Waiting for a liver transplant

Perspectives and experiences of mothers of school-age children with asthma: a qualitative study

INTRODUCTION AND AIMS

This study aimed to explore the perspectives and experiences of mothers of school-age children with asthma in care.

METHODS

A phenomenological study was conducted using qualitative research methods from August 2021 to November 2021. Mothers (from Sichuan, China) of school-aged children with asthma who sought outpatient care at the pediatric asthma clinic were purposively sampled based on their occupation, education level, and duration of their child's illness. Semi-structured face-to-face interviews were conducted in consultation room A07 of the pediatric asthma clinic. The interviews were audio-recorded, transcribed verbatim, and analyzed thematically.

RESULTS

23 mothers expressed interest, but data saturation was reached after recruiting 15 mothers.Four main themes encompassing ten sub-themes emerged from the analysis: (1) Negative psychological burden, with sub-themes including anxiety shock, fear of death, guilt, and stigma. (2) Family dysfunction, with sub-themes including impaired quality of life, family emotional crisis, and heavy economic burden. (3) Difficulty in seeking medical treatment. (4) Active response, with sub-themes including emotional adjustment, family empowerment, and social support.

CONCLUSIONS

In this sample, the caregiving experience of mothers of school-age children with asthma is diverse and complex, reflected not only in personal psychological aspects but also in family functioning and social support. Taking into account various factors, such as addressing psychological well-being, emphasizing family and social support, and promoting the sharing of positive experiences, may result in more effective alleviation of caregiving stress for mothers of school-age children with asthma.

'The last bridge'- How patients experience the CAR T-cell therapy. A qualitative study

PURPOSE

CAR T-cell therapy gives patients new hope, who are diagnosed with relapsed or refractory B-cell lymphoma or B-cell leukaemia. To date, there is no scientific knowledge about the experiences of patients with CAR T-cell therapy, their process of treatment decision making or how they handle potential side effects. The study aims at deepening the understanding of the patient's experiences, indicating how to improve nursing care for this patient population.

METHOD

A qualitative study was carried out. Episodic guideline-based interviews were conducted with 14 patients who had received CAR T-cell therapy. The data analysis was performed according to the Grounded Theory. The study took place at a German university hospital.

RESULTS

Data analysis showed five sequential phases including the following concepts: 'living with cancer recurrence', 'deciding on CAR T-cell therapy', 'waiting for the reinfusion of the CAR T-cells', 'experiencing CAR T-cell therapy' and 'recovering and staying healthy'. The decision for CAR T-cell therapy was characterised by the lack of alternatives and uncertainty about the outcome and side effects.

CONCLUSIONS

Before, during and after CAR T-cell therapy, patients are faced with major challenges for which they need nursing support and guidance. These include preparation for CAR T-cell therapy, handling of side effects and preparation for discharge home.

Caregiver Burden in Adult Solid Organ Transplantation

The informal caregiver plays a critical role in supporting patients with various end-stage diseases throughout the solid organ transplantation journey. Caregiver responsibilities include assistance with activities of daily living, medication management, implementation of highly specialized treatments, transportation to appointments and treatments, and health care coordination and navigation. The demanding nature of these tasks has profound impacts across multiple domains of the caregiver's life: physical, psychological, financial, logistical, and social. Few interventions targeting caregiver burden have been empirically evaluated, with the majority focused on education or mindfulness-based stress reduction techniques. Further research is urgently needed to develop and evaluate interventions to improve caregiver burden and outcomes for the patient-caregiver dyad.

The experience of nurses to reduce implicit rationing of nursing care: a phenomenological study

BACKGROUND

Implicit rationing of nursing care can adversely affect patient safety and the quality of care, and increase nurses' burnout and turnover tendency. Implicit rationing care occurs at the nurse-to-patient level (micro-level), and nurses are direct participants. Therefore, the strategies based on experience of nurses to reduce implicit rationing care have more reference value and promotion significance. The aim of the study is to explore the experience of nurses to reduce implicit rationing care, thereby to provide references for conducting randomized controlled trials to reduce implicit rationing care.

METHODS

This is a descriptive phenomenological study. Purpose sampling was conducted nationwide. There are 17 nurses were selected and semi-structured in-depth interviews were conducted. The interviews were recorded, transcribed verbatim and analyzed via thematic analysis.

RESULTS

Our study found that nurses' reported experience of coping with implicit rationing of nursing care contained three aspects: personal, resource, and managerial. Three themes were extracted from the results of the study: (1) improving personal literacy; (2) supplying and optimizing resources and (3) standardizing management mode. The improvement of nurses' own qualities are the prerequisites, the supply and optimization of resources is an effective strategy, and clear scope of work has attracted the attention of nurses.

CONCLUSION

The experience of dealing with implicit nursing rationing includes many aspects. Nursing managers should be grounded in nurses' perspectives when developing strategies to reduce implicit rationing of nursing care. Promoting the improvement of nurses' skills, improving staffing level and optimizing scheduling mode are promising measures to reduce hidden nursing rationing.

The Lived Experience of Critically-Ill Muslim Patients in Isolation

Purpose

This study explored critically ill Muslim patients’ experiences and perceptions related to confinement to isolation rooms.

Methods

The descriptive–interpretive lens of phenomenology was employed to explore and illuminate the isolation experience of critically ill Muslim patients). Semi-structured, face-to-face, audiotaped interviews were conducted . Colaizzi’s method of data analysis, in combination with an interpretive analysis supported by van Manen’s “lifeworld constituents” were used.

Results

Data analysis revealed four themes: Feeling isolated and imprisoned; losing basic patients’ rights; feeling rejected by healthcare providers; and accepting isolation and its adversity. Findings were illuminated by applying van Manen’s lifeworld constituents: spatiality, temporality, relationality and corporeality. The patients described the overwhelming impact of isolation on their physical, emotional, social and spiritual health.

Conclusions

This study provides healthcare providers with an in-depth understanding of critically ill patients’ physical, psychological and spiritual needs. Although the unique needs of Muslim patients are highlighted, it is evident that patients’ suffering in isolation is universal. Healthcare providers are encouraged to consider creative measures to support and help patients cope with the adversity of isolation.

The chosen and the unchosen: How eligibility for liver transplant influences the lived experiences of patients with advanced liver disease

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.

