advanced liver disease who had an unplanned hospital admission with decompensated cirrhosis were recruited from an inpatient liver unit. The intervention was delivered to patients once they had returned home. RESULTS We recruited 47 patients, 27 family carers and 13 case-linked professionals. The intervention was acceptable to all participants. They welcomed access to additional expert advice, support and continuity of care. The intervention greatly increased the number of electronic summary care plans shared by primary care and hospitals. The Palliative care Outcome Scale and EuroQol-5D-5L questionnaire were suitable outcome measurement tools. CONCLUSION This nurse-led intervention proved acceptable and feasible. We have refined the recruitment processes and outcome measures for a future randomised controlled trial.
Collapse
Affiliation(s)
- Barbara Kimbell
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Scott A Murray
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Heidi Byrne
- Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrea Baird
- Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Peter C Hayes
- Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | | | | | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Marilyn Kendall
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Kirsty Boyd
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| |
Collapse
|
16
|
Langberg KM, Kapo JM, Taddei TH. Palliative care in decompensated cirrhosis: A review. Liver Int 2018; 38:768-775. [PMID: 29112338 DOI: 10.1111/liv.13620] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 10/30/2017] [Indexed: 12/16/2022]
Abstract
Decompensated cirrhosis is an illness that causes tremendous suffering. The incidence of cirrhosis is increasing and rates of liver transplant, the only cure, remain stagnant. Palliative care is focused on improving quality of life for patients with serious illness by addressing advanced care planning, alleviating physical symptoms and providing emotional support to the patient and family. Palliative care is used infrequently in patients with decompensated cirrhosis. The allure of transplant as a potential treatment option for cirrhosis, misperceptions about the role of palliative care and difficulty predicting prognosis in liver disease are potential contributors to the underutilization of palliative care in this patient population. Studies have demonstrated some benefit of palliative care in patients with decompensated cirrhosis but the literature is limited to small observational studies. There is evidence that palliative care consultation in other patient populations lowers hospital costs and ICU utilization and improves symptom control and patient satisfaction. Prospective randomized control trials are needed to investigate the effects of palliative care on traditional- and patient-reported outcomes as well as cost of care in decompensated cirrhosis for transplant eligible and ineligible patient populations.
Collapse
Affiliation(s)
- Karl M Langberg
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer M Kapo
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Tamar H Taddei
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, West Haven, CT, USA
| |
Collapse
|
17
|
Cirrhosis with ascites in the last year of life: a nationwide analysis of factors shaping costs, health-care use, and place of death in England. Lancet Gastroenterol Hepatol 2018; 3:95-103. [DOI: 10.1016/s2468-1253(17)30362-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/14/2017] [Accepted: 09/15/2017] [Indexed: 01/02/2023]
|
18
|
Hansen L, Lyons KS, Dieckmann NF, Chang MF, Hiatt S, Solanki E, Lee CS. Background and design of the symptom burden in end-stage liver disease patient-caregiver dyad study. Res Nurs Health 2017; 40:398-413. [PMID: 28666053 PMCID: PMC5597485 DOI: 10.1002/nur.21807] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 06/05/2017] [Indexed: 12/25/2022]
Abstract
Over half a million Americans are affected by cirrhosis, the cause of end-stage liver disease (ESLD). Little is known about how symptom burden changes over time in adults with ESLD and their informal caregivers, which limits our ability to develop palliative care interventions that can optimize symptom management and quality of life in different patient-caregiver dyads. The purpose of this article is to describe the background and design of a prospective, longitudinal descriptive study, "Symptom Burden in End-Stage Liver Disease Patient-Caregiver Dyads," which is currently in progress. The study is designed to (i) identify trajectories of change in physical and psychological symptom burden in adults with ESLD; (ii) identify trajectories of change in physical and psychological symptom burden in caregivers of adults with ESLD; and (iii) determine predictors of types of patient-caregiver dyads that would benefit from tailored palliative care interventions. We aim for a final sample of 200 patients and 200 caregivers who will be followed over 12 months. Integrated multilevel and latent growth mixture modeling will be used to identify trajectories of change in symptom burden, linking those changes to clinical events, and quality of life outcomes and characterizing types of patient-caregiver dyads based on patient-, caregiver-, and dyad-level factors. Challenges we have encountered include unexpected attrition of study participants, participants not returning their baseline questionnaires, and hiring and training of research staff. The study will lay the foundation for future research and innovation in ESLD, end-of-life and palliative care, and caregiving.
