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Suddle A, Reeves H, Hubner R, Marshall A, Rowe I, Tiniakos D, Hubscher S, Callaway M, Sharma D, See TC, Hawkins M, Ford-Dunn S, Selemani S, Meyer T. British Society of Gastroenterology guidelines for the management of hepatocellular carcinoma in adults. Gut 2024; 73:1235-1268. [PMID: 38627031 DOI: 10.1136/gutjnl-2023-331695] [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: 12/06/2023] [Accepted: 03/19/2024] [Indexed: 05/01/2024]
Abstract
Deaths from the majority of cancers are falling globally, but the incidence and mortality from hepatocellular carcinoma (HCC) is increasing in the United Kingdom and in other Western countries. HCC is a highly fatal cancer, often diagnosed late, with an incidence to mortality ratio that approaches 1. Despite there being a number of treatment options, including those associated with good medium to long-term survival, 5-year survival from HCC in the UK remains below 20%. Sex, ethnicity and deprivation are important demographics for the incidence of, and/or survival from, HCC. These clinical practice guidelines will provide evidence-based advice for the assessment and management of patients with HCC. The clinical and scientific data underpinning the recommendations we make are summarised in detail. Much of the content will have broad relevance, but the treatment algorithms are based on therapies that are available in the UK and have regulatory approval for use in the National Health Service.
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Affiliation(s)
- Abid Suddle
- King's College Hospital NHS Foundation Trust, London, UK
| | - Helen Reeves
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Richard Hubner
- Department of Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | | | - Ian Rowe
- University of Leeds, Leeds, UK
- St James's University Hospital, Leeds, UK
| | - Dina Tiniakos
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Stefan Hubscher
- Department of Pathology, University of Birmingham, Birmingham, UK
| | - Mark Callaway
- Division of Diagnostics and Therapies, University Hospitals Bristol NHS Trust, Bristol, UK
| | | | - Teik Choon See
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Maria Hawkins
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | | | - Sarah Selemani
- King's College Hospital NHS Foundation Trust, London, UK
| | - Tim Meyer
- Department of Oncology, University College, London, UK
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Beresford CJ, Gelling L, Baron S, Thompson L. The experiences of people with liver disease of palliative and end-of-life care in the United Kingdom-A systematic literature review and metasynthesis. Health Expect 2023; 27:e13893. [PMID: 37855242 PMCID: PMC10768859 DOI: 10.1111/hex.13893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/03/2023] [Accepted: 10/06/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Liver disease is a growing health concern and a major cause of death. It causes multiple symptoms, including financial, psychological and social issues. To address these challenges, palliative care can support people alongside active treatment, and towards the end of life, but little is known about the care experiences of individuals with liver disease in the United Kingdom. This review aimed to explore the palliative and end-of-life care experiences of people with liver disease in the United Kingdom. METHOD A systematic review was conducted using a five-stage process and following Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. Searches were across Web of Science, Scopus, EBSCO and grey literature until 10 May 2023. The review was registered through International Prospective Register of Systematic Reviews (PROSPERO). NVivo 12.5 was used to facilitate data analysis (systematic review registration: PROSPERO CRD42022382649). RESULTS Of 6035 papers (excluding duplicates) found from searches, five met the inclusion criteria of primary research related to adults with liver disease receiving palliative and/or end-of-life care in the United Kingdom, published in English. Reflexive thematic analysis of the data was conducted. The themes identified were the experiences of people with liver disease of relating to healthcare professionals, using services, receiving support, and experiences of information and communication. These were connected by an overarching concept of disempowerment versus empowerment, with the notion of person-centred care as an important feature. CONCLUSION This review has found variations in the care experiences of people with advanced liver disease towards the end of life and an overall lack of access to specialist palliative care services. Where services are designed to be person-centred, experiences are more empowering. Further research is needed but with recognition that it is often unclear when care for people with liver disease is palliative or end-of-life. PATIENT AND PUBLIC CONTRIBUTION An online public involvement workshop was held on 18 April 2023 through Voice (2023). This included four people with liver disease and four carers to discuss the review findings and to design a qualitative research study to further explore the topic.
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Affiliation(s)
- Cathy J. Beresford
- Department of Nursing ScienceFaculty of Health and Social Sciences, Bournemouth UniversityBournemouthUK
| | - Leslie Gelling
- Department of Nursing ScienceFaculty of Health and Social Sciences, Bournemouth UniversityBournemouthUK
| | - Sue Baron
- Department of Nursing ScienceFaculty of Health and Social Sciences, Bournemouth UniversityBournemouthUK
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Elhence H, Dodge JL, Farias AJ, Lee BP. Quantifying days at home in patients with cirrhosis: A national cohort study. Hepatology 2023; 78:518-529. [PMID: 36994701 PMCID: PMC10363198 DOI: 10.1097/hep.0000000000000370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/04/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND AND AIMS Days at home (DAH) is a patient-centric metric developed by the Medicare Payment Advisory Commission, capturing annual health care use, including and beyond hospitalizations and mortality. We quantified DAH and assessed factors associated with DAH differences among patients with cirrhosis. APPROACH AND RESULTS Using a national claims database (Optum) between 2014 and 2018, we calculated DAH (365 minus mortality, inpatient, observation, postacute, and emergency department days). Among 20,776,597 patients, 63,477 had cirrhosis (median age, 66, 52% males, and 63% non-Hispanic White). Age-adjusted mean DAH for cirrhosis was 335.1 days (95% CI: 335.0 to 335.2) vs 360.1 (95% CI: 360.1 to 360.1) without cirrhosis. In mixed-effects linear regression, adjusted for demographic and clinical characteristics, patients with decompensated cirrhosis spent 15.2 days (95% CI: 14.4 to 15.8) in postacute, emergency, and observation settings and 13.8 days (95% CI: 13.5 to 14.0) hospitalized. Hepatic encephalopathy (-29.2 d, 95% CI: -30.4 to -28.0), ascites (-34.6 d, 95% CI: -35.3 to -33.9), and combined ascites and hepatic encephalopathy (-63.8 d, 95% CI: -65.0 to -62.6) were associated with decreased DAH. Variceal bleeding was not associated with a change in DAH (-0.2 d, 95% CI: -1.6 to +1.1). Among hospitalized patients, during the 365 days after index hospitalization, patients with cirrhosis had fewer age-adjusted DAH (272.8 d, 95% CI: 271.5 to 274.1) than congestive heart failure (288.0 d, 95% CI: 287.7 to 288.3) and chronic obstructive pulmonary disease (296.6 d, 95% CI: 296.3 to 297.0). CONCLUSIONS In this national study, we found that patients with cirrhosis spend as many, if not more, cumulative days receiving postacute, emergency, and observational care, as hospitalized care. Ultimately, up to 2 months of DAH are lost annually with the onset of liver decompensation. DAH may be a useful metric for patients and health systems alike.