From dreams to reality: a phenomenological study of the psychological contracts of ex-military personnel in the Australian Defence Force

Current recruitment and retention issues within the armed forces draw links with breach of the psychological contract – the dynamics of the employee–employer relationship. Compared with civilian contexts, a military position is unique, however, there is a dearth of conceptual investigation regarding the lived experiences of military personnel, particularly with respect to how such contracts form. This paper combined a phenomenological approach with the critical decision method to investigate the lived experiences informing contract formation and contract trajectory of ex-military personnel. Lived experiences pointed to the formulation of ‘fuzzy’ contracts, impressions from defence force recruitment, specific tipping points around organisational commitment, and large differences between the fidelity of the idealised and actualised self/job. Seven superordinate themes are elicited that trace the formation and trajectory of the contract. A schematised account of findings is developed to provide avenues to investigate how beliefs form in a military contract context and their outcomes.

Exploring patients' perceptions and experiences of treatments for the prevention of variceal bleeding: a qualitative study

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.

A choir or cacophony? Sample sizes and quality of conveying participants’ voices in phenomenological research

Misunderstandings about qualitative methods, whether phenomenological or otherwise, are prevalent in social science research. Such misunderstandings leave researchers, reviewers, and editors less equipped to conduct or evaluate this method. Evaluation of phenomenology is especially complicated given the different variants that exist and the need for flexibility within these studies. Methodologists have created guides for conducting specific variants of phenomenology; however, these do not provide clear guidance as to what is an adequate sample in phenomenology. The purpose of this systematic review was to help improve implementation of phenomenological methods by exploring sample issues as they relate to study quality. We implemented an explanatory sequential mixed methods design to test relationships between samples and studies’ quality then deepen our understanding of these findings with a focused content analysis. First, we reviewed and coded 200 manuscripts following the PRISMA method. Larger samples were associated with lower quality and studies aligned with a specific phenomenological method tended to be of higher quality. Second, we identified two cases from the studies reviewed and subjected them to deductive qualitative content analysis to identify features that demonstrate quality. Findings are discussed with respect to implications for phenomenological methods in social and health sciences.

Impact of liver disease on patients' quality of life: a mixed methods systematic review protocol

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.

Designing a Liver Transplant Patient and Family Decision Support Tool for Organ Offer Decisions

BACKGROUND

For liver transplant candidates on the waiting list, deciding to accept a donor organ with known or potential risk factors can be stressful and can lead to declined offers. Current education for patients and family often takes place during transplant evaluations and can be overwhelming and result in low retention and poor understanding of donor quality.

METHODS

In the first phase, we sought to understand provider experiences when counseling patients about donor risks and donor offers. We conducted interviews and focus groups with liver transplant providers at 1 local center and at a national clinician conference. Twenty providers participated: 15 hepatologists and 5 surgeons. The provider feedback was used to create an initial outline of content that is consistent with decision support frameworks. In a second phase, graphic design collaborators created mockups of a patient-friendly tool. We reviewed mockups with 4 transplant coordinators and 9 liver transplant candidates for feedback on clarity and utility to prepare for an organ offer. Patient responses allowed a comparison of perceived readiness to receive an offer call before and after viewing mockups.

RESULTS

We identified themes relating to the offer process, repetition and timing of education, and standardization and tailoring of content. The results indicated a gap in available education after the evaluation session, and information specific to offer decisions is needed. Patient feedback emphasized the need to review the offer process before a real offer.

CONCLUSIONS

Patients and providers responded favorably to a patient tool addressing existing gaps in education while waiting for a donor offer. Additional patient, family, and provider feedback will guide the development of an interactive tool to prepare patients and families for an offer decision.

Developing the Resilience Framework for Nursing and Healthcare

Despite four decades of resilience research, resilience remains a poor fit for practice as a scientific construct. Using the literature, we explored the concepts attributed to the development of resilience, identifying those that mitigate symptoms of distress caused by adversity and facilitate coping in seven classes of illness: transplants, cancer, mental illness, episodic illness, chronic and painful illness, unexpected events, and illness within a dyadic relationship. We identified protective, compensatory, and challenge-related coping-concept strategies that healthcare workers and patients use during the adversity experience. Healthcare-worker assessment and selection of appropriate coping concepts enable the individual to control their distress, resulting in attainment of equanimity and the state of resilience, permitting the resilient individual to work toward recovery, recalibration, and readjustment. We inductively developed and linked these conceptual components into a dynamic framework, The Resilience Framework for Nursing and Healthcare, making it widely applicable for healthcare across a variety of patients.

Moving from "I" to "We": A Grounded Theory Analysis of Couple Therapy with Liver Patients and Their Partners

Prior research indicates that couples who cope with chronic illness from a relational "we" orientation experience more positive outcomes than couples that cope individually; however, little prior research identifies clinical processes that promote reciprocity or how societal gender processes are involved. This grounded theory analysis of 25 videotaped therapy sessions with six heterosexual couples coping with chronic liver disease (LD) used a feminist-informed relational lens to focus on the clinical processes involved in shifting from an individual to a relational orientation. Findings identified three contextual barriers to attaining a "we orientation": (a) autonomy discourse, (b) illness-related power, and (c) gendered power. Analysis detailed therapist actions that decreased the impact of barriers to reciprocity and fostered relational coping. Clinical implications attend to complex intersections among gender, caregiving, and contextual barriers to reciprocity.

Palliative Care in End-Stage Liver Disease Patients Awaiting Liver Transplantation: Review

Introduction

End-stage liver disease (ESLD) is the advanced phase of most liver diseases. The cure is liver transplantation (LT), only available for a minority of patients. This review summarizes the evidence regarding palliative care (PC) in ESLD patients awaiting LT.

Methods

Review of the literature available in Medline, Scopus and Web of Knowledge, with keywords ESLD and PC.

Results

Fifteen of the 230 articles reviewed met the inclusion criteria. Ten main themes were addressed: symptom burden; perspectives of life-sustaining treatment and comfort for patients, families and health professionals; goals of care discussions; patient and family needs; quality of life; PC and survival; referral to PC, barriers and opportunities; integration of PC; outpatient care and cost-effectiveness analysis. The referral of patients to PC was only evaluated in a few studies, all of which reported low referral rates. Better knowledge of how PC professionals can support other professionals was considered important, and also better ways to integrate PC were considered essential.

