1
|
Beresford CJ, Rahman M, Gray Y, Ramshaw S, Gelling L, Baron S, Dominey J. Embedding Public Involvement in a PhD Research Project With People Affected by Advanced Liver Disease. Health Expect 2024; 27:e14097. [PMID: 38864117 PMCID: PMC11167232 DOI: 10.1111/hex.14097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 05/06/2024] [Accepted: 05/21/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Liver disease is an increasing cause of morbidity and mortality in the United Kingdom and can be challenging to live with in the advanced stages. There has been little research exploring the healthcare experiences of UK individuals with decompensated disease when the liver cannot carry out its functions properly. A PhD research project was developed with people who have liver disease to explore care experiences in decompensated advanced liver disease. Public involvement (PI) is an essential aspect of meaningful health research, and this paper reports on the progression of our PI approach in this ongoing study. OBJECTIVE To embed PI throughout the research project to ensure that the study is meaningful to individuals with liver disease and the people who support them. METHODS The research adopts a Constructivist Grounded Theory methodology to develop a theory of care experience. Various PI approaches were considered in developing the PI strategy for this qualitative study. Initially, Embedded consultation was the preferred model, which has evolved to include aspects of collaboration and coproduction. A PI group was set up to oversee the project through the national public engagement website VOICE, and reflections on PI from three members of the group are included in this paper to illuminate the PI process. RESULTS Six individuals with liver disease and three carers from across the United Kingdom are part of an ongoing PI group. Their role includes commenting on the findings of the systematic literature review for this project and contributing to decisions about recruitment, data collection and data analysis. Additionally, they had a direct impact on changing the focus of the research. The PI group will continue involvement until the completion of the project. CONCLUSION Successfully embedding PI into doctoral research, as demonstrated in this project, requires commitment, planning and dedication to reciprocal working for the benefit of PI contributors as well as the research. This approach could be adopted by other postgraduate researchers. PATIENT OR PUBLIC CONTRIBUTION This project is overseen by the PI group, whose contribution is described throughout, including reflections from three PI group members.
Collapse
Affiliation(s)
- Cathy J. Beresford
- Department of Nursing Science, Faculty of Health & Social SciencesBournemouth UniversityBournemouthDorsetUK
| | | | | | | | - Leslie Gelling
- Department of Nursing Science, Faculty of Health & Social SciencesBournemouth UniversityBournemouthDorsetUK
| | - Sue Baron
- Department of Nursing Science, Faculty of Health & Social SciencesBournemouth UniversityBournemouthDorsetUK
| | | |
Collapse
|
2
|
Manning ME, Fricker Z. Cardiopulmonary Resuscitation Outcomes and Trainee Perception of Code Status Discussions in Patients with Cirrhosis. Dig Dis Sci 2024:10.1007/s10620-024-08443-4. [PMID: 38652391 DOI: 10.1007/s10620-024-08443-4] [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: 10/09/2023] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Cardiopulmonary resuscitation (CPR) outcomes among patients with cirrhosis are poor, but factors associated with outcomes and provider awareness remain under-evaluated. AIMS We retrospectively investigated in-hospital CPR mortality among patients with cirrhosis, and, using these results, undertook an educational study among providers to improve knowledge of CPR outcomes and code status in patients with cirrhosis. METHODS We identified patients with cirrhosis admitted from 2012 to 2022 who underwent CPR at our center; the primary outcome was survival-to-discharge. A brief video based on these results was presented online to Internal Medicine residents, along with paired pre/post-surveys assessing attitudes toward holding code status conversations and knowledge of CPR outcomes in patients with cirrhosis. RESULTS 97 cases of CPR were identified. 27 patients (28%) survived to discharge post-CPR. A history of liver decompensation was significantly associated with lower survival (OR 0.21, p < 0.05). 22 residents participated in the educational intervention; afterward, their estimation of survival after CPR for patients with cirrhosis significantly improved (p < 0.05). Mean confidence in answering patient questions about prognosis, measured from 1 to 5, also significantly improved (2.4-"a little confident" vs. 3.8-"confident", p < 0.05). 59% of surveyed residents identified impact on liver transplant candidacy as at least a "somewhat significant" barrier to code status conversations. CONCLUSIONS We identified significant trainee uncertainty about outcomes in patients with cirrhosis. These deficits improved after an educational intervention and gave providers more confidence in holding informed code status conversations with patients with cirrhosis, a population that faces barriers to adequate code discussions.
Collapse
Affiliation(s)
- Margot E Manning
- Harvard Medical School, Boston, MA, USA.
- Internal Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Zachary Fricker
- Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Hepatology, & Nutrition, Beth Israel Deaconess Medical Center, Boston, MA, USA
| |
Collapse
|
3
|
Patel A, Walling A, Kanwal F, Serper M, Hernaez R, Sundaram V, Kaplan D, Taddei T, Mahmud N. Rates, patterns, and predictors of specialty palliative care consultation among patients with acute-on-chronic liver failure. JHEP Rep 2024; 6:100976. [PMID: 38274489 PMCID: PMC10808910 DOI: 10.1016/j.jhepr.2023.100976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 10/29/2023] [Accepted: 11/13/2023] [Indexed: 01/27/2024] Open
Abstract
Background & Aims There is growing acceptance that principles of palliative care should be integrated into the management of serious illnesses affecting the liver, such as acute-on-chronic liver failure (ACLF). However, rates, patterns, and predictors of specialty palliative care consultation among patients with ACLF have not been well-described. Methods We performed a retrospective cohort study of patients hospitalized with ACLF between 1/1/2008 and 12/31/2018 using the VOCAL cohort. Patients were followed until 6/2021. We used mixed-effects regression analyses to identify significant patient and facility factors associated with palliative care consultation. We examined timing of consultation, the influence of ACLF characteristics, and facility-level variation on receipt of palliative care consultation. Results We identified 21,987 patients hospitalized with ACLF, of whom 30.5% received specialty palliative care consultation. Higher ACLF grade (ACLF-2 [odds ratio (OR) 1.82, 95% CI 1.67-1.99], ACLF-3 [OR 3.06, 95% CI 2.76-3.40]), prior specialty palliative care consultation (OR 2.62, 95% CI 2.36-2.91), and hepatocellular carcinoma (OR 2.10, 95% CI 1.89-2.33) were associated with consultation. Consultation occurred latest and closest to the time of death for patients with ACLF-3 compared to ACLF-1 and ACLF-2. Significant facility-level variation in consultation persisted among patients with ACLF-3, despite adjusting for multiple patient and facility factors. Conclusion In this large cohort of hospitalized patients with ACLF, specialty palliative care consultation was rare, more common in patients with higher grade ACLF, and tended to occur closer to the time of death for the sickest patients. Greater attention should be placed on earlier integration of palliative care during acute hospitalizations in patients with ACLF. Impact and implications Though palliative care consultation is recommended for patients with acute-on-chronic liver failure, there is no data demonstrating how often this occurs during hospitalizations, on a population level. We found that consultation occurs in only 30.5% of patients and occurs later for patients with grade 3 acute-on-chronic liver failure. Our data should provoke clinicians to urgently consider quality improvement efforts to integrate palliative care into the management of these seriously ill patients.
Collapse
Affiliation(s)
- Arpan Patel
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
- Department of Medicine, Greater Los Angeles VA Healthcare System, Los Angeles, CA, United States
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Anne Walling
- Department of Medicine, Greater Los Angeles VA Healthcare System, Los Angeles, CA, United States
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX, United States
- Department of Internal Medicine, Houston VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX, United States
- Department of Internal Medicine, Houston VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States
| | - Vinay Sundaram
- Karsh Division of Gastroenterology and Hepatology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - David Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Tamar Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT, United States
- VA Connecticut Healthcare System, West Haven, CT, United States
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
4
|
Kearney A, Tiwari N, Cullen O, Legg A, Arbi I, Douglas C, Leggett B, Fenech M, Mina J, Hoey P, Skoien R. Improving palliative and supportive care in advanced cirrhosis: the HepatoCare model of integrated collaborative care. Intern Med J 2023; 53:1963-1971. [PMID: 37812158 DOI: 10.1111/imj.16248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/29/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Patients with advanced cirrhosis experience an unpredictable disease trajectory but are infrequently referred to palliative care (PC) services and rarely undertake advance care planning (ACP). AIM We assessed whether a novel model of care increased provision of meaningful PC in advanced cirrhosis compared with standard of care (SOC). METHODS Thirty consecutive hepatology clinic outpatients with advanced cirrhosis, meeting one or more cirrhosis-related PC referral criteria, consented to treatment in the HepatoCare clinic (PC physician, specialist liver nurse, pharmacist) in parallel with usual specialist hepatology care. A control cohort of 30 consecutive outpatients with advanced cirrhosis undergoing SOC treatment was retrospectively identified for comparison. The primary outcome was provision of meaningful PC using HepatoCare versus SOC. Additional clinical outcomes were assessed over 12 months or until death and significant differences were identified. RESULTS The intervention and control cohorts had similarly advanced cirrhosis (mean Child-Pugh scores 8.7 vs 8.2, P = 0.46; mean model for end-stage liver disease scores 14.4 vs 14.6, P = 0.88) but a lower 12-month mortality rate (33% HepatoCare vs 67% SOC; P = 0.02). The intervention cohort experienced higher uptake of formal ACP (100% vs 25% for the control cohort) and outpatient PC referral (100% vs 40%), and were more likely to die at home or in a PC bed/hospice (80% vs 30%). The majority of the HepatoCare cohort (81%) had medications safely deprescribed and experienced fewer unplanned admission days (470 vs 794). CONCLUSIONS HepatoCare is a novel multidisciplinary model of care that integrates effective PC and specialist hepatology management to improve outcomes in advanced cirrhosis.
