Assessment of Abilities of Gastroenterology Fellows to Provide Information to Patients With Liver Disease

Serious Illness Communication in Cirrhosis Care: Tools to Improve Illness Understanding, Prognostic Understanding, and Care Planning

Patients with cirrhosis frequently experience an unpredictable illness trajectory, with frequent hospitalizations and complications. Along with the uncertain nature of the disease, the possibility of a lifesaving and curative transplant often makes prognostic discussions and future care decisions challenging. Serious illness communication (SIC) refers to supportive communication whereby clinicians assess patients' illness understanding, share prognostic information according to patients' preferences, explore patients' goals, and make recommendations for care that align with these goals. SIC includes 3 key components: (1) illness understanding; (2) prognostic understanding; and (3) care planning. In this piece, we explore current barriers to early implementation of SIC in cirrhosis care and share possible solutions, including adopting a multidisciplinary approach, delivering culturally competent care, and training clinicians in SIC core skills. By use of a case example, we aim to demonstrate SIC in action and to provide clinicians with tools and skills that can be used in practice.

Dialysis initiation for patients with decompensated cirrhosis when liver transplant is unlikely

PURPOSE OF REVIEW

The purpose of this review is to describe an approach that emphasizes shared decision-making for patients with decompensated cirrhosis and acute kidney injury when liver transplantation is either not an option, or unlikely to be an option.

RECENT FINDINGS

When acute kidney injury occurs on a background of decompensated cirrhosis, outcomes are generally poor. Providers can also be faced with prognostic uncertainty. A lack of guidance from nephrology and hepatology professional societies means that providers rely on expert opinion or institutional practice patterns.

SUMMARY

For patients who are unlikely to receive liver transplantation, the occurrence of acute kidney injury represents an opportunity for a goals of care conversation. In this article, we share strategies through which providers can incorporate more shared decision-making when caring for these patients. The approach involves creating prognostic consensus amongst multidisciplinary teams and then relying on skilled communicators to share the prognosis. Palliative care consultation can be useful when teams need assistance in the conversations.

Knowledge needs in patients with Liver Disease: a qualitative study

BACKGROUND

Knowledge is essential for patients' disease management strategies and a critical component of healthcare. The importance of increasing patients level of knowledge has become more widely acknowledge in liver disease management in recent years, but further studies are needed to address patients experiences of unmet knowledge needs to develop appropriate patient education strategies. Therefore, the aim of this study was to explore knowledge needs in patients' with liver disease of different etiology and severity.

METHODS

A qualitative study was designed and an inductive method was chosen. Thirty-three patients with liver disease of different etiology and severity were interviewed using a semi-structured interview guide. Content analysis was used as an inspiration to describe and compare patients' needs for knowledge across disease etiology and severity. The reporting followed consolidated criteria for reporting qualitative research.

RESULTS

The analysis generated three categories and nine subcategories. In general, the patients described lack of knowledge related to their liver disease, which made it difficult for them to manage their disease. Patients wished to be more involved in care and treatment of the liver disease. However, patients' had difficulties to assess and understand the importance of the information they received from healthcare professionals. Due to lack of knowledge, patients' had a misconception of the liver disease. Patients' had variation in knowledge needs depending on liver disease etiology and severity.

CONCLUSION

Within liver disease management, knowledge of patients' experiences is vital to meet patients' knowledge needs and to develop appropriate patient education strategies. Therefore, it is important to ascertain a patient-centered approach to accommodate patients' individual knowledge needs, involve patients in care and treatment, and insure understanding to strengthen their self-management and give the patients the necessary skills to manage their disease and everyday life.

REGISTRATION NUMBER

Open Science Framework registration DOI https://doi.org/10.17605/OSF.IO/W28RC .

Palliative care experience and perceived gaps in training among transplant hepatology fellows: A national survey

Despite the likely benefits of palliative care (PC) for patients with cirrhosis, physician experiences and perspectives about best practices are variable. We aimed to assess PC experience and gaps in training among transplant hepatology fellows. We conducted a national survey of all transplant hepatology fellows enrolled in accredited fellowship programs during the 2020-2021 academic year. We assessed the frequency of PC provision and comfort with physical and psychological symptom management, psychosocial care, communication skills, advance care planning, and end-of-life care. A total of 45 of 56 (79%) of transplant hepatology fellows responded to the survey; 50% (n = 22) were female. Most trained at centers performing over 100 transplants per year (67%, n = 29) distributed evenly across geographic regions. Most fellows (69%, n = 31) had a PC or hospice care rotation during residency, and 42% (n = 19) of fellows received education in PC during transplant hepatology fellowship. Fellows reported feeling moderately to very comfortable with communication skills such as breaking bad news (93%, n = 41) and leading family meetings (75%, n = 33), but nearly one-third (30%, n = 13) reported feeling not very or not at all comfortable assessing and managing anxiety and depression (30%, n = 13) and spiritual distress (34%, n = 15). Nearly one-quarter (22%, n = 10) had never discussed or documented advance care plans during fellowship. Fellows wished to receive future instruction on the assessment and management of physical symptoms (68%, n = 30) and anxiety and depression (64%, n = 28). Conclusion: Our survey highlights gaps in PC experience and education during transplant hepatology fellowship, lack of comfort in managing psychological distress and advance care planning, and desire to improve skills, particularly in symptom management. Future studies should investigate how to enhance transplant hepatology competencies in these PC domains and whether this impacts clinical care, advance care planning, or patient experience.