Collapse
Affiliation(s)
- Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Karen S Lyons
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Nathan F Dieckmann
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Michael F Chang
- Gastroenterology and Hepatology, VA Portland Healthcare System, Portland, Oregon
| | - Shirin Hiatt
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Emma Solanki
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Christopher S Lee
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| |
Collapse
|
19
|
Standing H, Jarvis H, Orr J, Exley C, Hudson M, Kaner E, Hanratty B. How can primary care enhance end-of-life care for liver disease? Qualitative study of general practitioners' perceptions and experiences. BMJ Open 2017; 7:e017106. [PMID: 28864486 PMCID: PMC5588936 DOI: 10.1136/bmjopen-2017-017106] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Liver disease is the third most common cause of premature death in the UK. The symptoms of terminal liver disease are often difficult to treat, but very few patients see a palliative care specialist and a high proportion die in hospital. Primary care has been identified as a setting where knowledge and awareness of liver disease is poor. Little is known about general practitioners' (GPs) perceptions of their role in managing end-stage liver disease. OBJECTIVE To explore GPs' experiences and perceptions of how primary care can enhance end-of-life care for patients with liver disease. DESIGN Qualitative interview study, thematic analysis. PARTICIPANTS Purposive sample of 25 GPs from five regions of England. RESULTS GPs expressed a desire to be more closely involved in end-of-life care for patients with liver disease but identified a number of factors that constrained their ability to contribute. These fell into three main areas; those relating directly to the condition, (symptom management and the need to combine a palliative care approach with ongoing medical interventions); issues arising from patients' social circumstances (stigma, social isolation and the social consequences of liver disease) and deficiencies in the organisation and delivery of services. Collaborative working with support from specialist hospital clinicians was regarded as essential, with GPs acknowledging their lack of experience and expertise in this area. CONCLUSIONS End-of-life care for patients with liver disease merits attention from both primary and secondary care services. Development of care pathways and equitable access to symptom relief should be a priority.
Collapse
Affiliation(s)
- Holly Standing
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Jarvis
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - James Orr
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Mark Hudson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- Liver Unit, Freeman Hospital, High Heaton, Newcastle upon Tyne, UK
| | - Eileen Kaner
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Barbara Hanratty
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
20
|
Quinn S, Campbell V, Sikka K. Sooner rather than later: early hospice intervention in advanced liver disease. ACTA ACUST UNITED AC 2017. [DOI: 10.12968/gasn.2017.15.sup5.s18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sharon Quinn
- Assistant Director of Care and Clinical Development, St Luke's Hospice, Basildon, Essex
| | | | - Karen Sikka
- Project Support Officer, St Luke's Hospice, Basildon, Essex
| |
Collapse
|
21
|
Perri GA, Yeung H, Green Y, Bezant A, Lee C, Berall A, Karuza J, Khosravani H. A Survey of Knowledge and Attitudes of Nurses About Pain Management in End-Stage Liver Disease in a Geriatric Palliative Care Unit. Am J Hosp Palliat Care 2016; 35:92-99. [PMID: 28256899 DOI: 10.1177/1049909116684765] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Palliative care is often initiated late for patients with end stage liver disease (ESLD) with pain being a common morbidity that is under-treated throughout the disease trajectory. When admitted to a palliative care unit (PCU), nurses play a pivotal role and must be highly informed to ensure effective pain management. The aim of this study is to determine the baseline level of knowledge and attitudes of PCU nurses regarding pain management in patients with ESLD. METHODS A descriptive, cross-sectional self-administered survey design was used for this study. The sample comprised 35 PCU nurses working at a continuing chronic care facility in Toronto, Ontario, Canada. Data on the knowledge and attitudes of the nurses regarding pain management in patients with ESLD, was obtained using a modified version of the "Nurses Knowledge and Attitudes Survey Regarding Pain" (NKASRP) tool. RESULTS Thirty-one PCU nurses were included for the analysis, giving a response rate of 89%. The mean total percentage score for the nurses on the modified version of the NKASRP was 72%. Only 26% of the nurse participants obtained a passing score of 80% or greater. There were no significant differences in mean total scores by age, gender, years of nursing experience or education level. CONCLUSIONS The findings of this study provide important information about the inadequate knowledge and attitude in nurses regarding pain management for patients with ESLD. It is suggested that targeted educational programs and quality improvement initiatives in pain management for patients with ESLD could improve knowledge and attitudes for PCU nurses.
