Experiences of Individuals With Liver Cirrhosis: A Qualitative Study

Beyond the Diagnosis: A Deep Dive Into the End Stage Liver Disease Experience From the Patient Perspective

INTRODUCTION

End-stage liver disease (ESLD) presents a multifaceted challenge that encompasses not only physical but also emotional, psychological, and social dimensions. This study aims to explore the experiences of ESLD patients within the United States healthcare system.

METHODS

Utilizing a convenience sampling methodology, 15 ESLD patients from a tertiary care hospital in the USA participated in semi-structured interviews between April 2023 and January 2024. Data analysis was conducted using MAXQDA 2023, employing a phenomenological approach to identify common themes.

RESULTS

The study identified six primary themes: the significance of communication style in diagnosis delivery, the crucial role of family and social support, varied understanding and preferences for palliative care, diverse attitudes towards advanced care planning, preferences for coordinated healthcare experiences, and the emotional and psychological impact of ESLD.

CONCLUSION

Our study underscores the complexity of ESLD patient care beyond medical treatment, highlighting the importance of clear communication, empathetic care, and the integration of family and palliative care services.

Needs evaluation questionnaire for liver disease: a novel assessment of unmet needs in patients with chronic liver disease

Patients with chronic liver disease face debilitating complications in their daily living and constantly report several types of unmet needs, but there is a paucity of validated questionnaires to assess these needs. In this study, we present the development of the Needs Evaluation Questionnaire for Liver Diseases (NEQ-LD) for the assessment of unmet needs in patients with chronic liver disease. Two hundred eighty-six outpatients with chronic liver diseases from a single tertiary referral center completed the NEQ-LD and related validity measures. Item response theory analyses were performed and demonstrated the strong psychometric properties of the questionnaire. Differential item functioning analyses showed that the scale functions equally across groups differing for age, sex, and presence of cirrhosis, suggesting the large applicability of the NEQ-LD for the assessment of unmet needs and between-group comparisons. Criterion validity measures provided evidence that unmet needs were positively associated with measures of depression and anxiety and negatively associated with measures of subjective well-being and physical and mental health. Unmet needs were expressed by a high percentage of patients, especially in the areas of information and dialogue with clinicians. One third of the sample reported material needs. Most of the items describing unmet needs were reported more frequently by patients with cirrhosis. Conclusion: We developed a reliable, valid, and largely employable instrument that can promote patient-centered care and facilitate support services in Hepatology.

Quality of life and unmet needs in patients with chronic liver disease: A mixed-method systematic review

Background & Aims

In an attempt to uncover unmet patient needs, this review aims to synthesise quantitative and qualitative studies on patients’ quality of life and their experience of having liver disease.

Methods

Three databases (CINAHL, Embase, and PubMed) were searched from January 2000 to October 2020. The methodological quality and data extraction of both quantitative and qualitative studies were screened and appraised using Joanna Briggs Institute instruments for mixed-method systematic reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A convergent, integrated approach to synthesis and integration was used. Studies including patients with autoimmune and cholestatic liver disease, chronic hepatitis B and C, non-alcoholic fatty liver disease and non-alcoholic steatohepatitis, cirrhosis, and hepatocellular carcinoma were considered.

Results

The searches produced 5,601 articles, of which 95 (79 quantitative and 16 qualitative) were included in the review. These represented studies from 26 countries and a sample of 37,283 patients. The studies showed that patients´ quality of life was reduced. Unmet needs for information and support and perceived stigmatisation severely affected patients’ quality of life.

Conclusions

Our study suggests changes to improve quality of life. According to patients, this could be achieved by providing better education and information, being aware of patients’ need for support, and raising awareness of liver disease among the general population to reduce misconceptions and stigmatisation.

Registration number

PROSPERO CRD42020173501.

