A Feasibility Trial of A Supportive Care Liver Nurse Specialist

Selected Paper

Kimbell, B., Murray, S. A., Byrne, H., Baird, A., Hayes, P. C., Macgilchrist, A., . . . Boyd, K. (2018). Palliative care for people with advanced liver disease: A feasibility trial of a supportive care liver nurse specialist. Palliative Medicine,32(5), 919-929. doi:10.1177/0269216318760441

Introduction to Palliative Care for Advanced Liver Disease

Liver disease is tremendously increasing death rates worldwide, and it is necessary to take an important step for its treatment. Palliative care is not present for patients of liver disease, it is only available for people living with kidney, heart, or lung disease (Mokdad et al., 2014). For this reason, this research is conducted which focus on providing the model of care and accessed the model within a randomized control trial. The tile of this research is informative detailing the benefits of palliative care for treatment of liver disease. The initial section of this research article showing the clear and concise background of the study, along with further explanation of objectives, methods, discussion, results and future recommendations. The background of this study explains the importance of palliative care and support for patients of advanced liver disease (Murray et al., 2017).

The authors designed this research by delivering 6 months interventions to a patient of liver disease from a trained nurse liver specialist. The nurse provides quality and support to the patient to live and get early recovery. The authors conduct a mixed-method analysis, by doing case analysis, questionnaires, and interviews with patient, care takers as well as professionals. Results indicate that the researchers recruited patients, family care takers, & professionals, and delivered the interventions once the patient returned home. Support, advise by experts, care can be accessed, and electronic care plans are also increased by the hospitals and primary care staff. Tools used in this study, such as palliative care outcome scale (POS) and questionnaire were also producing suitable outcomes. Moreover, it has been concluded that it is feasible and acceptable to use nurse-led interventions to give quality care and support for people with liver disease and their families (Kimbell et al., 2018).

Literature Review of Palliative Care for Advanced Liver Disease

Literature review of this research is covered in the introduction part. In this section, the authors review the existing evidences for care and support provided for liver disease patients and the trials observed by palliative care. Worldwide the death rates are increasing because of liver diseases, in 70 years it causes 90% of the deaths. Among which 70% deaths occurred in hospital settings are due to other comorbidities. Patient also face psychological and physical challenges, such as depression, anxiety, and fatigue (Kimbell & Murray, 2013). It is critical to address palliative care and support for the people with liver failure. Moreover, nursing interventions and care is also important in liver units, along with the ongoing support for neurological conditions, cancer, respiratory disorders, and heart failure (Haun et al., 2017). Supportive care for liver transplantation and hepatitis C services are the common procedure follows in liver units. Support, effective identification, and care are must to be maintained for quality life of a person having advanced liver disease. This will also minimize the sudden hospital admissions during end stages of life (Siouta et al., 2016). To manage physical complications in liver failure, randomized controlled trials (RCT) has been undertaken. It has been observed that no trials are available related to palliative care for people with advanced liver diseases. Evidence based studies suggest that care specialist and palliative care are successfully integrated to treat cancer (Tassinari et al., 2016). Although, another research suggests it is complex to manage advance liver disease, due to which specific expertise are required that may not be made possible by clinicians of palliative care or primary care. However, Integration of existing hepatology with palliative care is more accessible, deliverable, and satisfactory (Baumann et al., 2015). For this reason, this research is conducted which focus on providing the model of care and accessed the model within a feasibility trial to treat advanced liver diseases. The authors examined interventions for supportive care provided by nursing staff for advanced liver diseases. They aimed to answer three questions, that are-

  1. Weather informal care takers and healthcare workers are suitable for supportive care of patients or not?
  2. To ensure the potentially feasible new method for regular health and social services, what improvements are required with this intervention?
  3. Is RCT is feasible for recruitment and retention data collection to quantify the primary and secondary results?

Methodology of Palliative Care for Advanced Liver Disease

The authors conducted a mixed-method evaluation with feasibility trial in collaboration with PPI group (Patient and Public Involvement), to design and evaluate the experience of research in end-of-life care. Patients above age of 18 with decompensated cirrhosis as well as their families were recruited from a hepatology hospital ward in Scotland (Low et al., 2015). Eligibility of the patients were checked on this basis of their complexity and comorbidities of the disease. Those who survived within 1 month of hospital administration, determined cognitive impairment, and lived far from the recruitment sites (more than 50 miles) were excluded from the study (De et al., 2016). Also, those patients who are in waiting list for liver transplantation are excluded, as they were already getting support by liver specialists.