Conclusion

ESLD patients awaiting LT have a significant need for PC and, despite the insufficient response, were reported to benefit from this type of care. Future research is essential to determine the means to overcome barriers and better integrate PC for ESLD patients awaiting LT.

Waiting for care: Chronic illness and health system uncertainties in the United States

Structures of power and inequality shape day-to-day life for individuals who are poor, imposing waiting in multiple forms and for a variety of services, including for healthcare (Andaya, 2018a; Auyero, 2012; Strathmann and Hay, 2009). Constraints, such as the age requirements for Medicare, losing employer-provided health insurance, or the bureaucracy involved in filing for disability often require people to wait to follow recommendations for medical treatments. In 2016–2017, we conducted 52 narrative interviews in St. Louis, a city with significant racial and economic health inequities and without Medicaid expansion. We interviewed people with one or more chronic illnesses for which they were prescribed medication and who identified as having difficulties affording their prescriptions. Throughout the interviews, participants frequently recounted 1) experiences of waiting for care, along with other services, and 2) the range of strategies they utilized to manage the waiting. In this article, we develop the concept of active waiting to describe both the lived experiences of waiting for care and the responses that people devise to navigate, shorten, or otherwise endure waiting. Waiting is structured into healthcare and other social services at various scales in ways that reinforce feelings of marginalization, and also that require work on the part of those who wait. While much medical and public health research focuses on issues of diagnostic or treatment delay, we conclude that this conceptualization of active waiting provides a far more productive frame for accurately understanding the emotional and physical experiences of individuals who are disproportionately poor and made to wait for their care. Only with such understanding can we hope to build more just and compassionate social systems.

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Poor and chronically ill people wait to receive medical care and social services.

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People wait actively, making decisions to manage the repercussions of waiting.

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The idea of delaying care is inadequate to explain realities of illness and poverty.

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Waiting broadens and deepens structural vulnerability for marginalized people.

An exploratory study of the experiences of deceased-donor liver transplant recipients and their need for psychotherapeutic support

AIMS AND OBJECTIVES

This study aimed to explore the experiences of liver transplant recipients during their journey through the treatment and their need for psychotherapeutic support related to this process.

BACKGROUND

Over time, measures of survival and quality of life in liver transplant recipients have continued to improve but their emotional needs remain under explored. In the longer-term recovery from transplantation, the focus shifts from physical health to psychological health. In the UK, there are no known embedded adult psychological services in liver transplant centres to react to this need.

DESIGN

A qualitative descriptive design was used.

METHODS

Grounded theory analysis was used to study the narratives of six adult liver transplant recipients. Through a process of coding, conceptual categories were established to describe the participant experiences. The study adhered to the EQUATOR checklist, SRQR.

RESULTS

Four categories emerged that were related to the experience of liver transplantation for the recipients. These were a process of adjustment, the phenomenon of waiting, liver transplant as a transformative experience and on the value of support. The participants identified a lack of psychotherapeutic support provided by the liver transplant service and felt that an embedded psychotherapeutic service would promote accessing such support during challenging times.

CONCLUSION

Through the process of liver transplantation, recipients experience challenges with adjustment, waiting, feeling transformed and they value support with these feelings. In correlation with other studies, the findings of this study highlight the need for providing psychotherapeutic support within liver transplant services.

RELEVANCE TO CLINICAL PRACTICE

The study provides evidence to support recommendations for a conjoined psychotherapy service within liver transplant services to support patients with their holistic needs.

Exploring Family Decisions to Refuse Organ Donation at Imminent Death

Communication about organ donation at the time of imminent death is a meaningful, yet less understood, area of health communication. We employed a multiple goals framework to explore family normative perceptions of organ donation and the conversational goal tensions experienced during a family member's imminent death. Semi-structured interviews were conducted with 14 family members who refused to donate when approached by an organ procurement coordinator (OPC) upon the imminent death of a family member. Thematic analysis revealed that family members described their decisions to refuse donation as (a) last acts of love, (b) responses to unnecessary requests, and (c) consistent with the known beliefs of the patient. Participants described several goal tensions operating within the organ donation conversation itself, including (a) the management of frequent requests, (b) pressure to donate, and (c) enduring unwanted requests from the OPC. Communication goals frameworks offer practical insights for improving organ-related conversations.

Predicting chance of liver transplantation for pediatric wait-list candidates

Information about wait-list time has been reported as one of the single most frequently asked questions by individuals awaiting a transplant but data regarding wait-list time have not been processed in a useful way for pediatric candidates. To predict chance of receiving a DDLT, we identified 6471 pediatric (<18 years), non status-1A, liver-only transplant candidates between 2006 and 2017 from the SRTR. Cox regression with shared frailty for DSA level effect was used to model the association of blood type, weight, allocation PELD and MELD, and DSA with chance of DDLT. Jackknife technique was used for validation. Median (interquartile range) wait-list time was 100 (34-309) days. Non-O Blood type, higher PELD/MELD score at listing, and DSA were associated with increased chance of DDLT, while age 1-5 years and 10-18 years was associated with lower chance of DDLT (P < 0.001 for all variables). Our model accurately predicted chance of transplant (C-statistic = 0.68) and was able to predict DDLT at specific follow-up times (eg, 3 months). This model can serve as the basis for an online tool that would provide useful information for pediatric wait-list candidates.

Relationship between device acceptance and patient-reported outcomes in Left Ventricular Assist Device (LVAD) recipients

The number of Left Ventricular Assist Devices (LVADs) implanted each year is rising. Nevertheless, there are minimal data on device acceptance after LVAD implant, and on its relationship with patient-reported outcomes. We designed a cross-sectional study to address this knowledge gap and test the hypothesis that low device acceptance is associated with poorer quality of life, depression and anxiety. Self-report questionnaires were administered to assess quality of life (12-item Kansas City Cardiomyopathy Questionnaire quality of life subscale), level of anxiety (7-item Generalized Anxiety Disorder; GAD-7), level of depression (9-item Patient Health Questionnaire; PHQ-9) and device acceptance (Florida Patient Acceptance Survey; FPAS) to 101 consecutive patients presenting to LVAD clinic. Regression analysis showed a strong correlation between device acceptance and both psychological distress (p < 0.001) and quality of life (p < 0.001). Analysis of the sub-scales of the FPAS showed that patients had significant body image concerns, but return to function and device-related distress were the main drivers of the observed correlation between device acceptance and patient well-being. Younger age was associated with lower device acceptance (r = 0.36, p < 0.001) and lower quality of life (r = 0.54, p < 0.001). These findings suggest that interventions targeting device acceptance should be explored to improve outcomes in LVAD recipients.