Collapse
Affiliation(s)
- Giulia-Anna Perri
- 1 Baycrest Health Sciences, Division of Palliative Care, Department of Family Medicine and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Herman Yeung
- 2 Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yoel Green
- 3 Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Abby Bezant
- 1 Baycrest Health Sciences, Division of Palliative Care, Department of Family Medicine and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Carman Lee
- 1 Baycrest Health Sciences, Division of Palliative Care, Department of Family Medicine and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anna Berall
- 1 Baycrest Health Sciences, Division of Palliative Care, Department of Family Medicine and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jurgis Karuza
- 1 Baycrest Health Sciences, Division of Palliative Care, Department of Family Medicine and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Houman Khosravani
- 4 Division of Critical Care Medicine, Department of Medicine, Western University, London, Ontario, Canada
| |
Collapse
|
22
|
Beck KR, Pantilat SZ, O'Riordan DL, Peters MG. Use of Palliative Care Consultation for Patients with End-Stage Liver Disease: Survey of Liver Transplant Service Providers. J Palliat Med 2016; 19:836-41. [PMID: 27092870 DOI: 10.1089/jpm.2016.0002] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND/AIM Palliative care services (PCS) are recommended to enhance quality of care for hospitalized patients. METHODS We evaluated the attitudes of liver transplant (LT) providers and perceived barriers to PCS for their patients by conducting a web-based survey of intensive care unit nurses, postgraduate year 1 (PGY1) physician trainees, nurse practitioners, fellows, and attending physicians on the LT service at an academic medical center. RESULTS The response rate was 44% (88/200). Providers agreed that LT and PCS are not mutually exclusive (86%, n = 76). Respondents reported confusion regarding criteria and timing for referral to PCS. Most suggested that referral is appropriate when death is imminent (78%, n = 69). Many providers felt that patients' depression (66%, n = 58) was poorly managed, although few identified that PCS were consulted for depression (28%, n = 25). Overall, 84% (n = 74) identified attending physicians as the main barrier to involving PCS, and attendings (93%, n = 82) were more likely than PGY1 (67%, n = 59) and nurses (55%, n = 48) to describe PCS as end-of-life care (p = 0.03). Nearly all LT providers agreed that patients welcomed goals of care discussions (83%, n = 73), were grateful for PCS (96%, n = 85), and received higher quality care with PCS (96%, n = 85). CONCLUSION LT providers overwhelmingly report that PCS benefit patients and are consistent with LT goals even while patients are listed for LT. Barriers to PCS include confusion over referral criteria and describing PCS as end-of-life care by attending physicians. PCS teams may expand access for LT patients by establishing clear criteria for PCS referral and targeting educational interventions about palliative care to attendings.
Collapse
Affiliation(s)
- Kendall R Beck
- 1 Division of Gastroenterology, Department of Medicine, University of California San Francisco , San Francisco, California
| | - Steven Z Pantilat
- 2 Palliative Care Program, Division of Hospital Medicine, Department of Medicine, University of California San Francisco , San Francisco, California
| | - David L O'Riordan
- 2 Palliative Care Program, Division of Hospital Medicine, Department of Medicine, University of California San Francisco , San Francisco, California
| | - Marion G Peters
- 1 Division of Gastroenterology, Department of Medicine, University of California San Francisco , San Francisco, California
| |
Collapse
|
23
|
Cognition Predicts Quality of Life Among Patients With End-Stage Liver Disease. PSYCHOSOMATICS 2016; 57:514-21. [PMID: 27184728 DOI: 10.1016/j.psym.2016.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 03/24/2016] [Accepted: 03/25/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Impaired cognitive functioning and poor quality of life (QoL) are both common among patients with end-stage liver disease; however, it is unclear how these are related. OBJECTIVE This study examines how specific cognitive domains predict QoL among liver transplant candidates by replicating Stewart and colleagues' (2010) 3-factor model of cognitive functioning, and determining how variability in these cognitive domains predicts mental health and physical QoL. METHODS The sample included 246 patients with end-stage liver disease who were candidates for liver transplant at a large, Midwestern health care center. Measures, including the Repeatable Battery for the Assessment of Neuropsychological Status, Trail Making Test, Shipley Institute of Living Scale, Short-Form Health Survey-36 Version 2, and Hospital Anxiety and Depression Scale, comprised latent variables representing global intellectual functioning, psychomotor speed, and learning and memory functioning. RESULTS Confirmatory factor analysis results indicate that the 3-factor solution model comprised of global intellectual functioning, psychomotor speed, and learning and memory functioning fit the data well. Addition of physical and mental health QoL latent factors resulted in a structural model also with good fit. Results related physical QoL to global intellectual functioning, and mental health QoL to global intellectual functioning and psychomotor functioning. CONCLUSIONS Findings elucidate a relationship between cognition and QoL and support the use of routine neuropsychological screening with end-stage liver disease patients, specifically examining the cognitive domains of global intellectual, psychomotor, and learning and memory functioning. Subsequently, screening results may inform implementation of targeted interventions to improve QoL.