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Affiliation(s)
- Hirsh Elhence
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jennifer L. Dodge
- Department of Population Public Health Sciences, University of Southern California, Los Angeles, California
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California
| | - Albert J. Farias
- Department of Population Public Health Sciences, University of Southern California, Los Angeles, California
| | - Brian P. Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California
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Fabrellas N, Künzler-Heule P, Olofson A, Jack K, Carol M. Nursing care for patients with cirrhosis. J Hepatol 2023; 79:218-225. [PMID: 36754211 DOI: 10.1016/j.jhep.2023.01.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/10/2023]
Abstract
Cirrhosis represents a major cause of morbidity and mortality, leading to a marked impairment in the quality of life of patients and their caregivers, and resulting in a major burden on healthcare systems. Currently, in most countries, nurses still play a limited role in the care of patients with cirrhosis, which is mainly restricted to the care of patients hospitalised for acute complications of the disease. The current manuscript reviews the established and potential new and innovative roles that nurses can play in the care of patients with cirrhosis. In the hospital setting, specialised nurses should become an integral part of interprofessional teams, helping to improve the quality of care and outcomes of patients with cirrhosis. In the primary care setting, nurses should play an important role in the care of patients with compensated cirrhosis and also facilitate early diagnosis of cirrhosis in those at risk of liver diseases. This review calls for an improved global liver disease education programme for nurses and increased awareness among all healthcare providers and policymakers of the positive impacts of advanced or specialist nursing practice in this domain.
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Affiliation(s)
- Núria Fabrellas
- Department of Public Health, Mental Health, and Maternal and Child Health Nursing, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques AugustPi-Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.
| | - Patrizia Künzler-Heule
- Nursing Science, Department of Public Health, Medical Faculty, University of Basel, Basel, Switzerland; Department of Gastroenterology/Hepatology and Department of Nursing, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | | | - Kathryn Jack
- Nottingham University Hospital NHS Trust, Notthingham, UK
| | - Marta Carol
- Department of Public Health, Mental Health, and Maternal and Child Health Nursing, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques AugustPi-Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
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Jordan RI, ElMokhallalati Y, Corless L, Bennett M. Quality of end-of-life care with non-malignant liver disease: Analysis of the VOICES National Survey of Bereaved People. Liver Int 2023; 43:308-316. [PMID: 36114763 PMCID: PMC10087137 DOI: 10.1111/liv.15428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 08/25/2022] [Accepted: 09/12/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIMS Patients with liver disease struggle to access palliative care. We aimed to compare carers' perceptions of end-of-life care for decedents with non-malignant liver disease, malignant liver disease and other non-malignant diseases, and to identify associated factors in non-malignant liver disease. METHODS A retrospective analysis of individual-level data from the National Survey of Bereaved People 2011-2015. RESULTS More decedents with non-malignant liver disease died in hospital than other diseases (76.9% vs. 40.9% vs. 50.2%, p < .001), despite 89% wishing to die at home. Fewer decedents received home/hospice specialist palliative care compared with those with malignant liver disease (10.0% vs. 54.6%, p < .001). Carers of decedents with non-malignant liver disease were less likely to rate overall end-of-life care quality as outstanding/excellent (29.3% vs. 43.9% vs. 42.3%, p < .001). For this group, poorer care was associated with younger (65-74 vs. 18-64 years, OR [odds ratio] 1.39, p = .01), more socially deprived decedents (OR .78, p = .02), and better care with greater social support (OR 1.82, p < .001) and community specialist palliative care involvement (OR 1.80, p < .001). There was no association between outstanding/excellent rating and underlying cause of non-malignant liver disease (alcohol-related vs. non-alcohol-related, p = .92) or place of death (hospital vs. non-hospital, p = .476). CONCLUSIONS End-of-life care could be improved by integrating hepatology and community services, particularly specialist palliative care, and advance care planning to facilitate care and death (where desired) at home. However, death in hospital may be appropriate for those with non-malignant liver disease.