Collapse
Affiliation(s)
- Alison Kearney
- Department of Palliative and Supportive Care, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
- School of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - Neha Tiwari
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Olivia Cullen
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Amy Legg
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Ismail Arbi
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Carol Douglas
- Department of Palliative and Supportive Care, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
- School of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - Barbara Leggett
- School of Medicine, The University of Queensland, St Lucia, Queensland, Australia
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Mary Fenech
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Joanne Mina
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Paris Hoey
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| | - Richard Skoien
- School of Medicine, The University of Queensland, St Lucia, Queensland, Australia
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Queensland, Herston, Australia
| |
Collapse
|
5
|
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.
Collapse
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
| | | |
Collapse
|
6
|
Petersile M, Devuni D. Palliative Care and Advanced Directive Practices at Liver Transplant Centers in the United States. J Palliat Med 2023; 26:1327-1332. [PMID: 37155706 DOI: 10.1089/jpm.2022.0556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Introduction: Patients with cirrhosis have a decreased quality of life due to decompensations of their underlying disease. While liver transplantation (LT) has improved outcomes and quality of life for patients with cirrhosis, many patients die or are delisted before transplant. Despite high morbidity and mortality, palliative care (PC) services are underutilized for patients with cirrhosis. Methods: To evaluate current PC and advance care practices at LT centers, a survey was designed and sent to 115 U.S. LT centers. Results: Forty-two surveys were completed (37% response rate) with representation from all United Network for Organ Sharing regions. Nineteen institutions (46.3%) reported 100 or fewer waitlisted patients, while 22 (53.6%) reported more than 100. Twenty-five institutions (59.5%) reported 100 or fewer transplants performed in the last year and 17 (40.5%) reported more than 100. Nineteen transplant centers (45.2%) require patients to discuss advance directives as part of the LT evaluation, while 23 (54.8%) do not. Only 5 centers (12.2%) reported having a dedicated PC provider as part of their transplant team and only 2 reported requiring patients to meet with a PC provider as part of the LT evaluation process. Discussion: This study shows many LT centers do not engage their patients in advance directive discussions and highlights the underutilization of PC services in the LT evaluation process. Our results also show minimal advancement in the collaboration between PC and transplant hepatology over the last decade. Encouraging or requiring LT centers to hold advance directive discussions and incorporate PC providers into the transplant team is a recommended area for improvement.
Collapse
Affiliation(s)
- Matthew Petersile
- Department of Internal Medicine, Division of Gastroenterology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| | - Deepika Devuni
- Department of Internal Medicine, Division of Gastroenterology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| |
Collapse
|
7
|
van Zyl C, Storms AD, van Deen W, Cardenas V, Ellis R, Flores A, Donovan J, Chu L, Patel T, Enguidanos S. A Pilot Study of a Palliative Care Service Embedded in a Hepatology Clinic at a Large Public Hospital. J Palliat Med 2023; 26:776-783. [PMID: 36577037 PMCID: PMC10398730 DOI: 10.1089/jpm.2022.0438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 12/29/2022] Open
Abstract
Background: End-stage liver disease (ESLD) patients carry heavy symptom burdens and risk receiving aggressive and sometimes unwanted care at end of life. Palliative care (PC), which aims to alleviate symptoms and facilitate goal-concordant care in serious illness, may offer substantial benefits for ESLD patients but is not widely provided. Objectives: To assess the impact of PC integrated within hepatology (PCIH) services on health care utilization, advance care planning (ACP), and hospice enrollment. Design: We compared patients who received PCIH (n = 55) to a retrospective cohort (n = 57) receiving usual care in an outpatient hepatology clinic. Setting/Subjects: From June 2016 to November 2017, we enrolled patients receiving care in a U.S. public hospital clinic who met the following inclusion criteria: (1) ESLD with a Model for End-Stage Liver Disease score ≥20, (2) hepatology approval for PC referral, and (3) at least one advanced complication of ESLD. Measurements: We assessed patient demographics, clinical information, health care insurance status, health care utilization, completion of psychosocial assessments, and ACP using two-sided Fisher's exact test and Mann-Whitney U tests. Results: Patients receiving PCIH more frequently had goals of care discussions (87.3% vs. 21.2% p ≤ 0.01), completed ACP documentation (56.4% vs. 7.0%, p ≤ 0.01), psychosocial assessments (98.2% vs. 35.1%, p ≤ 0.01), and hospice enrollment (25.5% vs. 7.0%, p = 0.01). Patients receiving PCIH who were hospitalized also had fewer mean hospitalization days (13 vs. 19.7 days, p ≤ 0.01). Conclusions: Embedding PC services in a hepatology clinic is a promising strategy to improve care for ESLD patients in public hospitals.
Collapse
Affiliation(s)
- Carin van Zyl
- Department of Medicine, Division of Geriatric, Hospital, Palliative, and General Internal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Aaron D. Storms
- Department of Medicine, Division of Geriatric, Hospital, Palliative, and General Internal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Welmoed van Deen
- Gehr Family Center for Health Systems Science, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Erasmus School of Health Policy and Management, Health Technology Assessment Section, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Valeria Cardenas
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA
| | - Robin Ellis
- Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Alicia Flores
- Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - John Donovan
- Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Medicine, Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lily Chu
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Tanu Patel
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Susan Enguidanos
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA
| |
Collapse
|
8
|
Davis S, Higgs P, Jones L, Greenslade L, Wilson J, Low JT. "I am in other people's hands as regards my health" A sociological critique of health care encounters of people with cirrhosis. A secondary analysis. Chronic Illn 2023; 19:102-117. [PMID: 34812061 PMCID: PMC9841472 DOI: 10.1177/17423953211058422] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES People with cirrhosis are encouraged to participate in shared decision-making with their doctors, but studies suggest that doctors limit the amount of information that is shared. In this study we explore the presence of medical power in clinical encounters in 2015 from a patient perspective and highlight its effects on healthcare interactions. METHODS Qualitative semi-structured interviews were conducted with ten people with cirrhosis attending a tertiary liver transplant centre in southern England. We explored their understanding of their disease and prognosis, and their participation in decision-making. Using the lens of medical power as a framework, we analysed findings into thematic sentences to summarise key ideas whilst preserving the complexity of identified concepts. RESULTS Three key concepts explained patient perspectives of their communication with doctors: (1) portraying a positive image to doctors, (2) avoiding confrontation with doctors, (3) feeling powerless in the face of doctors' medical knowledge. These concepts show deeper dynamic issues of power during healthcare encounters, illustrated by participants' reluctance to voice their concerns and express themselves, challenge decisions, or seek information. CONCLUSION People with cirrhosis struggle to articulate their concerns or challenge decisions on their care and treatment and may worry about potential consequences. Our findings demonstrate the continuing persistence of issues of power at play in contemporary health care.