Lay summary

Regardless of aetiology, patients with liver diseases have impaired quality of life. This is associated with disease progression, the presence of symptoms, treatment response, and mental, physical, and social factors such as anxiety, confusion, comorbidities, and fatigue, as well as limitations in daily living, including loneliness, low income, stigmatisation, and treatment costs. Patients highlighted the need for information to understand and manage liver disease, and awareness and support from healthcare professionals to better cope with the disease. In addition, there is a need to raise awareness of liver diseases in the general population to reduce negative preconceptions and stigmatisation.

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Patients with liver disease regardless of aetiology and severity have impaired quality of life.

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Patients call for better education and information to understand and manage their liver disease, and for increased awareness and support from healthcare professionals.

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Owing to the limited knowledge of liver diseases among the general population, patients experience stigmatisation, resulting in loneliness and social isolation.

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Addressing unmet needs of patients with liver disease could improve their quality of life.

Burdensome Transitions of Care for Patients with End-Stage Liver Disease and Their Caregivers

BACKGROUND

Patients with end-stage liver disease (ESLD) experience frequent readmissions; however, studies focused on patients' and caregivers' perceptions of their transitional care experiences to identify root causes of burdensome transitions of care are lacking.

AIM

To explore the transitional care experiences of patients with ESLD and their caregivers in order to identify their supportive care needs.

METHODS

We conducted interviews with 15 patients with ESLD and 14 informal caregivers. We used semi-structured interview guides to explore their experiences since the diagnosis of ESLD including their care transitions. Two raters coded interviews independently (κ = 0.95) using template analysis.

RESULTS

Participants reported feeling unprepared to manage their informational, psychosocial, and practical care needs as they transitioned from hospital to home after the diagnosis of ESLD. Delay in the timely receipt of supportive care services addressing these care needs resulted in hospital readmissions, emotional distress, caregiver burnout, reduced work capacity, and financial hardship. Participants shared the following resources that they perceived would improve their quality of care: (1) discharge checklist, (2) online resources, (3) mental health support, (4) caregiver support and training, and (5) financial navigation.

CONCLUSION

Transitional care models that attend to the informational, psychosocial, and practical domains of care are needed to better support patients with ESLD and their caregivers at the time of diagnosis and beyond. Without attending to the multidimensional care needs of newly diagnosed patients with ESLD and their caregivers, they are at risk of burdensome transitions of care, high healthcare utilization, and poor health-related quality of life.

Sexual dysfunction among women of reproductive age: A systematic review and meta-analysis

Background

Available statistics show a high prevalence of sexual dysfunction (SD) among women worldwide. Various factors affect SD among women of reproductive age.

Objective

To evaluate studies on the prevalence and determinants of SD in different parts of the world.

Materials and Methods

MEDLINE, EMBASE, Web of Science, Scopus and ProQuest databases were systematically reviewed during 2000–2019. All original articles were reviewed. The STROBE checklist was used to evaluate the quality of the papers. I2 was calculated to determine heterogeneity. Fixed effects and/or random-effects models were applied to estimate the pooled prevalence. Meta-regression analysis was also performed to identify the sources of heterogeneity.

Results

Based on the results of the meta-analysis (21 eligible studies), the pooled prevalence with 95% confidence interval of SD was estimated at 50.75% (41.73–59.78). The prevalence of pain and disorders in arousal, sexual desire, lubrication, orgasm, and sexual satisfaction were calculated (39.08%, 48.21%, 50.70%, 37.60%, 40.16%, and 35.02%, respectively). Also, age, depression, low education level, increased duration of the marriage, and the presence of chronic diseases were the highest risk factors for SD.

Conclusion

The prevalence of SD in women of reproductive age varies in different countries. Considering the importance of female SD, further studies are needed to facilitate the development of relevant educational interventions.

Social determinants of mental health of women living in slum: a systematic review

OBJECTIVE

With the rise of urbanization globally, the problem of living in slums has become a problem for the civil society. As a vulnerable segment, women make up half of the population in these regions; therefore, women's mental health has always been a concern. The purpose of this study was to review the social determinants of mental health in women living in slum areas.