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Affiliation(s)
- Roberta I Jordan
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Yousuf ElMokhallalati
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Michael Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Drysdale K, Rance J, Cama E, Treloar C, Mao L. What is known about the care and support provided for an ageing population with lived experience of chronic viral hepatitis as they near end-of-life: A scoping review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e3775-e3788. [PMID: 36259240 PMCID: PMC10092025 DOI: 10.1111/hsc.14066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 06/09/2022] [Accepted: 10/01/2022] [Indexed: 06/16/2023]
Abstract
Ageing with a chronic hepatitis B (HBV) or hepatitis C (HCV) infection is an emerging public health priority. For people living with chronic viral hepatitis, their disease progression into old age is both underpinned by their existing blood borne virus and the potential emergence of other infectious and non-infectious conditions. These twinned pathways bring additional challenges to the care and support for people as they near end of life. This scoping review sought to examine what is known about the experiences of the end-of-life phase of an increasing population ageing with HBV and HCV in studies conducted in high-income settings and published in peer reviewed literature (2010-2021). In interpreting this literature, we found that challenges in determining the end-of life phase for people with lived experience of HBV or HCV are exacerbated by the conflation of aetiologies into a singular diagnosis of end-stage liver disease. Studies overwhelmingly reported the clinical aspects of end-of-life care (i.e. prognosis assessment and symptom management) with less attention paid to educative aspects (i.e. advance care directives and surrogate decision makers, discussion of treatment options and determining goals of care). Psychosocial interventions (i.e. quality of life beyond symptom management, including emotional/spiritual support and family and bereavement support) received limited attention in the literature, though there was some recognition that psychosocial interventions should be part of end-of-life care provision. Given the focus on the prominent disease presentation of liver cirrhosis and/or end-stage liver disease, the social and cultural dimensions of these infections have received less attention in the literature on end-of-life in the context of chronic viral hepatitis.
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Affiliation(s)
- Kerryn Drysdale
- Centre for Social Research in HealthUNSW SydneySydneyAustralia
| | - Jake Rance
- Centre for Social Research in HealthUNSW SydneySydneyAustralia
| | - Elena Cama
- Centre for Social Research in HealthUNSW SydneySydneyAustralia
| | - Carla Treloar
- Centre for Social Research in HealthUNSW SydneySydneyAustralia
| | - Limin Mao
- Centre for Social Research in HealthUNSW SydneySydneyAustralia
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Symptom Frequency and Distress Underestimated in Decompensated Cirrhosis. Dig Dis Sci 2022; 67:4234-4242. [PMID: 34448980 PMCID: PMC8882195 DOI: 10.1007/s10620-021-07216-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 08/03/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Studies assessing multiple symptoms and the distress of these symptoms in decompensated cirrhosis are lacking. AIMS The aims of this study were to assess symptom prevalence and distress among patients with decompensated cirrhosis and to describe medical management of the most prevalent symptoms. METHODS Patients were recruited from hepatology clinics within two health-care systems. Eligibility criteria included a model for end-stage liver disease (MELD-Na) score ≥15. Patients completed the Condensed Memorial Symptom Assessment Scale and Patient Health Questionnaire. Comparative statistics were used to analyze the cross-sectional survey data. RESULTS Of the sample (n = 146), most patients were Child-Turcotte-Pugh (CTP) class B (49.7%) and C (46.2%). Mean age was 56.5 years, 65.1% were male, and 88.4% were white. Average MELD-Na score was 19.1 ± 4.5. The most prevalent symptoms were lack of energy and feeling drowsy while the most distressing were lack of energy and difficulty sleeping. Only 24 patients (16.4%) were treated for their difficulty sleeping with sleep medication. Importantly, those prescribed sleep medications had similar distress (3.9 ± 1.2 vs. 3.5 ± 1.2, p = 0.229) compared with patients not prescribed sleep medications. Opioids were prescribed to 57 (39.0%) patients; antidepressants to 34 (23.3%). Forty patients (27.4%) who reported moderate or greater depression were not prescribed an antidepressant. CONCLUSIONS The study highlights the multiple symptoms and distress experienced by patients with decompensated cirrhosis, and the need for improved medical management by health-care providers through enhanced awareness and attention to these complex symptoms. Future research should focus on improvements in symptom management.
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Gray C, Arney J, Clark JA, Walling AM, Kanwal F, Naik AD. The chosen and the unchosen: How eligibility for liver transplant influences the lived experiences of patients with advanced liver disease. Soc Sci Med 2022; 305:115113. [PMID: 35690034 DOI: 10.1016/j.socscimed.2022.115113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/31/2022] [Accepted: 06/03/2022] [Indexed: 02/07/2023]
Abstract
Advanced liver disease is often uncurable and fatal. Liver transplant is the only curative option for patients with advanced, irreversible liver disease, but the need for new livers far exceeds the supply. Patients with the greatest need as well as the greatest likelihood of benefit, based on a complex array of biomedical and psychosocial considerations, are prioritized for transplant. The opportunity to receive a life-saving surgery no doubt has enormous consequences for patients and their healthcare providers, as does the absence of that opportunity. But these consequences are poorly characterized, especially for patients deemed poor candidates for liver transplant. Through in-depth interviews with patients living with advanced liver disease and the providers who care for them, we explore how eligibility status affects illness experiences, including patients' interactions with clinicians, knowledge about their disease, expectations for the future, and efforts to come to terms with a life-limiting illness. We describe how the clinical and social requirements needed to secure eligibility for liver transplant lend themselves to a clinical and cultural logic that delineates "worthy" and "unworthy" patients. We describe how providers and candidates discuss the possibility of moral redemption for such patients through transplant surgeries, a discourse notably absent among patients not eligible for transplant.
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Affiliation(s)
- Caroline Gray
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA.
| | - Jennifer Arney
- Department of Sociology, University of Houston-Clear Lake, 2700 Bay Area Boulevard, Houston, TX, 77058, USA; VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA.
| | - Jack A Clark
- Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA.
| | - Anne M Walling
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA; Department of Medicine, Division of General Internal Medicine and Health Services Research University of California at Los Angeles, 1100 Glendon Ave STE 850, Los Angeles, CA, 90024, USA.
| | - Fasiha Kanwal
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA; Department of Medicine, Health Services Research and Gastroenterology and Hepatology, Baylor College of Medicine, 7200 Cambridge St., Houston, TX, 77030, USA.
| | - Aanand D Naik
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA; Department of Medicine, Department of Health Services Research, Geriatrics and Palliative Medicine, Baylor College of Medicine, Houston, TX 7200 Cambridge St., Houston, TX, 77030, USA.