Collapse
Affiliation(s)
- Sarah Davis
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Paul Higgs
- Division of Psychiatry, University College London, London, UK
| | - Louise Jones
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | | | - Jo Wilson
- Department of Palliative Care, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Joseph Ts Low
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | | |
Collapse
|
9
|
Abasseri M, Hoque S, Slavica Kochovska BA, Caldwell K, Sheahan L, Zekry A. Barriers to palliative care in hepatocellular carcinoma: A review of the literature. J Gastroenterol Hepatol 2023. [PMID: 36634200 DOI: 10.1111/jgh.16107] [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: 08/20/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 01/14/2023]
Abstract
Hepatocellular carcinoma (HCC) is a deadly and burdensome form of liver cancer with an increasing global prevalence. Its course is unpredictable as it frequently occurs in the context of underlying end-stage liver disease, and the associated symptoms and adverse effects of treatment cause severe suffering for patients. Palliative care (PC) is a medical specialty that addresses the physical, emotional, and spiritual needs of patients and their carers in the context of life-limiting illness. In other cancers, a growing body of evidence has demonstrated that the early introduction of PC at diagnosis improves patient and carer outcomes. Despite this, the integration of palliative care at the diagnosis of HCC remains suboptimal, as patients usually receive PC only at the very terminal phase of their disease, even when diagnosed early. Significant barriers to the uptake of palliative care in the treatment algorithm of hepatocellular carcinoma fall under four main themes: data limitations, disease, clinician, and patient factors. Barriers relating to data limitations mainly encapsulated the risk of bias inherent in published work in the field of PC. Clinician-reported barriers related to negative attitudes towards PC and a lack of time for PC discussions. Barriers related to the disease align with prognostic uncertainty due to the unpredictable course of HCC. Significantly, there exists a paucity of evidence exploring patient-perceived barriers to timely PC implementation in HCC. Given that patients are often the underrepresented stakeholder in the delivery of PC, future research should explore the patient perspective in adequately designed qualitative studies as the first step.
Collapse
Affiliation(s)
- Mostafa Abasseri
- School of Medicine and Health, UNSW, Sydney, New South Wales, Australia
| | - Shakira Hoque
- Gastroenterology and Hepatology Department, St George Hospital, Sydney, New South Wales, Australia
| | - B A Slavica Kochovska
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia.,IMPACCT, Faculty of Health, University of Technology, Sydney, New South Wales, Australia
| | - Kim Caldwell
- Palliative Medicine, Calvary Hospital Kogarah, Kogarah, New South Wales, Australia
| | - Linda Sheahan
- Clinical Ethics Service, South Eastern Sydney Local Health District, Randwick, New South Wales, Australia.,Sydney Health Ethics, The University of Sydney, Camperdown, New South Wales, Australia.,UNSW Medicine & Health, St George and Sutherland Clinical Campus.,Palliative Medicine Department, St George Hospital, Sydney, New South Wales, Australia
| | - Amany Zekry
- School of Medicine and Health, UNSW, Sydney, New South Wales, Australia.,Gastroenterology and Hepatology Department, St George Hospital, Sydney, New South Wales, Australia.,UNSW Medicine & Health, St George and Sutherland Clinical Campus
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Arney J, Gray C, Walling AM, Clark JA, Smith D, Melcher J, Asch S, Kanwal F, Naik AD. Two mental models of integrated care for advanced liver disease: qualitative study of multidisciplinary health professionals. BMJ Open 2022; 12:e062836. [PMID: 36691142 PMCID: PMC9445787 DOI: 10.1136/bmjopen-2022-062836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/16/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES The purpose of this paper is to present two divergent mental models of integrated advanced liver disease (AdvLD) care among 26 providers who treat patients with AdvLD. SETTING 3 geographically dispersed United States Veterans Health Administration health systems. PARTICIPANTS 26 professionals (20 women and 6 men) participated, including 9 (34.6%) gastroenterology, hepatology, and transplant physicians, 2 (7.7%) physician assistants, 7 (27%) nurses and nurse practitioners, 3 (11.5%) social workers and psychologists, 4 (15.4%) palliative care providers and 1 (3.8%) pharmacist. MAIN OUTCOME MEASURES We conducted qualitative in-depth interviews of providers caring for patients with AdvLD. We used framework analysis to identify two divergent mental models of integrated AdvLD care. These models vary in timing of initiating various constituents of care, philosophy of integration, and supports and resources needed to achieve each model. RESULTS Clinicians described integrated care as an approach that incorporates elements of curative care, symptom and supportive care, advance care planning and end-of-life services from a multidisciplinary team. Analysis revealed two mental models that varied in how and when these constituents are delivered. One mental model involves sequential transitions between constituents of care, and the second mental model involves synchronous application of the various constituents. Participants described elements of teamwork and coordination supports necessary to achieve integrated AdvLD care. Many discussed the importance of having a multidisciplinary team integrating supportive care, symptom management and palliative care with liver disease care. CONCLUSIONS Health professionals agree on the constituents of integrated AdvLD care but describe two competing mental models of how these constituents are integrated. Health systems can promote integrated care by assembling multidisciplinary teams, and providing teamwork and coordination supports, and training that facilitates patient-centred AdvLD care.
Collapse
Affiliation(s)
- Jennifer Arney
- Department of Sociology, University of Houston Clear Lake, Houston, Texas, USA
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Caroline Gray
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Anne M Walling
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California at Los Angeles, Los Angeles, California, USA
| | - Jack A Clark
- Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Donna Smith
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
| | - Jennifer Melcher
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
| | - Steven Asch
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Division of General Medical Disciplines, Stanford School of Medicine, Stanford, California, USA
| | - Fasiha Kanwal
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Aanand D Naik
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
- University of Texas Health Consortium on Aging, University of Texas Health Science Center, Houston, Texas, USA
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center, Houston, Texas, USA
| |
Collapse
|
12
|
Tobin J, Rogers A, Winterburn I, Tullie S, Kalyanasundaram A, Kuhn I, Barclay S. Hospice care access inequalities: a systematic review and narrative synthesis. BMJ Support Palliat Care 2022; 12:142-151. [PMID: 33608254 PMCID: PMC9125370 DOI: 10.1136/bmjspcare-2020-002719] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 01/09/2021] [Accepted: 01/17/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Inequalities in access to hospice care is a source of considerable concern; white, middle-class, middle-aged patients with cancer have traditionally been over-represented in hospice populations. OBJECTIVE To identify from the literature the demographic characteristics of those who access hospice care more often, focusing on: diagnosis, age, gender, marital status, ethnicity, geography and socioeconomic status. DESIGN Systematic literature review and narrative synthesis. METHOD Searches of Medline, PsycINFO, CINAHL, Web of Science, Assia and Embase databases from January 1987 to end September 2019 were conducted. Inclusion criteria were peer-reviewed studies of adult patients in the UK, Australia, New Zealand and Canada, receiving inpatient, day, outpatient and community hospice care. Of the 45 937 titles retrieved, 130 met the inclusion criteria. Narrative synthesis of extracted data was conducted. RESULTS An extensive literature search demonstrates persistent inequalities in hospice care provision: patients without cancer, the oldest old, ethnic minorities and those living in rural or deprived areas are under-represented in hospice populations. The effect of gender and marital status is inconsistent. There is a limited literature concerning hospice service access for the LGBTQ+ community, homeless people and those living with HIV/AIDS, diabetes and cystic fibrosis. CONCLUSION Barriers of prognostic uncertainty, institutional cultures, particular needs of certain groups and lack of public awareness of hospice services remain substantial challenges to the hospice movement in ensuring equitable access for all.
Collapse
Affiliation(s)
- Jake Tobin
- School of Clinical Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Alice Rogers
- School of Clinical Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Isaac Winterburn
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Sebastian Tullie
- School of Clinical Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
| | | | - Isla Kuhn
- Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Stephen Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
| |
Collapse
|
13
|
Orman ES, Yousef A, Xu C, Shamseddeen H, Johnson AW, Nephew L, Ghabril M, Desai AP, Patidar KR, Chalasani N. Palliative Care, Patient-Reported Measures, and Outcomes in Hospitalized Patients With Cirrhosis. J Pain Symptom Manage 2022; 63:953-961. [PMID: 35202730 PMCID: PMC9124687 DOI: 10.1016/j.jpainsymman.2022.02.022] [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: 11/24/2021] [Revised: 02/08/2022] [Accepted: 02/15/2022] [Indexed: 11/18/2022]
Abstract
CONTEXT Studies of palliative care (PC) in hospitalized patients with cirrhosis have been retrospective, with limited evaluation of patient-reported measures and outcomes. OBJECTIVES To examine the relationship between PC, patient-reported measures (quality of life and functional status), and outcomes. METHODS We performed a prospective cohort study of patients with cirrhosis hospitalized from 2014 to 2019. We recorded PC consultation details, quality of life (chronic liver disease questionnaire), and functional status (functional status questionnaire). Patients were followed for 90 days to assess readmissions, costs, and mortality. RESULTS Seventy-four of 679 patients saw PC, often later in the hospitalization (median hospital day 8; IQR 4-16). Those who saw PC had greater Charlson comorbidity index (mean 6.8 vs. 5.9), MELD (mean 25 vs. 20), and prior 30-day admission (47% vs. 35%). Compared to those who did not see PC, PC patients had greater impairments in intermediate activities of daily living (83% vs. 72%), social activity (72% vs. 59%), quality of interactions (49% vs. 36%), abdominal symptoms (mean score 3.1 vs. 3.6), activity (mean 3.3 vs. 3.6), and overall quality of life (mean 3.6 vs. 3.8). PC was associated with fewer transfusions and upper endoscopies and with greater completion of advanced directives. After multivariable adjustment, PC was not associated with intensive care, 30-day readmissions, 90-day costs, or mortality. CONCLUSION PC occurs infrequently and late in those with more severe liver disease and functional impairment. PC may be associated with reduction in utilization and greater completion of advanced directives. Randomized trials are needed to evaluate PC for this population.