METHODS

We systematically reviewed articles published between 2009 and 2019 on the social determinants of women's mental health in SID, Magiran, Google scholar, PubMed, Scopus, Science Direct, Embase, MEDLINE, PsychINFO, and PsychARTICLES databases using MeSH keywords according to PRISMA guidelines. The quality of the studies was assessed depending on the type of study using Ottawa Newcastle" scale and Joanna Briggs Institute quality assessment tools. Finally, 23 studies were analyzed.

RESULTS

Different social determinants influenced the mental health of women living in slum areas. Among the structural determinants, the socioeconomic level had the highest frequency, and gender was in the second rank with the highest correlation with poorer women's mental health status. Among the intermediate determinants, living conditions, food insecurity, social capital, and social support were most frequently associated with mental health status.

CONCLUSION

Women living in slum areas are prone to developing mental disorders and poorer mental health; therefore, supporting these women and creating job opportunities to raise their incomes and, subsequently, improve their social, economic, and living conditions should be taken into consideration. In addition, this requires careful planning and comprehensive social support.

Role of vitamin D and calcium in the relief of primary dysmenorrhea: a systematic review

Dysmenorrhea is one of the well-established problems among women of reproductive age and can have adverse effects on the quality of life of the individual. Some studies suggest a relationship between vitamin D (Vit D) and calcium deficiency and the emergence of early dysmenorrhea. Accordingly, a systematic study was performed to investigate the role of calcium and Vit D in the relief of primary dysmenorrhea. A systematic literature search was performed in PubMed, Web of Science, Scopus, Science Direct, and Google Scholar for papers published between 2010 and 2020. The Consolidated Standards of Reporting Trials and Strengthening the Reporting of Observational Studies in Epidemiology checklists were used to assess the quality of the studies. The risk of bias was assessed using the Cochrane risk-of-bias assessment tool. Low calcium levels lead to an increase in uterine muscle contraction and can cause pain after decreased uterine blood flow. Furthermore, low levels of Vit D can increase primary dysmenorrhea by increasing prostaglandin production or reducing intestinal calcium absorption. That being the case, Vit D and calcium intake can be effective in reducing the severity of primary dysmenorrhea and in reducing the rate of analgesic use. Low levels of Vit D and calcium are inversely related to the severity of primary dysmenorrhea, and Vit D and calcium intake can reduce the severity of primary dysmenorrhea and its associated systemic symptoms. Therefore, the use of calcium and Vit D supplements can be recommended to relieve dysmenorrhea.

Liver cirrhosis turns life into an unpredictable roller coaster: A qualitative interview study

AIM

To explore how persons living with liver cirrhosis experience day-to-day life.

BACKGROUND

Liver cirrhosis is the sixth most common cause of death among adults in Western countries. Persons with advanced liver cirrhosis report poor quality of life, in comparison with other chronic diseases. However, knowledge regarding day-to-day life during earlier stages of the disease is lacking. In other chronic diseases, the suffering process is well explored, while in liver cirrhosis, suffering is insufficiently investigated.

DESIGN

An exploratory study, with a qualitative inductive interview approach.

METHODS

A purposive maximum variation sample of 20 informants with liver cirrhosis aged 25-71, from two gastroenterology outpatient clinics in mid-Sweden, were interviewed from September 2016 to October 2017. Interview data were analysed inductively with qualitative content analysis. Reporting followed the COREQ guidelines.

RESULTS

The experiences of day-to-day life living with liver cirrhosis comprised four sub-themes. Living with liver cirrhosis implied varying levels of deterioration, the most apparent being exhaustion or tiredness. The informants had to find ways of adapting to a new life situation. The insecurity of future health evoked existential reflections such as feeling emotionally and existentially distressed. Shame and guilt were reasons for feeling stigmatised. These sub-themes emerged into one overarching theme of meaning: life turns into an unpredictable roller coaster. This is based on experiences of liver cirrhosis as an unpredictable disease with fluctuating symptoms, worries and disease progression.

CONCLUSION

Living with cirrhosis implies an unpredictable condition with a progressive, stigmatising disease. The fluctuating symptoms and deep concerns about future life pose an increased personal suffering.