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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.
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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
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Actions and Therapeutic Potential of Madecassoside and Other Major Constituents of Centella asiatica: A Review. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app11188475] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Centella asiatica is a popular herb well-known for its wide range of therapeutic effects and its use as a folk medicine for many years. Its therapeutic properties have been well correlated with the presence of asiaticoside, madecassoside, asiatic and madecassic acids, the pentacyclic triterpenes. The herb has been extensively known to treat skin conditions; nevertheless, several pre-clinical and clinical studies have scientifically demonstrated its effectiveness in other disorders. Among the active constituents that have been identified in Centella asiatica, madecassoside has been the subject of only a relatively small number of scientific reports. Therefore, this review, while including other major constituents of this plant, focuses on the therapeutic potential, pharmacokinetics and toxicity of madecassoside.
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Patel AA, Woodrell C, Ufere NN, Hansen L, Tandon P, Verma M, Lai J, Pinotti R, Rakoski M. Developing Priorities for Palliative Care Research in Advanced Liver Disease: A Multidisciplinary Approach. Hepatol Commun 2021; 5:1469-1480. [PMID: 34510839 PMCID: PMC8435283 DOI: 10.1002/hep4.1743] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/28/2021] [Accepted: 04/19/2021] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Arpan A. Patel
- Vatche and Tamar Manoukian Division of Digestive DiseasesDepartment of MedicineDavid Geffen School of Medicine at University of California Los AngelesLos AngelesCAUSA
- Veterans Affairs Greater Los Angeles Healthcare SystemLos AngelesCAUSA
| | - Christopher Woodrell
- Brookdale Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount SinaiNew YorkNYUSA
- James J. Peters Veterans Affairs Medical CenterBronxNYUSA
| | - Nneka N. Ufere
- Gastrointestinal UnitDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Lissi Hansen
- School of NursingOregon Health Sciences UniversityPortlandORUSA
| | - Puneeta Tandon
- Department of MedicineCirrhosis Care ClinicEdmontonALCanada
- Liver Transplant UnitUniversity of AlbertaEdmontonALCanada
| | - Manisha Verma
- Department of Digestive Diseases and TransplantationEinstein Healthcare NetworkPhiladelphiaPAUSA
| | - Jennifer Lai
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Rachel Pinotti
- Gustave L. and Janet W. Levy LibraryIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Mina Rakoski
- Division of Gastroenterology and HepatologyLoma Linda University HealthLoma LindaCAUSA
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12
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Poyner C, Tripathi D, Mathers J. Exploring patients' perceptions and experiences of treatments for the prevention of variceal bleeding: a qualitative study. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000684. [PMID: 34400438 PMCID: PMC8370546 DOI: 10.1136/bmjgast-2021-000684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/22/2021] [Indexed: 01/29/2023] Open
Abstract
Background The most common fatal complication of liver cirrhosis is haemorrhaging caused by variceal rupture. The prevention of the first variceal bleed is, therefore, an important clinical goal. Little is known about patients’ experience of treatments geared towards this, or of their perceptions of treatments prior to being exposed to them. Aims To explore the factors impacting patient preference for, and actual experience of carvedilol and variceal band ligation. Methods Semistructured interviews were conducted with 30 patients from across the UK at baseline, prior to random allocation to either carvedilol or variceal band ligation. Twenty patients were interviewed a second time at 6-month follow-up. Five patients who declined the trial were also interviewed. Data were analysed using thematic analysis. Results There was no clear preference for either treatment pathway at baseline. Key factors reported by patients to influence their treatment preference included: negative experiences with key treatment processes; how long-term or short-term treatment was perceived to be; treatment misconceptions; concerns around polypharmacy and worries around treatment adherence. Patient treatment experience was influenced by their perceptions of treatment effectiveness; clinical surveillance; clinician interaction and communication, or lack thereof. Carvedilol-specific experience was also influenced by the manifestation of side effects and patient dosage routine. Variceal band ligation-specific experience was positively influenced by the use of sedation, and negatively influenced by the procedure recovery period. Conclusions These data do not support a view that the patient experience of beta-blockade for prevention of variceal bleeds is likely to be superior to variceal band ligation.
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Affiliation(s)
- Chris Poyner
- Institute of Applied Health Research, University of Birmingham, Birmingham, Birmingham, UK
| | - Dhiraj Tripathi
- University of Birmingham, Birmingham, UK.,Liver Unit, Queen Elizabeth Hospital, Birmingham, Birmingham, UK
| | - Jonathan Mathers
- Institute of Applied Health Research, University of Birmingham, Birmingham, Birmingham, UK
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13
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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.