Collapse
Affiliation(s)
- Eric S Orman
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA.
| | - Andrew Yousef
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Chenjia Xu
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Hani Shamseddeen
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Amy W Johnson
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Archita P Desai
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Kavish R Patidar
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| |
Collapse
|
14
|
Kotha S, Berry P. The writing was on the wall: Decision making near the end of life in advanced liver disease. PROGRESS IN PALLIATIVE CARE 2022. [DOI: 10.1080/09699260.2022.2067702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Sreelakshmi Kotha
- Department of Gastroenterology, Guy’s and St Thomas’ Foundation Trust, London, UK
| | - Philip Berry
- Department of Gastroenterology, Guy’s and St Thomas’ Foundation Trust, London, UK
| |
Collapse
|
15
|
Bowers SP, Clare K, Hagerty L, McColl K, Smith E, Brown-Kerr A, Ahmed A, Finlay F, Dillon JF, Barclay S. Predicting 1-year mortality among patients with decompensated cirrhosis: results of a multicentre evaluation of the Bristol Prognostic Score. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000822. [PMID: 35318191 PMCID: PMC8943768 DOI: 10.1136/bmjgast-2021-000822] [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: 10/31/2021] [Accepted: 03/01/2022] [Indexed: 11/12/2022] Open
Abstract
Objective Chronic liver disease continues to be a significant cause of morbidity and mortality yet remains challenging to prognosticate. This has been one of the barriers to implementing palliative care, particularly at an early stage. The Bristol Prognostic Score (BPS) was developed to identify patients with life expectancy less than 12 months and to act as a trigger for referral to palliative care services. This study retrospectively evaluated the BPS in a cohort of patients admitted to three Scottish hospitals. Method Routinely collated healthcare data were used to obtain demographics, BPS and analyse 1-year mortality for patients with decompensated liver disease admitted to three gastroenterology units over two 90-day periods. Statistical analysis was undertaken to assess performance of BPS in predicting mortality. Results 276 patients were included in the final analysis. Participants tended to be late middle-aged men, socioeconomically deprived and have alcohol-related liver disease. A similar proportion was BPS+ve (>3) in this study compared with the original Bristol cohort though had more hospital admissions, higher ongoing alcohol use and poorer performance status. BPS performed poorer in this non-Bristol group with sensitivity 54.9% (72.2% in original study), specificity 58% (83.8%) and positive predictive value (PPV) 43.4% (81.3%). Conclusion BPS was unable to accurately predict mortality in this Scottish cohort. This highlights the ongoing challenge of prognostication in patients with chronic liver disease, furthering the call for more work in this field.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Fiona Finlay
- Queen Elizabeth University Hospital, Glasgow, UK
| | | | | |
Collapse
|
16
|
Arney J, Gray C, Clark JA, Smith D, Swank A, Matlock DD, Melcher J, Kanwal F, Naik AD. Prognosis conversations in advanced liver disease: A qualitative interview study with health professionals and patients. PLoS One 2022; 17:e0263874. [PMID: 35180233 PMCID: PMC8856527 DOI: 10.1371/journal.pone.0263874] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 01/31/2022] [Indexed: 12/16/2022] Open
Abstract
Advanced Liver Disease (AdvLD) is common, morbid, and associated with high likelihood of death. Patients may not fully understand their prognosis and are often unprepared for the course of illness. Little is known about how and when to deliver prognosis-related information to patients with AdvLD, who should participate, and what should be discussed. We conducted in-depth interviews with a multi-profession sample of Hepatology clinicians and patients with AdvLD. Participants were drawn from three geographically diverse facilities (New England, Texas, California). We used inductive and deductive qualitative data analysis approaches to identify themes related to AdvLD prognosis discussions. Thematic analysis focused on content, timing, and participants’ roles in prognosis discussions. In total, 31 patients with AdvLD and 26 multi-profession clinicians completed interviews. Most participants provided a broad conceptualization of prognosis beyond predictions of survival, including expectations about illness course, ways to manage or avoid complications and a need to address patients’ emotions. Patients favored initiating discussions early in the AdvLD course and welcomed a multi-profession approach to conducting discussions. Clinicians favored a larger role for specialty physicians. All participants recognized that AdvLD prognosis discussions occur infrequently and favored a structured, standardized approach to broadly discussing prognosis. Patients with AdvLD and their clinicians favored a multifaceted approach to prognosis conversations including discussions of life expectancy, predictions about likely course of liver disease, and expected changes in function and capabilities over time. Structured and early prognosis discussions should be part of routine AdvLD care.
Collapse
Affiliation(s)
- Jennifer Arney
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Sociology, University of Houston-Clear Lake, Houston, Texas, United States of America
| | - Caroline Gray
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, United States of America
| | - Jack A. Clark
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Donna Smith
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States of America
| | - Annie Swank
- Department of Sociology, University of Houston-Clear Lake, Houston, Texas, United States of America
| | - Daniel D. Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, Colorado
| | - Jennifer Melcher
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States of America
| | - Fasiha Kanwal
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, United States of America
| | - Aanand D. Naik
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Medicine, Section of Geriatrics and Palliative Medicine, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center, Houston, Texas, Colorado
- * E-mail:
| |
Collapse
|
17
|
Vijeratnam SS, Candy B, Craig R, Marshall A, Stone P, Low JTS. Palliative Care for Patients with End-Stage Liver Disease on the Liver Transplant Waiting List: An International Systematic Review. Dig Dis Sci 2021; 66:4072-4089. [PMID: 33433811 DOI: 10.1007/s10620-020-06779-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/09/2020] [Indexed: 01/21/2023]
Abstract
People with end-stage liver disease on the liver transplant waiting list have high symptom burden, which can successfully be addressed by specialist palliative care. Potential tensions with the perceived curative nature of liver transplant make delivering specialist palliative care challenging. This systematic review seeks to establish what is known on the impact of specialist palliative care for patients on liver transplant waiting lists, healthcare professionals' perspectives of providing specialist palliative care for this population, and uptake of advance care planning (ACP). Medline, Embase, and CINAHL were searched to May 5, 2020. Qualitative and quantitative findings were grouped together according to main relevant themes. Eight studies of mixed quality and mainly quantitative, were identified. Findings suggest early palliative care intervention improve patients' symptoms and prompt ACP conversations, but patients on the waiting list receive limited palliative care input. Liver physicians' lack of clarity on referral criteria and liver transplant patients' concerns of being abandoned, were reasons for reluctance to refer to specialist palliative care. They felt referral to specialist palliative care is appropriate only for patients receiving hospice or end of life care. Uptake and understanding of ACP and goals of care designation by patients is poor. This review found evidence of benefit of specialist palliative care for patients on liver transplant waiting lists, but found in a limited understanding of their role. Evidence is limited to studies from North America. Future research is needed to understand better how palliative care could be provided into this clinical environment.
Collapse
Affiliation(s)
- Shan Shan Vijeratnam
- Camden, Islington ELiPSe and UCLH and HCA Palliative Care Service, CNWL-Central and North West London NHS Foundation Trust, 2nd Floor Wing B, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Bridget Candy
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Rachel Craig
- Palliative Care Department, Royal Free London NHS Trust, Pond Street, London, NW3 2QG, UK
| | - Aileen Marshall
- Sheila Sherlock Liver Unit, Royal Free Hospital, University College London, London, UK
- Institute of Liver and Digestive Health, UCL Royal Free Campus, Pond Street, London, NW3 2QG, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Joseph T S Low
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
| |
Collapse
|
18
|
Ufere NN. Advance Care Planning and Goals of Care Discussions in Advanced Liver Disease. CURRENT HEPATOLOGY REPORTS 2021; 20:77-84. [PMID: 35083111 PMCID: PMC8788995 DOI: 10.1007/s11901-021-00565-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 06/14/2023]
Abstract
PURPOSE OF REVIEW Advance care planning (ACP) has been shown to improve multiple outcomes in patients with serious illnesses; however, patients with advanced liver disease, or cirrhosis, rarely receive timely ACP. The purpose of this review is to evaluate the current state of ACP for patients with advanced liver disease and to provide practical guidance for integrating early ACP into routine outpatient hepatology care. RECENT FINDINGS Due to multiple patient-, physician-, and systems-level barriers, patients with advanced liver disease have low rates of timely ACP engagement. Early identification and preparation of a surrogate decision-maker, enhancing clinician ACP communication skills, use of patient-centered educational tools, optimizing outpatient processes for ACP documentation, and early referral to specialty palliative care may help to improve current deficits in ACP for this population. SUMMARY Provision of early ACP to patients with advanced liver disease may better ensure that patients receive medical care that is consistent with their goals and values.