RELEVANCE TO CLINICAL PRACTICE

Within health care, knowledge of the person's experience is vital to enable and fulfil the person's healthcare needs. Clinical registered nurses need a person-centred approach to strengthen their patients to cope with their new life situation.

A scoping review to identify and map the multidimensional domains of pain in adults with advanced liver disease

Background: Pain is a significant problem in adults living with advanced liver disease, having limited guidance available for its clinical management. While pain is considered a multidimensional experience, there have been limited reviews of the pain literature in advanced liver disease conducted with a multidimensional framework. Aims: The goal of this scoping review was to identify and map the multidimensional domains of pain in adults with advanced liver disease using the biopsychosocial model. Methods: We used Arksey and O'Malley's scoping framework. A search was conducted in MEDLINE, Embase, AMED, and CINAHL databases and the gray literature using specific eligibility criteria (1990-2019). Citation selection and data extraction were performed by two independent reviewers and in duplicate. Results: Of the 43 studies that met inclusion criteria, 51% were from North America and 93% utilized quantitative methods. The combined studies reported on 168,110 participants with ages ranging between 23 to 87 years. Only 9% reported an objective scoring system for liver disease severity. Few studies reported pain classification (9%) and intensity (16%). Pain prevalence ranged between 18% and 100%, with pain locations including joint, abdomen, back, head/neck, and upper/lower extremities. We identified and mapped 115 pain factors to the biopsychosocial model: physical (81%), psychological (65%), and sociocultural (5%). Only 9% measured pain using validated multidimensional tools. Pharmacological intervention (92%) prevailed among pain treatments. Conclusions: Pain is not well understood in patients with advanced liver disease, having limited multidimensional pain assessment and treatment approaches. There is a need to systematically examine the multidimensional nature of pain in this population.

The impact of stressors and overload on informal caregivers of patients with cirrhosis: The first use of the Burden Scale for Family Caregivers in Brazil

INTRODUCTION

Cirrhosis affects liver functions and compromises much of the body's organs. The significant increase in chronic diseases, including cirrhosis, has led to changes in medical practice and health systems, leading the informal caregiver to play a major role because of family ties or some level of proximity to the patient, assuming daily care function. However, the burden generated by informal caregivers for uninterrupted care is present at different levels (physical, mental, social, professional, and financial) and even in the prognosis of the patient.

OBJECTIVE

The present study aims to evaluate the impact of stressors and overload on informal caregivers of cirrhosis patients.

METHOD

Cross-sectional study, conducted with 54 informal caregivers of cirrhosis patients, followed up at the Liver Transplant Service Outpatient Clinic of the University of São Paulo School of Medicine Hospital das Clínicas, where they had access to a sociodemographic questionnaire, history of the patient's disease and the scale Burden Scale for Family Caregivers.

RESULTS

It was observed that higher levels of education and income of the caregiver correlates with a lower degree of stress. In addition, there is a significant difference found in the caregiver's age variable, which indicates that the youngest are those who have the highest degree of stress. The variable Na mEg/l of the patient also presents a statistically significant difference.

CONCLUSION

Our study was a precursor using the BSFC scale of worldwide coverage and that had not yet been applied in any study in Brazil, thus allowing a look at the various aspects that affect the quality of life of caregivers of patients with cirrhosis. Our results and the literature corroborate the importance not only of the patient, but also the informal caregiver's health.

Integrated Model for Patient-Centered Advanced Liver Disease Care

Advanced liver disease (AdvLD) is a high-risk common condition with a progressive, highly morbid, and often fatal course. Despite effective treatments, there are substantial shortfalls in access to and use of evidence-based supportive and palliative care for AdvLD. Although patient-centered, chronic illness models that integrate early supportive and palliative care with curative treatments hold promise, there are several knowledge gaps that hinder development of an integrated model for AdvLD. We review these evidence gaps. We also describe a conceptual framework for a patient-centered approach that explicates key elements needed to improve integrated care. An integrated model of AdvLD would allow clinicians, patients, and caregivers to work collaboratively to identify treatments and other healthcare that best align with patients' priorities.