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14
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Donlan J, Ufere NN, Indriolo T, Jackson V, Chung RT, El-Jawahri A, Traeger L. Patient and Caregiver Perspectives on Palliative Care in End-Stage Liver Disease. J Palliat Med 2020; 24:719-724. [PMID: 32996824 DOI: 10.1089/jpm.2020.0551] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Specialty palliative care (PC) is underutilized for patients with end-stage liver disease (ESLD); however, studies exploring patient and caregiver perceptions of PC are lacking. Objectives: To explore patient and caregiver knowledge, perceptions, and preferences about PC in ESLD management. Setting/Subjects: Individuals with ESLD and their informal caregivers were recruited from a large academic medical center in the United States. Design: We conducted semistructured interviews with 15 patients with ESLD and 14 informal caregivers. Purposive sampling was used to balance both transplant-listed and transplant-ineligible patients. We used a brief description of PC to explore participants' knowledge, perceptions, and preferences about PC. Two raters coded interviews independently (κ = 0.95) using template analysis. Results: Participants' knowledge about PC came primarily from their loved ones' experiences with PC, with many conflating PC with end-of-life care. Transplant-listed patients expressed concern that a PC referral would negatively impact their likelihood of receiving a liver transplant. After hearing a brief description of PC, nearly all participants believed that patients with ESLD should learn about PC soon after diagnosis to help support their illness understanding and coping. Conclusions: Study participants reported limited knowledge of PC and often perceived it as hospice care. After receiving education on PC, nearly all participants, regardless of transplant eligibility, advocated for early introduction of PC in ESLD care. Interventions are needed to educate patients with ESLD and their caregivers on the potential role of PC to overcome misperceptions of PC and allow earlier integration of PC into ESLD management.
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Affiliation(s)
- John Donlan
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nneka N Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Teresa Indriolo
- Liver Center, 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
| | - Raymond T Chung
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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15
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Gorospe FF, Istanboulian L, Puts M, Wong D, Lee E, Dale CM. A scoping review to identify and map the multidimensional domains of pain in adults with advanced liver disease. Can J Pain 2020; 4:210-224. [PMID: 33987500 PMCID: PMC7951148 DOI: 10.1080/24740527.2020.1785855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/26/2020] [Accepted: 06/04/2020] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Franklin F. Gorospe
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Perioperative Services, Toronto General Hospital–University Health Network, Toronto, Ontario, Canada
| | - Laura Istanboulian
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Acute Inpatient Respiratory Unit, Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario, Canada
| | - Martine Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - David Wong
- Hepatology Division, Toronto General Hospital–University Health Network, Toronto, Ontario, Canada
| | - Elizabeth Lee
- Hepatology Division, Toronto General Hospital–University Health Network, Toronto, Ontario, Canada
| | - Craig M. Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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16
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Naik AD, Arney J, Clark JA, Martin LA, Walling AM, Stevenson A, Smith D, Asch SM, Kanwal F. Integrated Model for Patient-Centered Advanced Liver Disease Care. Clin Gastroenterol Hepatol 2020; 18:1015-1024. [PMID: 31357029 PMCID: PMC9319576 DOI: 10.1016/j.cgh.2019.07.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/11/2019] [Accepted: 07/24/2019] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Aanand D. Naik
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Jennifer Arney
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Sociology, University of Houston-Clear Lake, Houston, Texas
| | - Jack A. Clark
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Lindsey A. Martin
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Anne M. Walling
- Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California,Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Autumn Stevenson
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Donna Smith
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Steven M. Asch
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Medical Center, Palo Alto, California,Division of Primary Care and Population Health, Stanford University, Palo Alto, California
| | - Fasiha Kanwal
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
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17
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The Chronic Liver Disease Nurse Role in Australia: Describing 10 Years of a New Role in Cirrhosis Management. Gastroenterol Nurs 2020; 43:E9-E15. [PMID: 31904629 DOI: 10.1097/sga.0000000000000424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cirrhosis of the liver is increasing, with growing patient numbers in hospital outpatient departments, as well as increasing admissions due to decompensated liver disease. Decompensated cirrhosis of the liver is a common and debilitating illness causing disability, readmissions to hospital, and decreased quality of life, and can lead to liver cancer. The advent of the chronic liver disease nurse (CLDN) position in our hospital in 2009 was the first role in Australia dedicated to providing care to patients with cirrhosis. The role incorporates the care of patients with stable compensated disease, case management of patients with complications of decompensated disease, and hepatocellular carcinoma coordination. After a pilot randomized controlled trial and almost 10 years of service, this article describes the role of the CLDN and presents key performance indicators that will assist other centers considering introducing the role or elements of it into their service.
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18
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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: 17] [Impact Index Per Article: 3.4] [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.
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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
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19
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Abstract
OBJECTIVE Health literacy (HL) is a concept covering a range of cognitive and social skills that comprises aspects necessary for patients to navigate in the healthcare system. Our study aimed to investigate HL in patients with liver cirrhosis and determine factors associated with low HL. METHODS Data were collected among outpatients with cirrhosis (n = 108), using three dimensions from the Health Literacy Questionnaire. The selected dimensions were: 'Social support for health' (Social support scale), 'Ability to actively engage with healthcare providers' (Engagement scale), and 'Understand health information well enough to know what to do' (Information scale). Unpaired t-test was used to investigate differences on the HLQ scale scores. The effect sizes (ES) were calculated between groups using Cohen's d. RESULTS A total of 105 patients completed the questionnaire. Mean age of respondents was 60.6 years (45.5% females). A majority had alcoholic liver cirrhosis (64.8%) and 36.2% were living alone. Males had a low level of Social support HL (p < .05). Having an education level <12 years was also associated with low level of Social support HL (p < .05). All ESs were characterized as small. CONCLUSIONS Male outpatients with liver cirrhosis were found to have low levels of HL, so were patients with low education. In order to effectively communicate and support patients to self-manage their disease, healthcare providers can benefit from including a focus on HL in planning and delivering health care to patients with liver cirrhosis.