Physicians' Perspectives on Palliative Care for Patients With End-Stage Liver Disease: A National Survey Study

Specialty palliative care (PC) is underused for patients with end-stage liver disease (ESLD). We sought to examine attitudes of hepatologists and gastroenterologists about PC for patients with ESLD. We conducted a cross-sectional survey of these specialists who provide care to patients with ESLD. Participants were recruited from the American Association for the Study of Liver Diseases membership directory. Using a questionnaire adapted from prior studies, we examined physicians' attitudes about PC and whether these attitudes varied based on patients' candidacy for liver transplantation. We identified predictors of physicians' attitudes about PC using linear regression. Approximately one-third of eligible physicians (396/1236, 32%) completed the survey. Most (95%) believed that centers providing care to patients with ESLD should have PC services, and 86% trusted PC clinicians to care for their patients. Only a minority reported collaborating frequently with inpatient (32%) or outpatient (11%) PC services. Most believed that when patients hear the term PC, they feel scared (94%) and anxious (87%). Most (83%) believed that patients would think nothing more could be done for their underlying disease if a PC referral was suggested. Physicians who believed that ESLD is a terminal condition (B = 1.09; P = 0.006) reported more positive attitudes about PC. Conversely, physicians with negative perceptions of PC for transplant candidates (B = -0.22; standard error = 0.05; P < 0.001) reported more negative attitudes toward PC. In conclusion, although most hepatologists and gastroenterologists believe that patients with ESLD should have access to PC, they reported rarely collaborating with PC teams and had substantial concerns about patients' perceptions of PC. Interventions are needed to overcome misperceptions of PC and to promote collaboration with PC clinicians for patients with ESLD.

The incompatibility of healthcare services and end-of-life needs in advanced liver disease: A qualitative interview study of patients and bereaved carers

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.

An observational study of Donor Ex Vivo Lung Perfusion in UK lung transplantation: DEVELOP-UK

BACKGROUND

Many patients awaiting lung transplantation die before a donor organ becomes available. Ex vivo lung perfusion (EVLP) allows initially unusable donor lungs to be assessed and reconditioned for clinical use.

OBJECTIVE

The objective of the Donor Ex Vivo Lung Perfusion in UK lung transplantation study was to evaluate the clinical effectiveness and cost-effectiveness of EVLP in increasing UK lung transplant activity.

DESIGN

A multicentre, unblinded, non-randomised, non-inferiority observational study to compare transplant outcomes between EVLP-assessed and standard donor lungs.

SETTING

Multicentre study involving all five UK officially designated NHS adult lung transplant centres.

PARTICIPANTS

Patients aged ≥ 18 years with advanced lung disease accepted onto the lung transplant waiting list.

INTERVENTION

The study intervention was EVLP assessment of donor lungs before determining suitability for transplantation.

MAIN OUTCOME MEASURES

The primary outcome measure was survival during the first 12 months following lung transplantation. Secondary outcome measures were patient-centred outcomes that are influenced by the effectiveness of lung transplantation and that contribute to the health-care costs.

RESULTS

Lungs from 53 donors unsuitable for standard transplant were assessed with EVLP, of which 18 (34%) were subsequently transplanted. A total of 184 participants received standard donor lungs. Owing to the early closure of the study, a non-inferiority analysis was not conducted. The Kaplan-Meier estimate of survival at 12 months was 0.67 [95% confidence interval (CI) 0.40 to 0.83] for the EVLP arm and 0.80 (95% CI 0.74 to 0.85) for the standard arm. The hazard ratio for overall 12-month survival in the EVLP arm relative to the standard arm was 1.96 (95% CI 0.83 to 4.67). Patients in the EVLP arm required ventilation for a longer period and stayed longer in an intensive therapy unit (ITU) than patients in the standard arm, but duration of overall hospital stay was similar in both groups. There was a higher rate of very early grade 3 primary graft dysfunction (PGD) in the EVLP arm, but rates of PGD did not differ between groups after 72 hours. The requirement for extracorporeal membrane oxygenation (ECMO) support was higher in the EVLP arm (7/18, 38.8%) than in the standard arm (6/184, 3.2%). There were no major differences in rates of chest radiograph abnormalities, infection, lung function or rejection by 12 months. The cost of EVLP transplants is approximately £35,000 higher than the cost of standard transplants, as a result of the cost of the EVLP procedure, and the increased ECMO use and ITU stay. Predictors of cost were quality of life on joining the waiting list, type of transplant and number of lungs transplanted. An exploratory model comparing a NHS lung transplant service that includes EVLP and standard lung transplants with one including only standard lung transplants resulted in an incremental cost-effectiveness ratio of £73,000. Interviews showed that patients had a good understanding of the need for, and the processes of, EVLP. If EVLP can increase the number of usable donor lungs and reduce waiting, it is likely to be acceptable to those waiting for lung transplantation. Study limitations include small numbers in the EVLP arm, limiting analysis to descriptive statistics and the EVLP protocol change during the study.

CONCLUSIONS

Overall, one-third of donor lungs subjected to EVLP were deemed suitable for transplant. Estimated survival over 12 months was lower than in the standard group, but the data were also consistent with no difference in survival between groups. Patients receiving these additional transplants experience a higher rate of early graft injury and need for unplanned ECMO support, at increased cost. The small number of participants in the EVLP arm because of early study termination limits the robustness of these conclusions. The reason for the increased PGD rates, high ECMO requirement and possible differences in lung injury between EVLP protocols needs evaluation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN44922411.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 85. See the NIHR Journals Library website for further project information.