Advance Care Planning and Goals of Care Discussions in Advanced Liver Disease

PURPOSE OF REVIEW

Advance care planning (ACP) has been shown to improve multiple outcomes in patients with serious illnesses; however, patients with advanced liver disease, or cirrhosis, rarely receive timely ACP. The purpose of this review is to evaluate the current state of ACP for patients with advanced liver disease and to provide practical guidance for integrating early ACP into routine outpatient hepatology care.

RECENT FINDINGS

Due to multiple patient-, physician-, and systems-level barriers, patients with advanced liver disease have low rates of timely ACP engagement. Early identification and preparation of a surrogate decision-maker, enhancing clinician ACP communication skills, use of patient-centered educational tools, optimizing outpatient processes for ACP documentation, and early referral to specialty palliative care may help to improve current deficits in ACP for this population.

SUMMARY

Provision of early ACP to patients with advanced liver disease may better ensure that patients receive medical care that is consistent with their goals and values.

Developing Priorities for Palliative Care Research in Advanced Liver Disease: A Multidisciplinary Approach

Individuals with advanced liver disease (AdvLD), such as decompensated cirrhosis (DC) and hepatocellular carcinoma (HCC), have significant palliative needs. However, little research is available to guide health care providers on how to improve key domains related to palliative care (PC). We sought to identify priority areas for future research in PC by performing a comprehensive literature review and conducting iterative expert panel discussions. We conducted a literature review using search terms related to AdvLD and key PC domains. Individual reviews of these domains were performed, followed by iterative discussions by a panel consisting of experts from multiple disciplines, including hepatology, specialty PC, and nursing. Based on these discussions, priority areas for research were identified. We identified critical gaps in the available research related to PC and AdvLD. We developed and shared five key priority questions incorporating domains related to PC. Conclusion: Future research endeavors focused on improving PC in AdvLD should consider addressing the five key priorities areas identified from literature reviews and expert panel discussions.

Characterizing patient-reported outcomes in veterans with cirrhosis

Background and aims

The Veterans Health Administration (VA) cares for over 80,000 Veterans with cirrhosis annually. Given the importance of understanding patient reported outcomes in this complex population, we aimed to assess the associations between attitudes towards care, disease knowledge, and health related quality of life (HRQoL) in a national sample.

Methods

In this cross-sectional study, we mailed paper surveys to a random sample of Veterans with cirrhosis, oversampling those with decompensated disease. Surveys included the Veterans RAND 12-Item Health Survey (measuring HRQoL) and questions about demographics, characteristics of care, satisfaction with care (“attitudes towards care”), and symptoms of cirrhosis. Those who reported being “unsure” about whether they had decompensation events were defined as “unsure about cirrhosis symptoms” (“disease knowledge”). We used multivariable regression models to assess the factors associated with HRQoL.

Results

Of 1374 surveys, 551 (40%) completed surveys were included for analysis. Most Veterans (63%) were “satisfied” or “very satisfied” with VA liver care. Patients often self-reported being unsure about whether they had experienced hepatic decompensation events (34%). Overall average physical (PCS) and mental (MCS) component scores of HRQoL were 30±11 and 41±12. In multivariable regression models, hepatic decompensation (PCS:β = -3.8, MCS:β = -2.2), medical comorbidities (β = −-2.0, β = -1.7), and being unsure about cirrhosis symptoms (β = -1.9, β = -3.3) were associated with worse HRQoL, while age (β = 0.1, β = 0.2) and satisfaction with care (β = 0.6; β = 1.6) were associated with significantly better HRQoL.

Conclusions

Hepatic decompensation, lower satisfaction with care, and being unsure about cirrhosis symptoms were associated with reduced QOL scores in this national cohort.