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Affiliation(s)
| | - Palle Bager
- a Department of Hepatology and Gastroenterology , Aarhus University Hospital , Aarhus , Denmark
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20
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Hudson B, Hunt V, Waylen A, McCune CA, Verne J, Forbes K. The incompatibility of healthcare services and end-of-life needs in advanced liver disease: A qualitative interview study of patients and bereaved carers. Palliat Med 2018; 32:908-918. [PMID: 29393806 DOI: 10.1177/0269216318756222] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Liver disease represents the third commonest cause of death in adults of working age and is associated with an extensive illness burden towards the end of life. Despite this, patients rarely receive palliative care and are unlikely to be involved in advance care planning discussions. Evidence addressing how existing services meet end-of-life needs, and exploring attitudes of patients and carers towards palliative care, is lacking. AIM To explore the needs of patients and carers with liver disease towards the end of life, evaluate how existing services meet need, and examine patient and carer attitudes towards palliative care. DESIGN Qualitative study - semi-structured interviews analysed using thematic analysis. Settings/participants: A total of 17 participants (12 patients, 5 bereaved carers) recruited from University Hospitals Bristol. RESULTS Participants described escalating physical, psychological and social needs as liver disease progressed, including disabling symptoms, emotional distress and uncertainty, addiction, financial hardship and social isolation. End-of-life needs were incompatible with the healthcare services available to address them; these were heavily centred in secondary care, focussed on disease modification at the expense of symptom control and provided limited support after curative options were exhausted. Attitudes towards palliative care were mixed, however, participants valued opportunities to express future care preferences (particularly relating to avoidance of hospital admission towards the end of life) and an increased focus on symptomatic and logistical aspects of care. CONCLUSION The needs of patients with liver disease and their carers are frequently incompatible with the healthcare services available to them towards the end of life. Novel strategies, which recognise the life-limiting nature of liver disease explicitly and improve coordination with community services, are required if end-of-life care is to improve.
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Affiliation(s)
- Benjamin Hudson
- 1 University Hospitals Bristol NHS Foundation Trust, Bristol, UK.,2 Bristol Medical School, University of Bristol, Bristol, UK
| | - Victoria Hunt
- 1 University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Andrea Waylen
- 3 Bristol Dental School, University of Bristol, Bristol, UK
| | | | | | - Karen Forbes
- 1 University Hospitals Bristol NHS Foundation Trust, Bristol, UK.,2 Bristol Medical School, University of Bristol, Bristol, UK
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21
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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.
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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
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22
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Wang W, Wu L, Li Q, Zhang Z, Xu L, Lin C, Gao L, Zhao K, Liang F, Zhang Q, Zhou M, Jiang W. Madecassoside prevents acute liver failure in LPS/D-GalN-induced mice by inhibiting p38/NF-κB and activating Nrf2/HO-1 signaling. Biomed Pharmacother 2018; 103:1137-1145. [PMID: 29715757 DOI: 10.1016/j.biopha.2018.04.162] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 04/23/2018] [Accepted: 04/23/2018] [Indexed: 12/30/2022] Open
Abstract
Madecassoside (MA), a triterpenoid saponin isolated from Centella asiatica, exerts various pharmacological activities including antioxidative and anti-inflammatory effects. The aim of this study was to explore the protective effect of MA in the treatment of lipopolysaccharide (LPS) and D-galactosamine (D-GalN)-induced acute liver failure(ALF) in mice. We hypothesized that MA administration may decrease the degree of liver injury caused by LPS/D-GalN. In this study, we investigated this hypothesis by treating a mouse model of LPS/D-GalN-induced liver injury with MA. Our study demonstrated that MA (20 mg/kg and 40 mg/kg) treatment for 10 days attenuated LPS/D-GalN-induced liver injury by protecting liver function, suppressing the production of inflammatory cytokines such as tumor necrosis factor (TNF)-α, interleukin (IL)-1β and IL-6, and recovering antioxidant enzyme activity. MA also significantly suppressed LPS-stimulated protein levels of inducible nitric oxide synthase (iNOS) and cyclooxygenase (COX)-2 by blocking the phosphorylation of p38 mitogen-activated protein kinase (MAPK) and eukaryotic transcription factor nuclear factor-kappa B (NF-κB). In addition, MA treatment enhanced protein levels of heme oxygenase (HO)-1 and anti-oxidant enzymes (superoxide dismutase, catalase, and glutathione peroxidase) through the upregulation of nuclear factor E2-related factor 2 (Nrf2) in LPS-stimulated liver injury. These results suggest that MA is a promising agent for the treatment of LPS/D-GalN-induced liver injury that could serve as a candidate for the development of a hepatoprotective drug against ALF.
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Affiliation(s)
- Wei Wang
- Pharmaceutical College, Guangxi Medical University, Nanning 530021, China
| | - Lingling Wu
- Pharmaceutical College, Guangxi Medical University, Nanning 530021, China
| | - Qing Li
- Pharmaceutical College, Guangxi Medical University, Nanning 530021, China
| | - Zhuo Zhang
- Pharmaceutical College, Guangxi Medical University, Nanning 530021, China
| | - Liba Xu
- Pharmaceutical College, Guangxi Medical University, Nanning 530021, China
| | - Caixia Lin
- Pharmaceutical College, Guangxi Medical University, Nanning 530021, China
| | - Ling Gao
- Pharmaceutical College, Guangxi Medical University, Nanning 530021, China
| | - Kaili Zhao
- Pharmaceutical College, Guangxi Medical University, Nanning 530021, China
| | - Fei Liang
- Pharmaceutical College, Guangxi Medical University, Nanning 530021, China
| | - Qing Zhang
- Pharmaceutical College, Guangxi Medical University, Nanning 530021, China
| | - Mei Zhou
- Pharmaceutical College, Guangxi Medical University, Nanning 530021, China
| | - Weizhe Jiang
- Pharmaceutical College, Guangxi Medical University, Nanning 530021, China.