Collapse
Affiliation(s)
- Nneka N. Ufere
- Liver Center, Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| |
Collapse
|
19
|
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.
Collapse
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
| | | |
Collapse
|
20
|
Chen H, Johnston A, Palmer A, Mickenbecker M, O'Sullivan T, Clark P. Too little, too late: Palliation and end-stage liver disease. J Gastroenterol Hepatol 2021; 36:2303-2306. [PMID: 33738858 DOI: 10.1111/jgh.15499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/20/2021] [Accepted: 03/14/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM End-stage liver disease is a leading cause of mortality. Fewer than 60% of patients with decompensated cirrhosis survive after 2 years, with patients often experiencing distressing symptoms impairing quality of life. Early advanced care planning and timely palliative care referral can improve quality of life and the end of life experience. We aimed to determine palliative care referral rates and patterns for patients admitted with decompensated cirrhosis, and to identify the factors associated with referral. METHODS This was a retrospective, single-center study undertaken at a metropolitan tertiary referral hospital. Patients admitted between the 1 June 2016 and 31 January 2019 with a Child-Pugh score of B or C, and a model for end-stage liver disease score ≥ 15 were included. We assessed survival and compared those referred and not referred to palliative care, adjusting for lag-time to referral (Kaplan-Meier analysis). RESULTS One-hundred and sixteen admissions met eligibility criteria for referral. The median age at admission was 59 years, with 76% male participants. Only a fifth of eligible patients (25/116) were referred to palliative care. The median survival (from referral) for those referred to palliative care was 20 days, versus 148 days for those not referred. CONCLUSIONS Despite benefits from timely referral, less than one quarter of palliative care eligible patients was referred. Referral appears reserved for those facing imminent death-surviving just under 3 weeks postreferral, yet mortality in nonreferred patients remained high (148-day median). Low rates and late referral are a missed opportunity to improve the end of life care for patients with end-stage liver disease.
Collapse
Affiliation(s)
- Hayley Chen
- Mater Adult Hospital, Brisbane, Queensland, Australia.,Logan Hospital, Meadowbrook, Queensland, Australia
| | | | - Andrew Palmer
- Mater Adult Hospital, Brisbane, Queensland, Australia
| | - Matthew Mickenbecker
- Mater Adult Hospital, Brisbane, Queensland, Australia.,Logan Hospital, Meadowbrook, Queensland, Australia
| | | | - Paul Clark
- Mater Adult Hospital, Brisbane, Queensland, Australia.,Faulty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| |
Collapse
|
21
|
Das D, Ali M, Hussain IA, Ingram JTN, Johnstone RS, Lopes JJ, Wadee T, Chakraborty N. What do we know about patients' perspectives and expectations relating to palliative and end-of-life care in advanced liver disease? A systematic review of qualitative literature using ENTREQ guidelines. BMJ Support Palliat Care 2021:bmjspcare-2021-003057. [PMID: 34233896 DOI: 10.1136/bmjspcare-2021-003057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/20/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Liver disease, a major cause of death worldwide, affects younger people compared with other major causes of death. Palliative and end-of-life care for these patients are often overlooked. Guidelines are emerging on what good end-of-life care in liver disease should look like, but there is a dearth of research into patients' perspectives even though they are most affected by these guidelines. AIM To explore current knowledge and understanding of patients' lived experiences, perspectives and expectations in relation to palliative and end-of-life care in advanced liver disease. DESIGN Systematic review with thematic synthesis complying to the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) statement. SETTING AND PARTICIPANTS Database searches (Ovid Medline, 1946-2021 and Web of Science, 1970-2021) to identify qualitative studies exploring patients' perspectives of palliative and end-of-life care in advanced liver disease. FINDINGS Only eight articles met all criteria. Themes demonstrated repeated hospital admissions towards the end of life, lack of coordinated care in community and barriers in discussion about palliative care in end-stage liver disease due to lack of confidence among professionals and a negative view about palliative care among patients and carers. Emotional, financial and disability-related needs of patients and their carers are often neglected. CONCLUSION There is a dearth of studies exploring patients' perspectives about care in advanced liver disease relating to palliative and end-of-life care. Lack of coordinated community support and honest conversations around palliative care leads to reduced quality of life. More primary research from diverse population is needed to improve palliative care and end-of-life care in end-stage liver disease.
Collapse
Affiliation(s)
- Debasish Das
- Department of Digestive Diseases, Kettering General Hospital, Kettering, UK
- Medical School, University of Leicester, Leicester, UK
| | - Mafas Ali
- Medical School, University of Leicester, Leicester, UK
| | | | | | | | | | - Tasneem Wadee
- Medical School, University of Leicester, Leicester, UK
| | - Nandini Chakraborty
- PIER Team, Leicestershire Partnership NHS Trust, Leicester, UK
- Department of Health Sciences, University of Leicester, Leicester, UK
| |
Collapse
|
22
|
Orman ES, Johnson AW, Ghabril M, Sachs GA. Hospice care for end stage liver disease in the United States. Expert Rev Gastroenterol Hepatol 2021; 15:797-809. [PMID: 33599185 PMCID: PMC8282639 DOI: 10.1080/17474124.2021.1892487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Patients with end-stage liver disease (ESLD) have impaired physical, psychological, and social functions, which can diminish patient quality of life, burden family caregivers, and increase health-care utilization. For those with a life expectancy of less than six months, these impairments and their downstream effects can be addressed effectively through high-quality hospice care, delivered by multidisciplinary teams and focused on the physical, emotional, social, and spiritual wellbeing of patients and caregivers, with a goal of improving quality of life. AREAS COVERED In this review, we examine the evidence supporting hospice for ESLD, we compare this evidence to that supporting hospice more broadly, and we identify potential criteria that may be useful in determining hospice appropriateness. EXPERT OPINION Despite the potential for hospice to improve care for those at the end of life, it is underutilized for patients with ESLD. Increasing the appropriate utilization of hospice for ESLD requires a better understanding of patient eligibility, which can be based on predictors of high short-term mortality and liver transplant ineligibility. Such hospice criteria should be data-driven and should accommodate the uncertainty faced by patients and physicians.
Collapse
Affiliation(s)
- Eric S. Orman
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine,Corresponding author: Eric S. Orman, Address: Division of Gastroenterology & Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202,
| | - Amy W. Johnson
- Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine
| | - Marwan Ghabril
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine
| | - Greg A. Sachs
- Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine,Indiana University Center for Aging Research, Regenstrief Institute, Inc
| |
Collapse
|
23
|
Low J, Carroll C, Wilson J, Craig R, Vadera S, Cococcia S, Thorburn D, Stone P, Marshall A, Vickerstaff V. Do screening tools assess palliative care needs and 12-month mortality in patients admitted to hepatology in-patient wards? Frontline Gastroenterol 2021; 13:211-217. [PMID: 35493625 PMCID: PMC8996104 DOI: 10.1136/flgastro-2020-101709] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 05/18/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Many liver patients have unmet palliative care needs, but liver clinicians are unclear whom to refer to specialist palliative care (SPC). The Supportive and Palliative Care Indicator Tool (SPICT) and the Bristol Prognostic Screening Tool (BPST) could help identify suitable patients, but neither has been tested for this role. This study evaluated their role as screening tools for palliative care needs and for predicting 12-month mortality. METHODS A case note review of hepatology in-patients, who were not peritransplant and post-transplant status, was conducted in one tertiary unit. Main outcomes were clinical judgement of need for SPC referral, BPST scores, SPICT attribution of caseness and 12-month survival status. Discriminatory ability of tools was assessed using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the receiver operating characteristic (AUROC) curve. RESULTS 117 medical notes were reviewed for survival analysis, 47 of which were additionally assessed for suitability for SPC referral, using clinical judgement. SPICT (sensitivity=93%; PPV=93%; AUROC=0.933) and BPST (sensitivity=59%, PPV=79%, AUROC=0.693) demonstrated excellent and good performance, respectively, in predicting patients' need for SPC referral. SPICT and BPST only had moderate ability at predicting death at 12 months (PPV: 54% and 56%, respectively). CONCLUSION SPICT and BPST show potential as screening tools for identifying patients for referral to SPC. Further work is needed to determine how to implement these tools in a clinical setting.