What patients and members of their support networks ask about transplant program data

Transplant patients often seek specific data and statistics to inform medical decision making; however, for many relevant measures, patient-friendly information is not available. Development of patient-centered resources should be informed by patient needs. This study used qualitative document research methods to review 678 detailed Scientific Registry of Transplant Recipients (SRTR) entries and summary counts of 55 362 United Network for Organ Sharing (UNOS) entries to provide a better understanding of what was asked and what requests were most common. Incoming call and email logs maintained by SRTR and UNOS were reviewed for 2010-2015. Patients sought a wide range of information about outcomes, waiting times, program volumes, and willingness to perform transplants in candidates with specific diseases or demographics. Patients and members of their support networks requested explanation of complex information, such as actual-vs-expected outcomes, and of general transplant processes, such as registering on the waiting list or becoming a living donor. They sought transplant program data from SRTR and UNOS, but encountered gaps in the information they wanted and occasionally struggled to interpret some data. These findings were used to identify potential gaps in providing program-specific data and to enhance the SRTR website (www.srtr.org) with more patient-friendly information.

Beliefs of Living Donors About Recipients' End-Stage Liver Failure and Surgery for Organ Donation

BACKGROUND

The concept of beliefs could provide a basis for how donors may perceive recipients' end-stage liver failure (ESLF) and surgery for organ donation. However, there is no such quantitative study. Therefore, the objective of this study was to explore beliefs of living donors about recipients' ESLF and surgery for organ donation.

METHODS

The sample comprised 16 living donors who donated a part of their liver to a patient who had ESLF. The data were analyzed by following established procedures for inductive qualitative analysis.

RESULTS

Analysis showed that donors' beliefs can be viewed in a number of groups. Beliefs about recipients' ESLF included diverse explanations for ESLF (blaming oneself and physicians) and physical symptoms (developmental slowing down). Beliefs about being a donor included reasons for being a donor (performing a good deed, being healed), barriers to being a donor (other people being ignorant and selfish), ways to manage these barriers (following one's gut feeling), and factors facilitating being a donor (the feeling that one does not have many people to leave behind). Beliefs about surgery for organ donation included physical effects (pain, feeling stiff). Beliefs about organ donation included views that general organ donation should be encouraged and that people's awareness should be raised.

CONCLUSIONS

Existing psychological perspectives could help to interpret some beliefs. Nevertheless, other beliefs, not previously reported, could be considered as targets for individual consultations/psycho-educational programs for fostering emotional well-being.

Randomized trial of an uncertainty self-management telephone intervention for patients awaiting liver transplant

OBJECTIVE

We tested an uncertainty self-management telephone intervention (SMI) with patients awaiting liver transplant and their caregivers.

METHODS

Participants were recruited from four transplant centers and completed questionnaires at baseline, 10, and 12 weeks from baseline (generally two and four weeks after intervention delivery, respectively). Dyads were randomized to either SMI (n=56) or liver disease education (LDE; n=59), both of which involved six weekly telephone sessions. SMI participants were taught coping skills and uncertainty management strategies while LDE participants learned about liver function and how to stay healthy. Outcomes included illness uncertainty, uncertainty management, depression, anxiety, self-efficacy, and quality of life. General linear models were used to test for group differences.

RESULTS

No differences were found between the SMI and LDE groups for study outcomes.

CONCLUSION

This trial offers insight regarding design for future interventions that may allow greater flexibility in length of delivery beyond our study's 12-week timeframe.

PRACTICE IMPLICATIONS

Our study was designed for the time constraints of today's clinical practice setting. This trial is a beginning point to address the unmet needs of these patients and their caregivers as they wait for transplants that could save their lives.

Liver Transplantation: Recipients' Evaluation of Life From the Perspective of Living Donors

AIM

Liver transplantation affects not only recipients and living donors' lives, but also the nature and quality of their relationship. Moreover, the ways in which recipients of liver transplant experience life and views of living donors on how recipients experience life may differ. These differences may account for relational changes. It is also important to understand how recipients and their living donors' views differ if the aim is to devise psychoeducational programs for recipients and living donors. Therefore, the present study examined the recipients' experience of life after a diagnosis of end-stage liver failure (ESLF) and transplantation surgery from donors' perspective.

METHODS

The sample consisted of 16 living donors who donated a part of their liver to a patient with ESLF. Thematic analysis was undertaken in parallel with interviews during which an interview guide was followed.

FINDINGS

Donors felt that recipients evaluated life after the diagnosis of ESLF and transplantation surgery in terms of limitations, mixed relationships, emotional changes, and improvement in life.

CONCLUSION

Experience of social limitations, negative emotions, and the feeling that one is supported by others could be interpreted in terms of existing psychological theory. Some ways of adjusting that have not been reported before within the context of ESLF extended the literature. These included others being frightened of being infected by ESLF and being insensitive, experience of positive emotions, and ways of improving. Overall, compared with findings of previous qualitative work among recipients, our findings suggest that donors' evaluation of recipients' lives converge with that of recipients.

Waiting for a kidney transplant: the experience of patients with end-stage renal disease in South Korea

AIMS AND OBJECTIVES

To explore the experiences of Korean patients with end-stage renal disease awaiting kidney transplantation.

BACKGROUND

The need for kidney transplantation has increased worldwide, while the number of kidney donors has not increased commensurately. This mismatch is a serious issue in South Korea. Prolonged waits for transplantation may cause physical and psychosocial issues and lead to poor outcomes. Nevertheless, the experience of waiting for kidney transplantation in South Korea has never been explored in depth.

DESIGN

A qualitative descriptive design was used.

METHODS

The participants were eight patients diagnosed with end-stage renal disease on the waiting list for kidney transplantation in South Korea. Data were collected through individual in-depth interviews. All conversations during interviews were recorded and transcribed verbatim. Transcribed data were analysed using conventional content analysis.

RESULTS

The experience of waiting for kidney transplantation consisted of six categories: (1) the light at the end of the tunnel, (2) being on call without any promise, (3) a tough tug of war between excitement and frustration, (4) doubts in the complexity, (5) A companion on the hard journey and (6) getting ready for D-day.

CONCLUSIONS

Kidney transplantation candidates experience psychosocial difficulties and concerns while waiting for long periods of time without any assurance of resolution. Systematic education and psychosocial support from health care professionals and family members help patients get through what they describe as a difficult journey. Comprehensive management programs for kidney transplantation candidates are needed.

RELEVANCE TO CLINICAL PRACTICE

Health care professionals need to recognise the psychosocial concerns of patients awaiting kidney transplantation. Clinicians should provide patients with information and support throughout the waiting period.