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23
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Finucane AM, Carduff E, Lugton J, Fenning S, Johnston B, Fallon M, Clark D, Spiller JA, Murray SA. Palliative and end-of-life care research in Scotland 2006-2015: a systematic scoping review. BMC Palliat Care 2018; 17:19. [PMID: 29373964 PMCID: PMC5787303 DOI: 10.1186/s12904-017-0266-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 12/12/2017] [Indexed: 11/22/2022] Open
Abstract
Background The Scottish Government set out its 5-year vision to improve palliative care in its Strategic Framework for Action 2016–2021. This includes a commitment to strengthening research and evidence based knowledge exchange across Scotland. A comprehensive scoping review of Scottish palliative care research was considered an important first step. The aim of the review was to quantify and map palliative care research in Scotland over the ten-year period preceding the new strategy (2006–15). Methods A systematic scoping review was undertaken. Palliative care research involving at least one co-author from a Scottish institution was eligible for inclusion. Five databases were searched with relevant MeSH terms and keywords; additional papers authored by members of the Scottish Palliative and End of Life Care Research Forum were added. Results In total, 1919 papers were screened, 496 underwent full text review and 308 were retained in the final set. 73% were descriptive studies and 10% were interventions or feasibility studies. The top three areas of research focus were services and settings; experiences and/or needs; and physical symptoms. 58 papers were concerned with palliative care for people with conditions other than cancer – nearly one fifth of all papers published. Few studies focused on ehealth, health economics, out-of-hours and public health. Nearly half of all papers described unfunded research or did not acknowledge a funder (46%). Conclusions There was a steady increase in Scottish palliative care research during the decade under review. Research output was strong compared with that reported in an earlier Scottish review (1990–2005) and a similar review of Irish palliative care research (2002–2012). A large amount of descriptive evidence exists on living and dying with chronic progressive illness in Scotland; intervention studies now need to be prioritised. Areas highlighted for future research include palliative interventions for people with non-malignant illness and multi-morbidity; physical and psychological symptom assessment and management; interventions to support carers; and bereavement support. Knowledge exchange activities are required to disseminate research findings to research users and a follow-up review to examine future research progress is recommended. Electronic supplementary material The online version of this article (10.1186/s12904-017-0266-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anne M Finucane
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, EH10 7DR, UK. .,Centre for Population Health Sciences, The Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK.
| | - Emma Carduff
- Marie Curie Hospice Glasgow, 133 Balornock Road, Glasgow, G21 3US, UK.,School of Medicine, Nursing and Healthcare, University of Glasgow, 59 Oakfield Avenue, Glasgow, G12 8LL, UK
| | - Jean Lugton
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, EH10 7DR, UK
| | - Stephen Fenning
- Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, UK
| | - Bridget Johnston
- Florence Nightingale Foundation, Clinical Nursing Practice Research, School of Medicine, Dentistry & Nursing, College of Medical, Veterinary & Life Sciences, University of Glasgow and NHS Greater Glasgow and Clyde, 57-61 Oakfield Avenue, Glasgow, G12 8LL, UK
| | - Marie Fallon
- Institute of Genetics and Palliative Medicine, University of Edinburgh, Western General Hospital, Edinburgh, EH4 2XR, UK
| | - David Clark
- School of Interdisciplinary Studies, University of Glasgow, Bankend Road, Dumfries, DG1 4ZL, UK
| | - Juliet A Spiller
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, EH10 7DR, UK
| | - Scott A Murray
- Centre for Population Health Sciences, The Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
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Shin J, Yoon SJ, Kim SH, Lee ES, Koh SJ, Park J. A Qualitative Study of Physicians’ Perspectives on Non-Cancer Hospice-Palliative Care in Korea: Focus on AIDS, COPD and Liver Cirrhosis. ACTA ACUST UNITED AC 2017. [DOI: 10.14475/kjhpc.2017.20.3.177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Jinyoung Shin
- Department of Family Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Seok-Joon Yoon
- Department of Family Medicine, Konkuk University School of Medicine, Seoul, Korea
- Department of Family Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sun-Hyun Kim
- Department of Family Medicine, International St. Mary’s Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Eon Sook Lee
- Department of Family Medicine, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Su-Jin Koh
- Department of Hematology and Oncology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Korea
| | - Jeanno Park
- Palliative and Hospice Center, Bobath Memorial Hospital, Seongnam, Korea
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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.
