Liver failure, life support, family support, and palliation: an inside story

Narrative critical care: A literary analysis of first-person critical illness pathographies

BACKGROUND

Life-threatening illness can be devastating for patients as they experience shifting levels of consciousness, recurrent delirium, and repeated setbacks. Narrative Medicine and its sub-discipline Narrative Critical Care increase healthcare professionals' understanding of the patient perspective, and interpretation of their stories is a means to improving practice.

PURPOSE

We aimed to investigate book length first-person accounts of critical illness to gain a deeper understanding of universal and individual patient responses and to provide an example of Narrative Critical Care.

METHOD

We performed a comparative literary analysis of five books supported by the Biographical Narrative Interpretive Method (BNIM) that moves through stages of structural analysis, thematic analysis, and cross-case theoretisation.

FINDINGS

Universal patient responses evolved through five existential dichotomies of life/death, sanity/madness, before/after, gain/loss and inner strength/external support. Individual patient responses were expressed as turning points along the illness trajectory, and biographical continuity was restored by integration of new self and old self.

CONCLUSION

We uncovered commonalities and differences in storied accounts of critical illness and survival. New insights might enable healthcare professionals to personalize patient care. More consistency is needed during transitions and rehabilitation of intensive care survivors.

Palliative care in liver disease: what does good look like?

The mortality rate from chronic liver disease in the UK is rising rapidly, and patients with advanced disease have a symptom burden comparable to or higher than that experienced in other life-limiting illnesses. While evidence is limited, there is growing recognition that care of patients with advanced disease needs to improve. Many factors limit widespread provision of good palliative care to these patients, including the unpredictable trajectory of chronic liver disease, the misconception that palliative care and end-of-life care are synonymous, lack of confidence in prescribing and lack of time and resources. Healthcare professionals managing these patients need to develop the skills to ensure effective delivery of core palliative care, with referral to specialist palliative care services reserved for those with complex needs. Core palliative care is best delivered by the hepatology team in parallel with active disease management. This includes ensuring that discussions about disease trajectory and advance care planning occur alongside active management of disease complications. Liver disease is strongly associated with significant social, psychological and financial hardships for patients and their carers; strategies that involve the wider multidisciplinary team at an early stage in the disease trajectory help ensure proactive management of such issues. This review summarises the evidence supporting palliative care for patients with advanced chronic liver disease, presents examples of current best practice and provides pragmatic suggestions for how palliative and disease-modifying care can be run in parallel, such that patients do not miss opportunities for interventions that improve their quality of life.

Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care

BACKGROUND

Seriously ill patients and their physicians often avoid discussing prognosis, which may compromise optimal end-of-life (EOL) care planning. The relation between prognosis discussion and patient and family satisfaction with EOL care is unknown.

METHODS

Using a 5-domain questionnaire, we surveyed inpatients with cancer or end-stage medical disease and their families on their satisfaction with specific aspects of EOL care and their overall satisfaction with EOL care. Scores were standardized to 0-100 points. We compared the results based on whether or not a physician had discussed the patient's prognosis with them, as well as on whether the patient and family member agreed on whether the patient was nearing the end of life. Supplementary questions were also asked (e.g., preferred location of death, willingness to discuss cardiopulmonary resuscitation).

RESULTS

Of 569 eligible patients and 176 eligible family members, 440 (77%) patients and 160 (91%) family members participated in the study. Overall, 18% of patients and 30.1% of families recalled a prognosis discussion with a physician. Patients who recalled such a discussion were more satisfied with overall care (76.1 v. 73.1 points, difference 3.0, 95% confidence interval [CI] 0.40 to 5.67, p = 0.02) and with communication and decision-making aspects of care (77.9 v. 72.4 points, difference 5.5, 95% CI 1.43 to 9.52, p = 0.008), and were more willing to discuss cardiopulmonary resuscitation status (69.6% v. 55.3%, difference 14.3, 95% CI 2.15 to 26.45, p = 0.03), than those who did not. Patients who were in accord with their family member as to whether they were nearing the end of life also showed significant satisfaction in these 3 areas. Family members' overall satisfaction was also higher among those who recalled a prognosis discussion (75.3 v. 70.4 points, difference 4.9, 95% CI 0.53 to 9.24, p = 0.03). Multivariate analyses confirmed the significance of the relation between the prognosis discussion and overall satisfaction with care for both patients and family members.

CONCLUSION

Although discussions about prognosis occur infrequently for patients who have advanced terminal disease, such discussions with patients and their families may facilitate advance care planning and improve satisfaction with EOL care. Encouraging discussion regarding EOL status between the patient and family members may also lead to greater satisfaction with EOL care for patients.