Waiting for a kidney from a deceased donor: an interpretative phenomenological analysis

Demand for kidneys from deceased donors far outstrips supply. Despite this, there appears to be little research that focuses solely on the experience of waiting for a kidney from a deceased donor. This study uses the qualitative methodology interpretative phenomenological analysis to explore the lives of 10 people on the transplant list, with the aims of illuminating the potential psychological challenges those on the list may face during this time, and providing information to help clinicians more fully support such people in the future. Two themes connected to the experience of waiting - adjustment to the uncertainty of waiting and thinking about receiving a kidney from a living donor - are presented here. Participants describe a sense of confusion and uncertainty around life on the list, and discuss their strategies for dealing with this. Novel complexities around the ambiguous challenge of receiving an organ from a deceased donor are revealed. It is recommended that health care teams provide a forum for this patient group to work through these feelings of confusion and ambiguity.

Complex and dynamic times of being chronically ill: Beyond disease trajectories of patients with ulcerative colitis

This article contributes to health research literature by problematizing the linear, sequential and intelligible understanding of time in the studies of illness. Drawing on the work of Martin Heidegger, it attempts to overcome the problem of considering the time of illness as either a framework controlling patients' experiences or a mind-dependent feature of their lives. The paper offers a conceptual analysis of the stories of ulcerative colitis patients from a recent clinical trial to present temporalities of illness as both objective and subjective, relational and dynamic. We attend to a combination of temporalities related to the ambiguous unfolding of illness and patients' relationships with such an unpredictable world of changing bodies, medical practices and temporal norms. Furthermore, our analysis reveals openness of times and considers ulcerative colitis patients as constantly evolving beings, with multiple possibilities brought about by illness. The paper highlights co-existence of times and considers patients' lives as incorporating a multiplicity of futures, presents and pasts. It concludes with conceptual observations about the consequences of developing complex approaches to illness in health research, which can better highlight the situatedness of patients and their multi-dimensional temporal foundations.

Medical Family Therapists in Action: Embracing Multiple Roles

Medical family therapy (MedFT) is a growing area of interest within the field of marriage and family therapy. Its practice necessitates a shift from conventional family therapy practices to include diverse ways of providing care. Literature highlights approaches for patients with specific illnesses and for particular healthcare contexts. Less is understood about frameworks for treating patients with different illnesses across settings. Contributing to the growing discourse surrounding MedFT, we present a role-based practice framework that identifies six consistent roles, Therapist, Brief Interventionist, Health Coach, Patient Advocate, Consultant to Health Professionals, and Trainer specific tasks associated with each. We describe the skills needed to perform each role and describe how we move fluidly between roles to provide comprehensive care.

Integration of palliative care in end-stage liver disease and liver transplantation

BACKGROUND

Patients with end-stage liver disease (ESLD) have a life-limiting illness that causes multiple distressing symptoms and negatively affects quality of life (QOL). This population traditionally has not had much attention within the palliative care community.

DISCUSSION

This article provides an evidence-based review of palliative care issues that patients with ESLD and those awaiting liver transplant face, including approaches to prognosis, symptom management, advance care planning, and end-of-life care.

CONCLUSION

Tremendous opportunity exists to integrate palliative medicine into the care of these patients.

"Don't Think Paralysis Takes Away Your Womanhood": Sexual Intimacy After Spinal Cord Injury

Sexuality and intimacy are important components of health and well-being. Issues surrounding sexuality and intimacy are equally important for men and women living with physical disabilities, including spinal cord injury (SCI). Yet, women's sexuality after SCI remains largely unexamined. This article presents the findings from an in-depth qualitative investigation of the sexual and reproductive health experiences of 20 women with SCI in or around Detroit, MI. Findings echo existing literature documenting the sexual consequences of life after SCI and suggest new areas of inquiry important for better addressing sexual concerns across the lifespan. Specifically, findings suggest a need to consider the variable effects of SCI on sexual intimacy in relation to a person's developmental trajectory, the appropriate timing of sexual education, the need to expand conceptualizations of sexual intimacy, and the ways SCI may affect sexuality in later life.

Heart transplants: Identity disruption, bodily integrity and interconnectedness

Of heart transplant recipients, 30 per cent report ongoing or episodic emotional issues post-transplant, which are not attributable to medications or pathophysiological changes. To this end, our team theorized that cardiac transplantation introduces pressing new questions about how patients incorporate a transplanted heart into their sense of self and how this impacts their identity. The work of Merleau-Ponty provided the theoretical underpinning for this project as it rationalizes how corporeal changes affect one’s self and offer an innovative framework to access these complex aspects of living with a transplanted heart. We used visual methodology and recorded 25 semi-structured interviews videographically. Both visual and verbal data were analyzed at the same time in an iterative process. The most common theme was that participants expressed a disruption to their own identity and bodily integrity. Additionally, participants reported interconnectedness with the donor, even when the transplanted heart was perceived as an intruder or stranger. Finally, transplant recipients were very vivid in their descriptions and speculation of how they imagined the donor. Receiving an anonymous donor organ from a stranger often leaves the recipient with questions about who they themselves are now. Our study provides a nuanced understanding of heart transplant recipients’ embodied experiences of self and identity. Insights gained are valuable to educate transplant professionals to develop new supportive interventions both pre- and post-transplant, and to improve the process of informed consent. Ultimately, such insights could be used to enable heart transplant recipients to incorporate the graft optimally over time, easing distress and improving recovery.

For the sake of others: reciprocal webs of obligation and the pursuit of transplantation as a caring act

This article highlights reciprocal webs of care and moral obligations toward kin during transplantation, using an expansive notion of "care" to include both its obvious and more hidden forms. Evidence from 24 months of ethnographic fieldwork among transplant patients, their loved ones, and clinical personnel in the U.S. Midwest suggests that patients are simultaneously caregivers to others and are considered vital members of reciprocal webs of care without whom their kin networks could not effectively operate. Transplantation can become a person's main, perhaps only hope of fulfilling ongoing obligations to others, so pursuing a transplant becomes not a matter of choice, but rather a moral orientation. A potential implication of these findings is that rather quotidian and conventional (even if contested) notions of what kin ought to do and be for each other may be among the underpinnings of high-tech biomedical practices like transplantation.