Collapse
|
24
|
Wordingham SE, Swetz KM. Overview of palliative care and hospice services. Clin Liver Dis (Hoboken) 2015; 6:30-32. [PMID: 31040982 PMCID: PMC6490640 DOI: 10.1002/cld.486] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 04/26/2015] [Indexed: 02/04/2023] Open
Affiliation(s)
- Sara E. Wordingham
- Department of Medicine, Division of Hematology/Oncology, Palliative MedicineMayo ClinicPhoenixAZ
| | - Keith M. Swetz
- Department of Medicine, Division of General Internal Medicine, Section of Palliative MedicineMayo ClinicRochesterMN
| |
Collapse
|
25
|
George N, Barrett N, McPeake L, Goett R, Anderson K, Baird J. Content Validation of a Novel Screening Tool to Identify Emergency Department Patients With Significant Palliative Care Needs. Acad Emerg Med 2015; 22:823-37. [PMID: 26171710 DOI: 10.1111/acem.12710] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/20/2015] [Accepted: 01/25/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND The emergency department (ED) is increasingly used by patients with life-limiting illness. These patients are frequently admitted to the hospital, where they suffer from poorly controlled symptoms and are often subjected to marginally effective therapies. Palliative care (PC) has emerged as the specialty that cares for patients with advanced illness. PC has been shown to reduce symptoms, improve quality of life, and decrease resource utilization. Unfortunately, most patients who could benefit from PC are never identified. At present, there exists no validated screening tool to identify significant unmet PC needs among ED patients with life-limiting illness. OBJECTIVES The objective was to develop a simple, content-valid screening tool for use by ED providers to identify ED patients with significant PC needs. A positive screen would result in an inpatient PC consultation. METHODS An initial screening tool was developed based on a critical review of the literature. Content validity was determined by a two-round modified Delphi technique using a panel of PC experts. The expert panel reviewed the items of the tool for accuracy and necessity using a Likert scale and provided narrative feedback. Expert's responses were aggregated and analyzed to revise the tool until consensus was achieved. Greater than 80% agreement, as well as meeting Lawshe's critical values, was required to achieve consensus. RESULTS Fifteen experts completed two rounds of surveys to reach consensus on the content validity of the tool. Three screening items were accepted with minimal revisions. The remaining items were revised, condensed, or eliminated. The final tool contains 13 items divided into three steps: 1) presence of a life-limiting illness, 2) unmet PC needs, and 3) hospital admission. The majority of panelists (86%) endorsed adoption of the final screening tool. CONCLUSIONS Use of a modified Delphi technique resulted in the creation of a content-validated screening tool for identification of ED patients with significant unmet PC needs. Further validation testing of the instrument is warranted.
Collapse
Affiliation(s)
- Naomi George
- The Department of Emergency Medicine; Alpert Medical School; Brown University; Providence RI
| | - Nina Barrett
- The New York University School of Medicine; New York NY
| | - Laura McPeake
- The Department of Emergency Medicine; Alpert Medical School; Brown University; Providence RI
| | - Rebecca Goett
- The Department of Emergency Medicine; Alpert Medical School; Brown University; Providence RI
| | | | - Janette Baird
- The Department of Emergency Medicine; Alpert Medical School; Brown University; Providence RI
| |
Collapse
|
26
|
Abstract
Liver disease results in over four million physician visits and over 750,000 hospitalizations per year in the USA. Those with chronic liver disease frequently progress to cirrhosis, end-stage liver disease (ESLD), and death. Patients with ESLD experience numerous complications, including muscle cramps, confusion (hepatic encephalopathy), protein calorie malnutrition, muscle wasting, fluid overload (ascites, edema), bleeding (esophagogastric variceal hemorrhage), infection (spontaneous bacterial peritonitis), fatigue, anxiety, and depression. Despite significant improvements in palliation of these complications, patients still suffer reduced quality of life and must confront the fact that their disease will often inexorably progress to death. Liver transplantation is a valid option in this setting, increasing the duration of survival and palliating many of the symptoms. However, many patients die waiting for an organ or are not candidates for transplantation due to comorbid illness. Others receive a transplant but succumb to complications of the transplant itself. Patients and families must struggle with simultaneously hoping for a cure while facing a life-threatening illness. Ideally, the combination of palliative care with life-sustaining therapy can maximize the patients' quality and quantity of life. If it becomes clear that life-sustaining therapy is no longer an option, these patients are then already in a system to help them with end-of-life care.