Collapse
Affiliation(s)
- Joseph Low
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | | | - Jo Wilson
- Palliative Care, Royal Free London NHS Trust, London, UK
| | - Rachel Craig
- Palliative Care, Royal Free London NHS Trust, London, UK
| | - Shree Vadera
- Department of Hepatology, Royal Free London NHS Trust, London, UK
| | - Sara Cococcia
- Department of Hepatology, Royal Free London NHS Trust, London, UK,First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Lombardia, Italy
| | - Douglas Thorburn
- Department of Hepatology, Royal Free London NHS Trust, London, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Aileen Marshall
- Department of Hepatology, Royal Free London NHS Trust, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, University College London, London, UK
| |
Collapse
|
24
|
Patel AA, Ryan GW, Tisnado D, Chuang E, Walling AM, Saab S, Khemichian S, Sundaram V, Brook RH, Wenger NS. Deficits in Advance Care Planning for Patients With Decompensated Cirrhosis at Liver Transplant Centers. JAMA Intern Med 2021; 181:652-660. [PMID: 33720273 PMCID: PMC7961470 DOI: 10.1001/jamainternmed.2021.0152] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE The burden of end-of-life care for patients with cirrhosis is increasing in the US, and most of these patients, many of whom are not candidates for liver transplant, die in institutions receiving aggressive care. Advance care planning (ACP) has been associated with improved end-of-life outcomes for patients with other chronic illnesses, but it has not been well-characterized in patients with decompensated cirrhosis. OBJECTIVE To describe the experience of ACP in patients with decompensated cirrhosis at liver transplant centers. DESIGN, SETTING, AND PARTICIPANTS For this multicenter qualitative study, face-to-face semistructured interviews were conducted between July 1, 2017, and May 30, 2018, with clinicians and patients with decompensated cirrhosis at 3 high-volume transplant centers in California. Patient participants were adults and had a diagnosis of cirrhosis, at least 1 portal hypertension-related complication, and current or previous Model for End-Stage Liver Disease with sodium score of 15 or higher. Clinician participants were health care professionals who provided care during the illness trajectory. MAIN OUTCOMES AND MEASURES Experiences with ACP reported by patients and clinicians. Participants were asked about the context, behaviors, thoughts, and decisions concerning elements of ACP, such as prognosis, health care preferences, values and goals, surrogate decision-making, and documentation. RESULTS The study included 42 patients (mean [SD] age, 58.2 [11.2] years; 28 men [67%]) and 46 clinicians (13 hepatologists [28%], 11 transplant coordinators [24%], 9 hepatobiliary surgeons [20%], 6 social workers [13%], 5 hepatology nurse practitioners [11%], and 2 critical care physicians [4%]). Five themes that represent the experiences of ACP were identified: (1) most patient consideration of values, goals, and preferences occurred outside outpatient visits; (2) optimistic attitudes from transplant teams hindered the discussions about dying; (3) clinicians primarily discussed death as a strategy for encouraging behavioral change; (4) transplant teams avoided discussing nonaggressive treatment options with patients; and (5) surrogate decision makers were unprepared for end-of-life decision-making. CONCLUSIONS AND RELEVANCE This study found that, despite a guarded prognosis, patients with decompensated cirrhosis had inadequate ACP throughout the trajectory of illness until the end of life. This finding may explain excessively aggressive life-sustaining treatment that patients receive at the end of life.
Collapse
Affiliation(s)
- Arpan Arun Patel
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles.,Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Gery W Ryan
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Diana Tisnado
- Department of Public Health, California State University, Fullerton
| | - Emmeline Chuang
- School of Social Welfare, University of California, Berkeley, Berkeley.,Department of Health Policy and Management, UCLA Fielding School of Public Health
| | - Anne M Walling
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA
| | - Sammy Saab
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles.,Division of Liver Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA
| | - Saro Khemichian
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles
| | - Vinay Sundaram
- Karsh Division of Gastroenterology and Comprehensive Transplant Center, Cedars Sinai Medical Center, Los Angeles, California
| | - Robert H Brook
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA.,RAND Health Care, Santa Monica, California
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA
| |
Collapse
|
25
|
Subramoney K, Orman E, Johnson AW, Kara A. The Impact of Obesity in End of Life Care in Patients With End Stage Liver Disease: An Observational Study. Am J Hosp Palliat Care 2020; 38:1177-1181. [PMID: 33280394 DOI: 10.1177/1049909120978768] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Both obesity and end stage liver disease (ESLD) are increasing. Obesity's impact on hospice and palliative care in patients with ESLD is unknown. METHODS We retrospectively evaluated patients admitted to an academic, Midwestern, tertiary center between January 2016 and May 2019 with a diagnosis of ESLD. Body Mass Index and MELD Na were calculated for each patient's first admission during the study period. Patients with MELD Na scores ≥ 21 or 18-20 with additional criteria were considered potentially eligible for hospice and palliative care referrals. RESULTS Of 3863 patients admitted with ESLD, 1556 (40%) were potentially eligible for hospice and palliative care referrals. Of these, 703 (45%) were obese. Comorbidity burden was higher in obese patients (15.6% of obese patients had a Charlson Comorbidity Index ≥ 5, while 5% of non-obese patients had a comorbidity index of ≥ 5 (p < 0.001). Referral rates to hospice and palliative services in obese patients were 10.1% and 16.4% respectively. Hospice and palliative referral rates among non-obese patients were similar (10.1% and 15.5%). Among patients who died within 6 months of the first hospitalization, the mean time to referral to hospice or palliative care from index admission was longer in obese patients. CONCLUSION Obesity is common in patients hospitalized with ESLD who may be approaching the end of life. Referral rates to hospice and palliative care services are low and similar regardless of BMI and despite higher co-morbidity burdens in obese patients. Obesity may delay referrals to hospice and palliative care.
Collapse
Affiliation(s)
| | - Eric Orman
- 10668Indiana University School of Medicine, Indianapolis, IN, USA
| | - Amy W Johnson
- 10668Indiana University School of Medicine, Indianapolis, IN, USA
| | - Areeba Kara
- 10668Indiana University School of Medicine, Indianapolis, IN, USA
| |
Collapse
|
26
|
Arshad A, Irshad L, Nabavi T, Whitehouse T. Acute-on-chronic liver failure: to admit to intensive care or not? Br J Hosp Med (Lond) 2020; 81:1-6. [PMID: 32990068 DOI: 10.12968/hmed.2020.0310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Acute-on-chronic liver failure is used to describe an acute decline in liver function in a patient with existing liver disease combined with other organ failure. Acute-on-chronic liver failure is associated with high short-term mortality, and the greater the number and severity of organ failures, the higher the mortality. The most commonly identified precipitants of acute-on-chronic liver failure include bacterial infection, gastrointestinal haemorrhage, viral hepatitis and recent excessive alcohol intake. Since some of these aetiologies are treatable, organ failure may return to pre-decompensation levels in up to 55% of patients. As a result, a trial of critical care treatment may be appropriate for many of these patients. Clinical scoring tools may help clinicians recognise futility, allowing timely withdrawal of organ support and shifting the focus of care toward palliation.
Collapse
Affiliation(s)
- Asif Arshad
- Department of Critical Care, University Hospital Birmingham, Birmingham, UK
| | - Lylah Irshad
- University of Birmingham Medical School, University of Birmingham, Birmingham, UK
| | - Theodore Nabavi
- University of Birmingham Medical School, University of Birmingham, Birmingham, UK
| | - Tony Whitehouse
- Department of Critical Care, University Hospital Birmingham, Birmingham, UK
| |
Collapse
|
27
|
Schaffhausen CR, Bruin MJ, Chu S, Fu H, McKinney WT, Schladt D, Snyder JJ, Kim WR, Lake JR, Kasiske BL, Israni AK. Tool to Aid Patients in Selecting a Liver Transplant Center. Liver Transpl 2020; 26:337-348. [PMID: 31923342 PMCID: PMC8193801 DOI: 10.1002/lt.25715] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 12/13/2019] [Indexed: 12/31/2022]
Abstract
Variations in candidate and donor acceptance criteria may influence access and mortality for liver transplantation. We sought to understand how recipient and donor characteristics vary across centers and how patients interpret this information, and we used these data to develop a tool to provide tailored information to candidates seeking a center (www.transplantcentersearch.org). We analyzed liver recipient data from the Scientific Registry of Transplant Recipients to determine how recipient and donor characteristics (eg, age, Medicaid use, and human immunodeficiency virus status) varied across programs. Data included recipients and donors at each US program between January 1, 2015, and December 31, 2017. The variation in characteristics was plotted with centers stratified by total transplant volume and by volume of each characteristic. A subset of characteristics was plotted to show variation over 3 years. We created mockups of potential reports displaying recipient characteristics alongside pretransplant and posttransplant outcomes and solicited feedback at patient and family interviews and focus groups, which included 39 individuals: 10 pilot interviews with candidates seeking liver transplant at the University of Minnesota-Fairview (UMNF) and 5 focus groups with 13 UMNF candidates, 6 UMNF family members, and 10 national recipients. Transcripts were analyzed using a thematic analysis. Several themes emerged: (1) Candidates experience gaps in existing education about center options; (2) patients requested information about how selection criteria might impact access to transplant; and (3) information tailored to a candidate's medical characteristics can inform decisions. Characteristics shown on mockups varied across centers (P < 0.01). Variation was widespread for small and large centers. In conclusion, variation exists in recipient and donor characteristics across centers. Liver transplant patients provide positive feedback upon viewing patient-specific search tools.