Medicine use and medicine-related problems in patients with liver cirrhosis: a systematic review of quantitative and qualitative studies

PURPOSE

This review aimed to determine the prevalence, causes and risk factors of medicine-related problems (MRPs) in patients with liver cirrhosis.

METHODS

Eight online databases were searched up to 30 September 2018 with no start date. Appropriate Critical Appraisal Skills Programme tools were used to assess the quality of included studies.

RESULTS

An overall 16 quantitative and 11 qualitative studies were included in the review. Methodological quality of the included studies was variable. Mean frequency of MRPs reported in the quantitative studies ranged from 14 to 23.4%. The most frequent causes of MRPs included drug interactions, inappropriate dosing and use of contraindicated drugs. The qualitative analysis identified three themes: patient-related factors, healthcare professionals' related factors and stigma associated with liver cirrhosis.

CONCLUSION

MRPs were found to be prevalent in patients with liver cirrhosis. Factors contributing to MRPs in liver cirrhosis were not limited to medicines' effects and interactions but included healthcare systems and patients. Therefore, management of liver cirrhosis should not be limited to providing an effective medicine therapy and should take into account the patients' behaviour towards the condition.

Overt Hepatic Encephalopathy Experienced by Individuals With Cirrhosis: A Qualitative Interview Study

Hepatic encephalopathy (HE) markedly reduces an individual's quality of life as measured by established scoring systems. However, the experiences of having HE that can be assumed to cause the loss of quality of life have not yet been examined. This study aimed to explore how individuals with cirrhosis experienced overt HE by means of an in-depth interview with a tailored semistructured interview guide and qualitative analysis. Eight patients with cirrhosis who had clinically recovered from disorientation, somnolence, and stupor due to episodic HE Grade II or III were interviewed. The collected data were analyzed using systematic text condensation, as described by K. . The analysis process identified 4 themes, "multiple losses," "anxiety," "dependence on others," and "social isolation," which described the experiences of HE both during an episode and in recovery. We believe that these findings provide an important contribution to gain a deeper understanding of the widespread loss of quality of life caused by HE. Management of these individuals should involve procedures and attitudes targeted against the described experiences. However, more research is needed about the individuals' experiences of HE to further detail such efforts.

Supportive and palliative care in people with cirrhosis: International systematic review of the perspective of patients, family members and health professionals

BACKGROUND & AIMS

People with cirrhosis have unmet needs, which could benefit from a palliative care approach. Developing effective services needs to be based on evidence from those with personal experience. This review aims to explore; patient and family perspectives of perceived needs including communication; health professionals' perspectives on delivery of care and improving palliative care between specialities.

METHODS

A literature search was conducted in Medline, Embase and CINAHL using key words reporting on the perspectives of patients with liver cirrhosis (18 years and over), family members or health professionals on the provision of care in liver cirrhosis. Study quality was assessed using the Mixed Methods Appraisal Tool. Qualitative and quantitative findings were grouped together according to the main relevant themes identified.

RESULTS

Nineteen research studies predominantly from high-income Western countries were identified, with a total sample consisting of 1,413 patients, 31 family carers and 733 health professionals. Patients and family members had limited understanding of cirrhosis or its impact. They wanted better information about their disease, its treatment and help with psychological and practical needs. Health professionals had difficulty communicating about these issues to patients and their families. General practitioners left care predominantly to the liver clinicians, who lacked confidence to have discussions about prognosis or future care preferences. The role of palliative care was recognised as important in caring for this group through earlier integration with liver and community services.

CONCLUSIONS

Health professionals need support to improve their communication with patients, to address patients' broader needs beyond medical treatment and to develop new models to improve palliative care coordination between different medical specialities. Future research should focus on developing communication aides, testing existing tools to identify suitable patients for supportive care and exploring robust ways of evaluating supportive care interventions, with more studies needed from middle- and low-income countries. Registration number: PROSPERO CRD42017064770.