Collapse
Affiliation(s)
- Anne M Larson
- Swedish Liver Center, 1101 Madison Street #200, Seattle, WA, 98104, USA,
| |
Collapse
|
27
|
Affiliation(s)
- Barbara Kimbell
- Primary Palliative Care Research Group, University of Edinburgh, Edinburgh EH8 9AG, UK
| | - Kirsty Boyd
- Primary Palliative Care Research Group, University of Edinburgh, Edinburgh EH8 9AG, UK
| | | | - Scott A Murray
- Primary Palliative Care Research Group, University of Edinburgh, Edinburgh EH8 9AG, UK.
| |
Collapse
|
28
|
Poonja Z, Brisebois A, van Zanten SV, Tandon P, Meeberg G, Karvellas CJ. Patients with cirrhosis and denied liver transplants rarely receive adequate palliative care or appropriate management. Clin Gastroenterol Hepatol 2014; 12:692-8. [PMID: 23978345 DOI: 10.1016/j.cgh.2013.08.027] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 07/22/2013] [Accepted: 08/14/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with cirrhosis who are receiving palliative care and are not eligible for liver transplantation (LT) are often hospitalized multiple times, with lack of expectations or understanding of death and dying. We evaluated how frequently these patients received appropriate and palliative care. METHODS We performed a retrospective study of 102 consecutive adult patients (67% men; mean age, 55 years) who were removed from the list for or declined LT from January 2005 through December 2010 at the University of Alberta, Canada. Patients' medical records were reviewed to determine their access to palliative care and relief of symptoms, the appropriateness of the goals for their care, and their requirements for acute care services. RESULTS The patients' median Model for End-stage Liver Disease score was 20, and median time from denial of LT to death was 52 days (range, 10-332 days). The most common reasons that patients were removed from the transplant wait list were noncompliance or substance abuse (26%) and severe illness or organ dysfunction (25%). After patients were removed from the list, 17% received renal replacement therapy, and 48% were subsequently admitted to the intensive care unit. Patients spent a median of 14 days (range, 6-33 days) in the hospital after they were removed from the transplant wait list. On the basis of the Edmonton Symptom Assessment System, 65% of patients had evidence of pain, 58% had evidence of nausea, 10% had depression, 36% had anxiety, 48% had dyspnea, and 49% had symptoms of anorexia. Twenty-eight percent of all the patients had documentation of do not resuscitate status on their charts, and only 11% were referred for palliative care. CONCLUSIONS Patients with cirrhosis who have been removed from the wait list for LT are infrequently referred for palliative care (∼ 10% of cases), although a high percentage have pain or nausea. Goals of care and do not resuscitate status are rarely discussed. Improved planning of goals of care and access to palliative services are required for these patients.
Collapse
Affiliation(s)
- Zafrina Poonja
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Amanda Brisebois
- Division of General Internal Medicine and Palliative Care, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Sander Veldhuyzen van Zanten
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Puneeta Tandon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Glenda Meeberg
- Liver Transplant Program, Alberta Health Services, Edmonton, Alberta, Canada
| | - Constantine J Karvellas
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|
29
|
Lee PC, Lo C, Ko WJ, Huang SJ, Lee PH. When and how should physicians determine the need for palliative and hospice care for patients with end-stage liver disease?: an experience in Taiwan. Am J Hosp Palliat Care 2013; 31:454-8. [PMID: 23861543 DOI: 10.1177/1049909113495707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We analyzed one case of end-stage liver disease and discussed whether the palliative care should be considered for this case. The medical record of a 56-year-old woman with alcoholic liver cirrhosis admitted to our hospital due to hypovolemic shock and esophageal varices (EV) was reviewed. The EV with active bleeding were arrested by panendoscopic intervention. However, repeat surgery revealed transmural laceration over the cardia, and immediate surgery and splenectomy were needed. The patient died postoperatively in the surgical intensive care unit due to bleeding tendency and hypovolemic shock. We suggest that palliative care and/or hospice care should have been considered for this patient before the crisis developed and that physicians require education about timely palliative and hospice care for patients with end-stage nonmalignant disease.
Collapse
Affiliation(s)
- Po-Chu Lee
- 1Department of Trauma, National Taiwan University Hospital, Taipei, Taiwan
| | | | | | | | | |
Collapse
|
30
|
Kimbell B, Murray SA. What is the patient experience in advanced liver disease? A scoping review of the literature. BMJ Support Palliat Care 2013; 5:471-80. [DOI: 10.1136/bmjspcare-2012-000435] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 06/01/2013] [Indexed: 11/03/2022]
|