Barriers to Disease Monitoring and Liver Cancer Surveillance Among Patients with Chronic Hepatitis B in the United States

Chronic hepatitis B infection (CHB) is a condition that needs ongoing care such as monitoring for liver enzymes (ALT) and HBV DNA tests in treated and untreated patients, and annual imaging evaluation for liver cancer. Although follow-up care and treatment might seem straight forward, an estimated two-thirds of those who are aware of their infection are not seeing a health care provider, and more than half of those who are eligible for treatment do not receive it. This study aimed to compile and examine studies related to the barriers of disease monitoring, treatment, and liver cancer surveillance for CHB patients in the United States (US). A total of 4439 studies on monitoring and surveillance of CHB published between 2007 and 2018 were identified through a search of electronic databases. After critical assessment, the authors included 42 studies, divided into categories: 'patient-related barriers'; 'provider-related barriers'; and 'system-related barriers'. Among the patient-related barriers, one of the most frequent factors invoked in failing to have adequate surveillance was lack of patient's knowledge. In the provider-related barrier category, a lack of disease knowledge and adherence to guidelines was frequently reported. For the system-related barrier category, the only recurrent mention was a lack of clarity in guidelines or lack of guidelines from certain national institutions. This review summarizes and highlights the need for long-term disease management improvement of chronic hepatitis B infection for patients and healthcare providers that care for them.

Correlation analysis of empathy satisfaction and empathy, mental resilience, and social support in elderly patients with functional dyspepsia

BACKGROUND

The development direction of empathic satisfaction as helping industry is gradually shifting from medical personnel to patients. The level of empathy satisfaction is closely related to the levels of empathy ability, social support, and mental resilience.

AIM

To explore the correlation among empathy satisfaction, empathy ability, mental resilience, and social support in elderly patients with functional dyspepsia (FD).

METHODS

One hundred and thirty elderly patients with FD who were admitted to our hospital from June 2017 to August 2019 were selected as the study subjects. The professional quality of life scale, the Chinese-version Jefferson empathy scale, the comprehension social support scale, and the self-recovery strength scale were used for investigations.

RESULTS

The scores of empathy competence, mental resilience, social support, and empathy satisfaction in elderly FD patients were 106.94 ± 9.36, 35.72 ± 6.87, 67.83 ± 8.34, and 33.94 ± 4.90, respectively, all of which were positively correlated [r = 0.765- (-0.423), P < 0.05]. Regression analysis was conducted with empathy ability as the independent variable, mental resilience as the mediating variable, and empathy satisfaction as the dependent variable. The results showed that both empathy (β = 0.189, P < 0.01) and resilience (β = 0.282, P < 0.01) positively predicted empathy satisfaction, and the predictive effect of empathy on empathy satisfaction was decreasing (β = 0.153, P < 0.01), indicating that psychological resilience has a mediating effect between empathy ability and empathy satisfaction. The moderating effect test program of the mediating variable was used for multiple regression analysis, and equation 1 and equation 2 were established, respectively, with mental resilience and empathy satisfaction as the dependent variables. The results showed that in equation 1, the moderating effect of mental resilience on empathy × social support was not significant (β = -0.031, P > 0.05). In equation 2, empathy satisfaction had a significant moderating effect on psychological resilience × social support (β = 0.179, P < 0.01).

CONCLUSION

The level of empathy in elderly FD patients is low, which may be related to age and course of disease. Empathy ability, psychological resilience, social support, and empathy satisfaction are positively correlated, so we should attach importance to the role of psychological resilience in clinical work and provide a high level of social support, so as to improve the empathy satisfaction of elderly FD patients.

Challenging the myth of the attrition of empathy in paediatrics residents

CONTEXT

Empathy is vital to the physician-patient relationship. It promotes patient compliance and increases treatment efficacy. Studies evaluating the loss of empathy as residents advance through training curricula have generated inconsistent claims. Those considering diverse resident populations have supported a decline, whereas the few studies focused on paediatrics note stable empathy scores during training, which, indeed, exceed those of the general population. To better understand the issue as it pertains to paediatrics trainees, this study aimed to explore the state, and map a trajectory, of empathy in paediatrics residents, to identify factors influencing the learning and retention of empathy.

METHODS

This qualitative descriptive study was conducted at an urban children's hospital in Canada. A total of 10 participants were recruited for semi-structured interviews via a purposeful sampling strategy. The institutional research ethics board approved the project.

RESULTS

Senior residents (R3 and R4) reported increased empathy, attributable to greater knowledge regarding paediatric illnesses, according them a fuller sense of the impact on families. Challenges to sustained empathy correlated with published literature: time constraints, compassion fatigue and burnout with poor coping, and the hidden curriculum. Empathy was learned from peers, preceptors and other health care providers. Resident resilience, borne out of personal adversity, was protective against the loss of empathy. Residents advocated for increased autonomy and responsibility for patient care, and increased exposure to longitudinal care, including the patient's social context and home life, to increase resident empathy.

CONCLUSIONS

Curriculum development committees could consider the inclusion of these encounters and experiences in residency training, although similar descriptive research in other specialty contexts would be needed to refine understanding.