Collapse
Affiliation(s)
| | | | - Sauman Chu
- College of Design, University of Minnesota, Minneapolis, MN
| | - Helen Fu
- Hennepin Healthcare Research Institute, Minneapolis, MN
| | | | - David Schladt
- Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Jon J. Snyder
- Hennepin Healthcare Research Institute, Minneapolis, MN,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
| | - W. Ray Kim
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN
| | - Jack R. Lake
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
| | - Bertram L. Kasiske
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, MN
| | - Ajay K. Israni
- Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, MN
| |
Collapse
|
28
|
Holden JH, Shamseddeen H, Johnson AW, Byriel B, Subramoney K, Cheng YW, Saito A, Ghabril M, Chalasani N, Sachs GA, Orman ES. Palliative Care and Hospice Referrals in Patients with Decompensated Cirrhosis: What Factors Are Important? J Palliat Med 2020; 23:1066-1075. [PMID: 32091954 DOI: 10.1089/jpm.2019.0501] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Palliative care (PC) and hospice care are underutilized for patients with end-stage liver disease, but factors associated with these patterns of utilization are not well understood. Objective: We examined patient-level factors associated with both PC and hospice referrals in patients with decompensated cirrhosis (DC). Design: Retrospective cohort study. Setting/Subjects: Patients with DC hospitalized at a single tertiary center and followed for one year. Measurements: We assessed PC and hospice referrals during follow-up and examined patient-level factors associated with the receipt of PC and/or hospice, as well as associated clinical outcomes. We also examined late referrals (within one week of death). Results: Of 397 patients, 61 (15.4%) were referred to PC, 71 (17.9%) were referred to hospice, and 99 (24.9%) were referred to PC and/or hospice. Two hundred patients (50.4%) died during the one-year follow-up. In multivariable logistic regression, referral to PC was associated with increased comorbidity burden, ascites, increased MELD (Model for End-Stage Liver Disease)-Na score, lack of listing for liver transplant, and unmarried status. Hospice referral was associated with increased comorbidities, portal vein thrombosis, and hepatocellular carcinoma. PC referrals were late in 68.5% of cases, and hospice referrals were late in 62.7%. Late PC referrals were associated with younger age and married status. Late hospice referrals were associated with younger age and recent alcohol use. Conclusions: PC and hospice is underutilized in patients with DC, and most referrals are late. Patient-level factors associated with these referrals differ between PC and hospice.
Collapse
Affiliation(s)
- John H Holden
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Hani Shamseddeen
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Amy W Johnson
- Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, USA
| | - Benjamin Byriel
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Kavitha Subramoney
- Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, USA
| | - Yao-Wen Cheng
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, California, USA
| | - Akira Saito
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Greg A Sachs
- Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, USA.,Regenstrief Institute, Inc., Indianapolis, Indiana
| | - Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| |
Collapse
|
29
|
Improving Communication in Outpatient Consultations in People With Cirrhosis: The Development of a Question Prompt List (QPL). J Clin Gastroenterol 2020; 54:898-904. [PMID: 32301836 PMCID: PMC7664949 DOI: 10.1097/mcg.0000000000001347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS Liver health professionals have difficulty discussing liver cirrhosis and its prognosis with patients and families. Question Prompt Lists (QPLs), which are evidence-based lists of "recommended questions," may improve communication but need to be designed specifically for the target population. This study aimed to develop and pilot a QPL for patients with cirrhosis. METHODS A mixed-methods design in 3 phases. In phase 1 (item generation), potential questions for inclusion in the QPL were identified from 3 sources-a scoping literature review; an online survey; and interviews with patients, family members, and health professionals. In phase 2 (QPL construction), a multidisciplinary expert panel finalized the selection of questions and the format of the QPL. In phase 3 (pilot study), the QPL was assessed for acceptability and feasibility in a hepatology outpatient clinic population. RESULTS From 258 topics initially identified, 30 questions were included in the first draft of the QPL. After review by a multidisciplinary expert panel including patients, the QPL was reduced to 22 questions. In the pilot study, 133/215 eligible patients consented to participate, although only 67/133 used the QPL in their clinic appointment. Among those who used the QPL, all questions were asked at least once. The most commonly asked question related to life expectancy. Most participants expressed support for the content of the QPL. CONCLUSIONS A QPL, suitable for use in patients with liver cirrhosis attending hepatology outpatient clinics, has been developed and piloted. The QPL seems to be feasible to use and acceptable to patients and clinicians. Further work is needed to evaluate its effectiveness and to determine optimum delivery in clinical practice.
Collapse
|
30
|
Barnes A, Woodman RJ, Kleinig P, Briffa M, To T, Wigg AJ. Early palliative care referral in patients with end stage liver disease is associated with reduced resource utilisation. J Gastroenterol Hepatol 2019; 35:840-845. [PMID: 31613397 DOI: 10.1111/jgh.14877] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/14/2019] [Accepted: 09/17/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Palliative care referral for end stage liver disease (ESLD) is uncommon and usually occurs late. We aimed to review the rate of early palliative care referral (EPCR) in ESLD patients, its associations, and its impacts on resource utilisation and survival. METHODS A retrospective review of all patients with ESLD admitted to a single hepatology unit between 2013 and 2016. Inclusion criteria for study entry were at least two admissions for decompensated liver disease within a six month period and not eligible for liver transplantation. The EPCR group was defined as those patients who received palliative care referral at least 30 days prior to mortality. RESULTS 74 patients were included in the study. EPCR rate was 19%. On multivariate analysis EPCR was associated with hepatocellular carcinoma (OR 4.47, 95% CI 1.02-19.5, p=0.047), and negatively associated with alcoholic liver disease (OR 0.16, 95% CI 0.032-0.88 p=0.035). There was no difference in survival based on EPCR status. Hospitalization costs were lower in the EPCR group (p=0.027). There was also a significantly lower number of endoscopies (p=0.009), and blood transfusions (p=0.001) in the EPCR group. EPCR was also associated with higher rates of outpatient palliative care and advanced care planning. CONCLUSIONS EPCR in ESLD was uncommon and associated with hepatocellular carcinoma and lack of alcoholic liver disease. EPCR was associated with decreased resource utilisation and further high quality studies are required to confirm the benefits of EPCR in ESLD.
Collapse
Affiliation(s)
- Alex Barnes
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, Australia
| | - Richard J Woodman
- Department of Epidemiliology and Biostatistics, College of Medicine and Public Health, Flinders University of South Australia, Australia
| | - Paul Kleinig
- Southern Adelaide Palliative Care Services, Australia
| | | | - Timothy To
- Southern Adelaide Palliative Care Services, Australia
| | - Alan J Wigg
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, Australia
- College of Medicine and Public Health, Flinders University of South Australia, Australia
| |
Collapse
|
31
|
Fricker ZP, Serper M. Current Knowledge, Barriers to Implementation, and Future Directions in Palliative Care for End-Stage Liver Disease. Liver Transpl 2019; 25:787-796. [PMID: 30758901 DOI: 10.1002/lt.25434] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 02/10/2019] [Indexed: 02/07/2023]
Abstract
End-stage liver disease (ESLD) is associated with a high degree of morbidity and mortality as well as symptom burden. Despite this, the rate of consultation with palliative care (PC) providers remains low, and invasive procedures near the end of life are commonplace. Studies show that involvement of PC providers improves patient satisfaction, and evidence from other chronic diseases demonstrates reduced costs of care and potentially increased survival. Better integration of PC is imperative but hindered by patient and provider misconceptions about its role in the care of patients with ESLD, specifically among candidates for liver transplantation. Additionally, reimbursement barriers and lack of provider knowledge may contribute to PC underutilization. In this review, we discuss the benefits of PC in ESLD, the variability of its delivery, and key stakeholders' perceptions about its use. Additionally, we identify barriers to more widespread PC adoption and highlight areas for future research.