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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
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Rocker G, Downar J, Morrison RS. Palliative care for chronic illness: driving change. CMAJ 2016; 188:E493-E498. [PMID: 27551031 DOI: 10.1503/cmaj.151454] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Graeme Rocker
- Department of Medicine (Rocker), Dalhousie University, Halifax, NS; Division of Respirology (Rocker), QEII Health Sciences Centre, Halifax, NS; Palliative Care and Critical Care (Downar), University Health Network, Toronto, Ont.; Divisions of Critical Care and Palliative Care (Downar), University of Toronto, Toronto, Ont.; National Palliative Care Research Center (Morrison), New York, NY; Hertzberg Palliative Care Institute (Morrison), Mt. Sinai School of Medicine, New York, NY; Brookdale Department of Geriatrics and Palliative Medicine (Morrison), Icahn School of Medicine at Mount Sinai, New York, NY
| | - James Downar
- Department of Medicine (Rocker), Dalhousie University, Halifax, NS; Division of Respirology (Rocker), QEII Health Sciences Centre, Halifax, NS; Palliative Care and Critical Care (Downar), University Health Network, Toronto, Ont.; Divisions of Critical Care and Palliative Care (Downar), University of Toronto, Toronto, Ont.; National Palliative Care Research Center (Morrison), New York, NY; Hertzberg Palliative Care Institute (Morrison), Mt. Sinai School of Medicine, New York, NY; Brookdale Department of Geriatrics and Palliative Medicine (Morrison), Icahn School of Medicine at Mount Sinai, New York, NY
| | - R Sean Morrison
- Department of Medicine (Rocker), Dalhousie University, Halifax, NS; Division of Respirology (Rocker), QEII Health Sciences Centre, Halifax, NS; Palliative Care and Critical Care (Downar), University Health Network, Toronto, Ont.; Divisions of Critical Care and Palliative Care (Downar), University of Toronto, Toronto, Ont.; National Palliative Care Research Center (Morrison), New York, NY; Hertzberg Palliative Care Institute (Morrison), Mt. Sinai School of Medicine, New York, NY; Brookdale Department of Geriatrics and Palliative Medicine (Morrison), Icahn School of Medicine at Mount Sinai, New York, NY
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Kimbell B, Boyd K, Kendall M, Iredale J, Murray SA. Managing uncertainty in advanced liver disease: a qualitative, multiperspective, serial interview study. BMJ Open 2015; 5:e009241. [PMID: 26586325 PMCID: PMC4654301 DOI: 10.1136/bmjopen-2015-009241] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 10/13/2015] [Accepted: 10/23/2015] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To understand the experiences and support needs of people with advanced liver disease and those of their lay and professional carers to inform improvements in the supportive and palliative care of this rapidly growing but currently neglected patient group. DESIGN Multiperspective, serial interviews. We conducted up to three qualitative in-depth interviews with each patient and lay carer over 12 months and single interviews with case-linked healthcare professionals. Data were analysed using grounded theory techniques. PARTICIPANTS Patients with advanced liver disease of diverse aetiologies recruited from an inpatient hepatology ward, and their lay carers and case-linked healthcare professionals nominated by the patients. SETTING Primary and secondary care in South-East Scotland. RESULTS 37 participants (15 patients, 11 lay and 11 professional carers) completed 51 individual and 13 joint patient-carer interviews. Nine patients died during the study. Uncertainty dominated experiences throughout the course of the illness, across patients' considerable physical, psychological, social and existential needs and affected patients, lay carers and professionals. This related to the nature of the condition, the unpredictability of physical deterioration and prognosis, poor communication and information-sharing, and complexities of care. The pervasive uncertainty also shaped patients' and lay carers' strategies for coping and impeded care planning. While patients' acute medical care was usually well coordinated, their ongoing care lacked structure and focus. CONCLUSIONS Living, dying and caring in advanced liver disease is dominated by pervasive, enduring and universally shared uncertainty. In the face of high levels of multidimensional patient distress, professionals must acknowledge this uncertainty in constructive ways that value its contribution to the person's coping approach. Pervasive uncertainty makes anticipatory care planning in advanced liver disease challenging, but planning 'just in case' is vital to ensure that patients receive timely and appropriate supportive and palliative care alongside effective management of this unpredictable illness.
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Affiliation(s)
- Barbara Kimbell
- Primary Palliative Care Research Group, Centre of Population Health Sciences, The University of Edinburgh, Edinburgh, UK
| | | | - Marilyn Kendall
- Primary Palliative Care Research Group, Centre of Population Health Sciences, The University of Edinburgh, Edinburgh, UK
| | | | - Scott A Murray
- Primary Palliative Care Research Group, Centre of Population Health Sciences, The University of Edinburgh, Edinburgh, UK
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Palliative care in patients with liver cirrhosis: it is the time to deal with the burden. BMJ Support Palliat Care 2015; 5:466-7. [PMID: 26124513 DOI: 10.1136/bmjspcare-2015-000923] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 06/13/2015] [Indexed: 11/03/2022]
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Carduff E, Finucane A, Kendall M, Jarvis A, Harrison N, Greenacre J, Murray SA. Understanding the barriers to identifying carers of people with advanced illness in primary care: triangulating three data sources. BMC FAMILY PRACTICE 2014; 15:48. [PMID: 24690099 PMCID: PMC3992158 DOI: 10.1186/1471-2296-15-48] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 02/25/2014] [Indexed: 11/16/2022]
Abstract
Background Approximately 10% of the UK population have an unpaid caring role for a family member or friend. Many of these carers make a significant contribution to supporting patients at the end of life. Carers can experience poor physical and psychosocial wellbeing, yet they remain largely unsupported by health and social care services. Despite initiatives for general practices to identify carers and their needs, many remain unidentified. Neither are carers self-identifying and requesting support. This study set out to explore the barriers to, and consider strategies for, identifying carers in primary care. Methods We integrated findings from three data sources – a review of the caregiving literature; a workshop with researchers who have undertaken research with those caring at the end of life, and focus groups with carers and health professionals. Results Three categories of barrier emerged. 1) Taking on the care of another person is often a gradual process, carers did not immediately identify with being a ‘carer’ – preferring to think of themselves in relational terms to the patient e.g. spouse, sibling, son or daughter. Often it was health and social care professionals who encouraged carers to consider themselves as an unpaid carer. 2) As the cared-for person’s condition deteriorated, the caring role often became all-encompassing so that carers were managing competing demands, and felt unable to look after their own needs as well as those of the cared-for person. 3) There was ambiguity about the legitimacy of carer needs and about the role of the primary health care team in supporting carers, from both the perspective of the carers and the health professionals. GPs were thought to be reactive rather than proactive which discouraged carers from asking for help. Conclusions The needs of carers have to be legitimised to ensure primary care staff are proactive in their approach and carers are empowered to utilise the support available. Strategies to identify carers have to be sensitive to the complex dynamics of a caring relationship as well as the primary care context. Identification is a key factor in improving support for carers themselves and to enable them to support the patient.
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Affiliation(s)
- Emma Carduff
- Primary Palliative Care Research Group, Centre for Population Health Sciences, The University of Edinburgh, Medical School, Teviot Place, Edinburgh, UK.
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