LAY SUMMARY

Patients and their families had a poor understanding of advanced liver disease and its impact on them. They need more information about the treatments they receive and how to get practical and psychological support. Liver specialists and GPs found it difficult to talk to patients and their families about the seriousness of advanced liver disease and the lack of healthcare options available to them if their condition gets worse. All doctors and nurses involved in the care of patients with advanced liver disease recognise that palliative and supportive care have an important role in improving patient care.

Validation of a Symptoms Distress Scale in a Cirrhotic Population Using Item Response Theory

BACKGROUND

The assessment of symptoms distress is an important strategy for symptoms management and treatment of patients with liver cirrhosis (LC); however, appropriate instruments are limited.

OBJECTIVE

The objective of this study was to validate a symptoms distress scale (SDS) by confirming the appropriateness of each item using item response theory.

METHODS

A cross-sectional and convenience sampling was conducted to recruit eligible cirrhotic outpatients from the gastroenterology outpatient department of a single medical university hospital. In total, 163 patients with LC completed the 21-item SDS. A graded response model with two-parameter (discrimination and difficulty) estimation was used for data analysis.

RESULTS

The item response theory model identified the validity of the SDS and found that most of the items in the SDS represented a high level of symptoms distress; moreover, three items of bruising, drowsiness, and dark urine were reported in cirrhotic patients with severe symptom distress. Four items comprising bodily pain, right upper quadrant pain, muscle cramps, and change in appearance can be appropriately represented in cirrhotic patients with mild symptoms distress. Moreover, the amount of test information in the SDS was >0.70, indicating acceptable reliability.

DISCUSSION

Items of the SDS can be useful for assessing different levels of symptoms distress; however, using the scale to assess mild symptoms distress in populations with LC should be done with great caution.

Self-Management Behaviors Among Patients With Liver Cirrhosis in Shanghai, China: A Cross-Sectional Study

Effective self-management of liver cirrhosis requires medication adherence and lifestyle modifications. The purpose of this study was to investigate the self-management behaviors of liver cirrhosis patients and how their knowledge of cirrhosis, psychological status, and self-efficacy contributes to self-management practices in Shanghai, China. Subjects were recruited from the hepatology units in an infectious hospital in Shanghai, China. Self-administered questionnaires were collected and medical charts were reviewed by the research staff. A total of 134 subjects were enrolled from November 2016 to March 2017. The results indicate that the self-management behaviors mean score was 2.51 out of 4 and that depression, severity of cirrhosis, and self-efficacy significantly affected self-management behaviors and explained 22.9% of the total variance. The findings also indicate that psychological stress, disease severity, and self-efficacy affected self-management behaviors in liver cirrhosis patients. Interventions focusing on decreasing depression and enhancing self-efficacy according to disease severity should improve self-management behaviors in this population.

ASPECTOS PSICOSSOCIAIS DA QUALIDADE DE VIDA DE RECEPTORES DE TRANSPLANTE HEPÁTICO

RESUMO Objetivo: avaliar a dimensão psicossocial da qualidade de vida de pacientes antes e depois do transplante hepático. Método: estudo descritivo, transversal, com abordagem quantitativa, com 150 pacientes submetidos ao transplante de fígado em seguimento a partir do sexto mês, no ambulatório de um centro de referência em transplante hepático. A coleta de dados foi realizada a partir da aplicação de um instrumento com dados sociodemográficos/clínicos e do questionário Liver Disease Quality of Life. Foi utilizada análise estatística descritiva, teste t de Student para comparação das médias dos domínios e Games-Howell para comparações múltiplas. Resultados: houve melhoria nos níveis de qualidade de vida pós-transplante nos quatro domínios avaliados (<0,0001), com maior elevação de escores para os domínios: preocupação (55,5 vs 87,9) e estigma da doença hepática (58,6 vs 93,7). Conclusão: o estudo demonstrou que os pacientes submetidos ao transplante hepático obtiveram uma melhoria significativa da percepção da qualidade de vida no que diz respeito à dimensão psicossocial, sendo mais perceptiva nos domínios preocupação e estigma da doença hepática.