Collapse
Affiliation(s)
- Zachary P Fricker
- Division of Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Marina Serper
- Division of Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
32
|
Thomas T, Chandan JS, Bhala N. Unmet needs in end-of-life care for chronic liver disease. Lancet Gastroenterol Hepatol 2019; 4:6-7. [DOI: 10.1016/s2468-1253(18)30386-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 11/19/2018] [Indexed: 11/15/2022]
|
33
|
Low JTS, Rohde G, Pittordou K, Candy B, Davis S, Marshall A, Stone P. Supportive and palliative care in people with cirrhosis: International systematic review of the perspective of patients, family members and health professionals. J Hepatol 2018; 69:1260-1273. [PMID: 30243996 DOI: 10.1016/j.jhep.2018.08.028] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 08/15/2018] [Accepted: 08/21/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS People with cirrhosis have unmet needs, which could benefit from a palliative care approach. Developing effective services needs to be based on evidence from those with personal experience. This review aims to explore; patient and family perspectives of perceived needs including communication; health professionals' perspectives on delivery of care and improving palliative care between specialities. METHODS A literature search was conducted in Medline, Embase and CINAHL using key words reporting on the perspectives of patients with liver cirrhosis (18 years and over), family members or health professionals on the provision of care in liver cirrhosis. Study quality was assessed using the Mixed Methods Appraisal Tool. Qualitative and quantitative findings were grouped together according to the main relevant themes identified. RESULTS Nineteen research studies predominantly from high-income Western countries were identified, with a total sample consisting of 1,413 patients, 31 family carers and 733 health professionals. Patients and family members had limited understanding of cirrhosis or its impact. They wanted better information about their disease, its treatment and help with psychological and practical needs. Health professionals had difficulty communicating about these issues to patients and their families. General practitioners left care predominantly to the liver clinicians, who lacked confidence to have discussions about prognosis or future care preferences. The role of palliative care was recognised as important in caring for this group through earlier integration with liver and community services. CONCLUSIONS Health professionals need support to improve their communication with patients, to address patients' broader needs beyond medical treatment and to develop new models to improve palliative care coordination between different medical specialities. Future research should focus on developing communication aides, testing existing tools to identify suitable patients for supportive care and exploring robust ways of evaluating supportive care interventions, with more studies needed from middle- and low-income countries. Registration number: PROSPERO CRD42017064770. LAY SUMMARY Patients and their families had a poor understanding of advanced liver disease and its impact on them. They need more information about the treatments they receive and how to get practical and psychological support. Liver specialists and GPs found it difficult to talk to patients and their families about the seriousness of advanced liver disease and the lack of healthcare options available to them if their condition gets worse. All doctors and nurses involved in the care of patients with advanced liver disease recognise that palliative and supportive care have an important role in improving patient care.
Collapse
Affiliation(s)
- Joseph T S Low
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London W1T 7NF, United Kingdom.
| | - Gudrun Rohde
- Faculty of Health and Sport Sciences, University of Agder and Department of Clinical Research, Sorlandet Hospital, Postboks 422, 4604 Kristiansand, Norway
| | - Katherine Pittordou
- Whittington Health NHS Trust, Magdala Avenue, London N19 5NF, United Kingdom
| | - Bridget Candy
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London W1T 7NF, United Kingdom
| | - Sarah Davis
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London W1T 7NF, United Kingdom
| | - Aileen Marshall
- Sheila Sherlock Liver Unit, Royal Free Hospital & University College London Institute of Liver and Digestive Health, UCL Royal Free Campus, Pond Street, London NW3 2QG, United Kingdom
| | - Paddy Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London W1T 7NF, United Kingdom
| |
Collapse
|
34
|
Mazzarelli C, Prentice WM, Heneghan MA, Belli LS, Agarwal K, Cannon MD. Palliative care in end-stage liver disease: Time to do better? Liver Transpl 2018; 24:961-968. [PMID: 29729119 DOI: 10.1002/lt.25193] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/28/2018] [Accepted: 04/08/2018] [Indexed: 12/12/2022]
Abstract
Optimal involvement of palliative care (PC) services in the management of patients with decompensated cirrhosis and end-stage liver disease (ESLD) is limited. This may result from both ignorance and the failure to recognize the spectrum and unpredictability of the underlying liver condition. Palliative care is a branch of medicine that focuses on quality of life (QoL) by optimizing symptom management and providing psychosocial, spiritual, and practical support for both patients and their caregivers. Historically, palliative care has been underutilized for patients with decompensated liver disease. This review provides an evidence-based analysis of the benefits of the integration of palliative care into the management of patients with ESLD. Liver Transplantation 24 961-968 2018 AASLD.
Collapse
Affiliation(s)
- Chiara Mazzarelli
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom.,Hepatology and Gastroenterology Unit, ASST Ospedale Niguarda, Milan, Italy
| | - Wendy M Prentice
- Cicely Saunders Institute, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Luca S Belli
- Hepatology and Gastroenterology Unit, ASST Ospedale Niguarda, Milan, Italy
| | - Kosh Agarwal
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Mary D Cannon
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| |
Collapse
|
35
|
Low J, Marshall A, Craig R, Davis S, Gola A, Greenslade L, Henawi N, Stone P, Vickerstaff V, Wilson J, Thorburn D. Why do we offer palliative care so late to patients with liver disease? Lancet Gastroenterol Hepatol 2018. [PMID: 29533195 DOI: 10.1016/s2468-1253(18)30044-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Joseph Low
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London W1T 7NF, UK.
| | - Aileen Marshall
- Sheila Sherlock Liver Unit, Royal Free Hospital & University College London Institute of Liver and Digestive Health, UCL Royal Free Campus, London, UK
| | - Rachel Craig
- Department of Palliative Care, Royal Free London NHS Foundation Trust, London, UK
| | - Sarah Davis
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London W1T 7NF, UK
| | - Anna Gola
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London W1T 7NF, UK
| | - Lynda Greenslade
- Sheila Sherlock Liver Unit, Royal Free Hospital & University College London Institute of Liver and Digestive Health, UCL Royal Free Campus, London, UK
| | - Nicola Henawi
- Department of Palliative Care, Royal Free London NHS Foundation Trust, London, UK
| | - Paddy Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London W1T 7NF, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London W1T 7NF, UK
| | - Jo Wilson
- Department of Palliative Care, Royal Free London NHS Foundation Trust, London, UK
| | - Douglas Thorburn
- Sheila Sherlock Liver Unit, Royal Free Hospital & University College London Institute of Liver and Digestive Health, UCL Royal Free Campus, London, UK
| |
Collapse
|
36
|
Effiong A, Kumari P. Pharmacotherapies for fatigue in chronic liver disease (CLD): a systematic review and meta-analysis (protocol). Syst Rev 2018; 7:28. [PMID: 29444700 PMCID: PMC5813416 DOI: 10.1186/s13643-018-0688-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 01/15/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND This is the protocol for a systematic review (and meta-analysis) of an intervention. The primary objective of this systematic review will be to assess the benefits and harms of pharmacological therapies (pharmacotherapies) for the management of fatigue in adults with CLD of any etiology. The effects of pharmacological therapies on fatigue in CLD will be compared against those of placebo, no intervention, or non-pharmacological interventions. Specifically, this review will examine whether pharmacological therapies improve CLD-associated fatigue, and if they do, what key elements are associated with their effectiveness. The results of this systematic review will assist clinicians, policy-makers, researchers, and people with CLD in decision-making on how best to manage fatigue and its associated symptoms. METHODS MEDLINE, SCOPUS, EMBASE, EU Clinical Trials Register, WHO International Clinical Trials Registry Platform, CENTRAL (The Cochrane Library), ClinicalTrials.gov, reference lists of articles and conference proceedings will be searched for relevant studies. No language or date restrictions will be applied. Eligible studies will include adults with CLD of any etiology. Included studies will be randomized controlled trials. From included studies, data on participant characteristics, study design, setting, research ethics compliance, and intervention outcomes will be extracted. Risk of bias in included studies will be assessed using the Cochrane Risk of Bias Tool. A random-effects meta-analysis will be conducted. If substantial or considerable levels of heterogeneity are detected, analysis will be limited to a narrative synthesis. DISCUSSION This systematic review will examine the effectiveness of pharmacological therapies on fatigue reduction in people with CLD. Such therapies may be more effective than non-pharmacological interventions in treating fatigue symptoms in CLD. Evidence derived from the findings of this study will guide future practice, policy, and research. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42017076957.
Collapse
Affiliation(s)
- Andem Effiong
- Georgetown University, 3700 O St NW, Washington, DC, 20057, USA.
| | - Prerna Kumari
- Manipal College of Pharmaceutical Sciences, Manipal, Karnataka, India
| |
Collapse
|