Anesthetic complications including two cases of postoperative respiratory depression in living liver donor surgery

Background:

Living liver donation is becoming a more common means to treat patients with liver failure because of a shortage of cadaveric organs and tissues. There is a potential for morbidity and mortality, however, in patients who donate a portion of their liver. The purpose of this study is to identify anesthetic complications and morbidity resulting from living liver donor surgery.

Patients and Methods:

The anesthetic records of all patients who donated a segment of their liver between January 1997 and January 2006 at University of Minnesota Medical Center-Fairview were retrospectively reviewed. The surgical and anesthesia time, blood loss, hospitalization length, complications, morbidity, and mortality were recorded. Data were reported as absolute values, mean ± SD, or percentage. Significance (P < 0.05) was determined using Student's paired t tests.

Results:

Seventy-four patients (34 male, 40 female, mean age = 35.5 ± 9.8 years) donated a portion of their liver and were reviewed in the study. Fifty-seven patients (77%) donated the right hepatic lobe, while 17 (23%) donated a left hepatic segment. The average surgical time for all patients was 7.8 ± 1.5 hours, the anesthesia time was 9.0 ± 1.3 hours, and the blood loss was 423 ± 253 ml. Forty-six patients (62.2%) received autologous blood either from a cell saver or at the end of surgery following acute, normovolemic hemodilution, but none required an allogenic transfusion. Two patients were admitted to the intensive care unit due to respiratory depression. Both patients donated their right hepatic lobe. One required reintubation in the recovery room and remained intubated overnight. The other was extubated but required observation in the intensive care unit for a low respiratory rate. Twelve patients (16.2%) had complaints of nausea, and two reported nausea with vomiting during their hospital stay. There were four patients who developed complications related to positioning during the surgery: Two patients complained of numbness and tingling in the hands which resolved within two days, one patient reported a blister on the hand, and one patient complained of right elbow pain that resolved quickly. Postoperative hospitalization averaged 7.4 ± 1.5 days. There was no patient mortality.

Discussion:

Living liver donation can be performed with low morbidity. However, postoperative respiratory depression is a concern and is perhaps due to altered metabolism of administered narcotics and anesthetic agents.

Occupational therapy services to enable liver patients to thrive following transplantation

ABSTRACT Transplantation is the only viable treatment for end-stage liver failure. With advances in biomedicine and surgical technique, survival rates have improved and current research is beginning to focus on patient-related outcomes such as of quality of life (QOL) and life satisfaction. However, attention to the rehabilitation needs of those patients whose lives are saved, is lagging. Pretransplantation, there are serious strains to role function and limitations to mental and physical capacity. Following transplantation, the ability to perform once easy familiar tasks is difficult for a prolonged recovery period. Within a year many people do well, others do not. Little has been done for this latter group. The purpose of this article is to systematically describe the contributions occupational therapy can make to the people struggling with the challenges faced during the transplantation process. The first part presents a framework for understanding the impact of end-stage liver disease, then the transplant, and the subsequent recovery through the combination of two frameworks: the International Classification of Functioning Disability and Health (ICF) and the Model of Human Occupation. The second part of this article will present the implications for occupational therapists throughout seven stages: (1) decline in health, (2) organ failure, (3) referral for transplantation, (4) the waiting period, (5) the transplant surgery, (6) recovery, and (7) return of health. Attention to the needs of transplant recipients who lack the adaptive skills to resume productive lifestyles has the capacity to improve participation outcomes for this population.

The impact of biopsychosocial factors on quality of life: women with primary biliary cirrhosis on waiting list and post liver transplantation

OBJECTIVES

Primary biliary cirrhosis (PBC) is the second most common reason for liver transplants among women in the USA. While survival rates are high, there is evidence of persistent problems post-transplant. This study aimed to identify significant contributors to quality of life (QOL) for women with PBC on waiting list (WL) and post-transplant (PT) and compare QOL in each group with US population norms.

DESIGN

A cross-sectional, two-group study design was used.

METHODS

WL and PT participants were recruited through medical centres and on-line. QOL was measured by the Short Form-36 and an indicator of Social QOL created for this study. A biopsychosocial model incorporating demographic, biomedical, psychological, and sociological factors guided choice of variables affecting QOL. Analyses examined (1) all factors for differences between WL and PT groups, (2) association between factors and QOL outcomes within each group, (3) multivariate regression of QOL on factors in the model for the sample as a whole, and (4) comparison of QOL outcomes with national norms.

RESULTS

One hundred women with PBC participated in the study, 25 on WL and 75 PT. Group comparisons showed improvement for PT participants in most biomedical and psychological variables and in QOL outcomes. QOL was related to many, but not all, of the variables in the model. In multivariate analysis, Fatigue, Depression, Coping, and Education - but not Transplant Status - were identified as indicators of QOL. Physical QOL improved significantly after 5 years PT, when it was no longer worse than national norms. Mental QOL remained worse than national norms despite distance in time from transplant.

CONCLUSIONS

The model proved useful in identifying a range of factors that contributed to QOL for women with PBC before and after transplant. Recommendations were made for clinical practice to improve QOL through a combination of treatment and self-management.

The Changing Horizons of U.S. Families Living With Pediatric HIV

Although HIV is considered a chronic pediatric illness that is on the wane in the United States, challenges remain for those affected. The purpose of this longitudinal qualitative study was to examine the phenomenon of raising an HIV-positive child in the United States from the parental perspective. This study incorporated a longitudinal, phenomenological approach. The purposive sample included parents and guardians from 10 families from the northeast region of the United States with children diagnosed with asymptomatic HIV infection at the study onset. The researcher conducted in-depth interviews with the parents over a 7-year period. The common themes identified included: balancing normalcy with uncertainty, facing the multifaceted dilemmas associated with disclosure, and addressing the evolving medication and treatment challenges. The findings of this study can enhance the understanding of nurses and other health care professionals to improve policies, standards of care, and interventions for children and families living with pediatric HIV infection.

Patients on the waiting list for liver transplantation: caregiver burden and stress

Over the last few decades, informal caregivers of patients with chronic diseases have received more attention, and there is a growing volume of studies demonstrating high rates of burden, stress, and mental disorders in this group of individuals. The objective of this study was to evaluate the burden, stress, and psychosocial characteristics of informal caregivers of liver transplantation candidates. Participants were assessed by individual evaluations with the following instruments: a semistructured interview, the Caregiver Burden Scale, the Inventário de Sintomas de Stress para Adultos de Lipp, and the Beck Depression Inventory. The Mann-Whitney test was used for statistical analysis with a significance level of 0.05. The characteristics of the study group (n = 61) were similar to those of groups in other studies with respect to gender (82% were women), kinship (64% were spouses), and age (the mean age was 47.6 years). The main stressors identified by the participants were as follows: doubts about ways to react in a crisis or in emergency situations (42.6%), mood swings of the patient (29.5%), and care involving food and medications (27.9%). Approximately 25% of the caregivers reported that they felt unprepared to adequately perform their roles. Data analysis indicated a greater burden overall on caregivers when the patient's Model for End-Stage Liver Disease score was greater than or equal to 15 points (P = 0.041). Furthermore, caregivers of patients with alcoholic liver disease showed higher depression (P = 0.034) and overall burden scores (P = 0.031) versus caregivers of patients with liver disease due to other etiologies. In conclusion, the participants showed significantly high levels of burden, stress, and depression. Support measures and caregiver preparation should be implemented by health care providers.

Quality of life in spanish patients with liver transplant

BACKGROUND

Liver transplantation is the optimal method of treatment in patients with end-stage liver failure. Transplantation medicine has significantly progressed in the last time, but some psychology and psychosomatic problems still remain unsolved. Health-Related Quality of Life (HRQL) in liver transplant is considered a useful measure of evolutionary process of the illness.

OBJECTIVE

The authors analyzed the evolution of HRQL in pre-transplant (waiting-list patients) and post-transplant (first year after liver transplant) periods of liver transplant Spanish patients.

METHODS

A prospective and longitudinal study was carried out among patients who received a liver transplant from a deceased donor. They were assessed in four phases: at the time of inclusion on the transplant waiting-list, and 3, 6, and 12 months after receiving the graft. We used a structured interview and SF-36 and Euroqol-5D (EQ-5D) Health Questionnaires.

RESULTS

The greater differences were found between pre-transplant and post-transplant stages with less well-being in the stage before the transplant. No significantly differences were observed when comparing the 3, 6 and 12 months from post-transplant stage.

CONCLUSION

The HQRL of liver patients improved after the transplant, being appreciated a tendency to the stabilization from three months onwards. We suggest that the psychological intervention, in liver patients, should be conducted in waiting-list patients and in the first 3 months post-transplant, periods with a poor mental health (anxiety, depression, and stress by fear to the unknown thing) and a low adhesion to the treatment that can generate a smaller graft and/or patient survival.

Medical waiting periods: imminence, emotions and coping

The diagnosis and treatment of various medical conditions requires patients to wait for results that are potentially threatening to their wellbeing (e.g., breast biopsy results, pregnancy test results after fertility treatment and genetic screening outcomes). Little research has been carried out to document the psychological processes that unfold during such waiting periods. The aim of the present study was to document the course of anxiety, depression, positive affect and coping during the waiting period before a pregnancy test result in fertility treatment. Using a daily record-keeping chart designed for fertility treatment, 61 women undergoing IVF were monitored daily for emotional reactions (e.g., anxiety, depression and positive affect) and coping during 7 days of active treatment (stimulation), 7 days of waiting to find out whether a pregnancy was achieved (waiting) and 4 days of reacting to the pregnancy test results (outcome). The stimulation stage of treatment was characterized by positive affect with a lesser degree of anxiety, whereas the predominant emotions in the waiting stage were a combination of positive affect and anxiety symptoms versus depression. From the pregnancy test day onwards, the predominant emotion was depression. There was a significant increase in coping activity between the stimulation and waiting stages, with variable effects across coping strategies. It was concluded that whilst medical waiting periods have a clearly defined emotional trajectory, the coping pattern is less differentiated. This may explain why waiting for medical test results is so demanding. Healthcare professionals can assist their patients by facilitating coping strategies that better fit the demands of the waiting period and by offering support once outcomes are known.

Medical, personal, and social forms of uncertainty across the transplantation trajectory

We designed this study to identify sources of uncertainty across the transplantation trajectory. We interviewed 38 transplant patients, who reported medical, personal, and social forms of uncertainty. Prior to transplantation, they reported uncertainty related to insufficient information about diagnosis, complex decisions about transplantation, unknown/unknowable organ availability, unclear expectations about medical procedures/outcomes, ambiguity in meaning of life, complex role and identity challenges, unclear financial consequences, questioning from others, and unclear relational implications. They reported that uncertainty experienced after transplantation was related to complex medication regimens, unpredictable future health/prognosis, complex role and identity challenges, unclear financial consequences, possible stigmatizing reactions, unclear relational implications, and complex interactions with the deceased donor's family. These findings lay the groundwork for additional research on uncertainty management for transplant patients, and suggest that health care professionals and supportive others cannot apply a one-size-fits-all solution when aiding in uncertainty management.

The Lived Experience of Waiting

The purposes of this study were to discover the structure of the lived experience of waiting and to generate new knowledge about health and quality of life. The participants in this study were 11 persons who were on a waiting list for a lung transplant. The Parse research method was used to answer the research question: What is the structure of the lived experience of waiting? The central finding of this study was: The lived experience of waiting is arduous constraint arising with anticipating the cherished in fortifying engagements. This finding illustrates waiting as an immensely difficult and agonizing experience of persistently expecting a prized opportunity, finding strength in being with other persons, and engaging in diverse activities. The findings are discussed in relation to nursing knowledge and as to how they inform future research and humanbecoming patient-centered nursing practices.

Failing bodies: body image and multiple chronic conditions in later life

There is a rich qualitative tradition of examining the lived experience of singular chronic conditions as well as the relationship between illness and identity in chronic disease. There has been little exploration of the experience of multiple chronic conditions or how these health issues may influence body image in later life. Building on the extant research and providing an alternative lens for understanding the experience of health issues, this article examines the body images of older adults with five or more chronic conditions. We use data from in-depth interviews with 10 men and 10 women aged 68 to 88 to analyze how older adults perceive their bodies to be failing in terms of their appearances, functional abilities, and impending mortality. We discuss how the participants view their bodies as both aesthetic and instrumental entities and how gender norms and discourses of successful aging and healthism shape their body evaluations.