Intervention is provided for 21 hours each week by two liver nurses that has experience of above 10 years. There are 3 major defined roles of liver nurses, that is they cat as coordinator and manager, provide support care as professionals, and support and care for the patient as well as their care takers. Along with good clinical practice, palliative care training is also provided for more health opportunities while working in hospitals, and communities. Initially, face-to-face interaction is placed between the liver nurses and patients and their care takers. For supportive care, liver nurses guide the patient on calls for 6 months. After this duration, updated electronic summary and final review letter for care plan are delivered to the patient, their general practitioners, and hepatologist (Denvir et al., 2016).

All the records of nursing interactions, patient and family questionnaires were analyzed and approved by the PPI group. To measure the outcome of palliative care services, POS was used. To access quality life and economic evaluations, EuroQol-5D-5L was used, and to screen the depression and anxiety of patients, HADS (Hospital Anxiety and Depression Score) comes into role. Moreover, the interviews explore the feasibility, impact, and acceptability of the interventions. Lastly, the data was analyzed based on the research questions using NVivo qualitative data management software of 10th version. Data from questionnaires were analyzed by SPSS for 19 version of Windows (IBM, NY). To analyze the quality of life outcomes, descriptive studies were used, and compared using one-way ANOVA test (Analysis of Variance) for normal distribution, otherwise Friedman test has been used (Low et al., 2015).

Ethics Considerations

The researchers provided a detailed description of ethical authorization. Ethical approval was granted from South-East Scotland Research Ethics Committee 01 (reference 14/SS/1069). The research also received approval from governance, that was deliberated by the local NHS Research & Development service on 6 November 2014. Moreover, confidentiality and privacy of patient was also maintained throughout the study.

Significant Results

The interventions provided were meant to enhance the patient care with decompensated liver disease. The authors successfully recruit target population with advanced liver disease, and has planned or sudden hospital administration. Results from questionnaire at initial time suggest that delivery methods and instruments used in the study were acceptable. To detect the changes, feasibility is not designed, however statistical data analysis explained enhancement in palliative care outcomes as well as quality life of the patients over time (Murray et al., 2017). For improvement in patient anxiety and depressive conditions, little effect has been observed by HADS. This is due to the fact that if liver functioning gets worsen, then symptoms were frequently increased such as poor sleeping patterns, and fatigue. Interviews conducted were provide suggestions to improve the interventions for future trials. Moreover, nurse support was appreciated by many of the patients and their family care takers (Bhanji et al., 2017).

Discussion on Palliative Care for Advanced Liver Disease

This study proves that nurse-led interventions are beneficial, feasible, and acceptable for patients with advanced liver diseases. The ability of nurse to care and support the patients while managing their needs for advanced liver disease was appreciated. Interviews were conducted to measure the quality of life of people based on the scores of questionnaires (Kimbell et al., 2015). Results indicate that unplanned hospital administration can be reduced by help of nursing interventions. It can also minimize clinic non-attendance, visits, appointments for primary care, and improve early discharge facilities for patients. Liver nurses must be provided training for palliative care to improve their confidence while dealing with patients care planning, improvement in community care understanding, and other sensitive conversations (Salamanca-Balen et al., 2017). This study mainly highlights the positive outcomes of specialist nursing interventions for providing care to people living with advanced liver diseases. However, this study was limited to white patients of Scotland, and evaluation of palliative care is also unpredictable.

Recommendations on Palliative Care for Advanced Liver Disease

Future recommendation is to include a first administration with complex cirrhosis. RCT can be improved by seeking random interventions against continuation of ongoing best practice. To improve return rates, patient support through phones are recommended, along with the outcome measures by POS and EuroQol-5D-5L. Mindful analysis, education and training of professionals must be emphasized with potential treatment on mortality to provide holistic care for patients (Colantuoni et al., 2018).

References for Palliative Care for Advanced Liver Disease

Baumann, A. J., Wheeler, D. S., James, M., Turner, R., Siegel, A., & Navarro, V. J. (2015). Benefit of early palliative care intervention in end-stage liver disease patients awaiting liver transplantation. Journal of Pain and Symptom Management,50(6). doi: 10.1016/j.jpainsymman.2015.07.014

Bhanji, R. A., Carey, E. J., & Watt, K. D. (2017). Review article: Maximising quality of life while aspiring for quantity of life in end-stage liver disease. Alimentary Pharmacology & Therapeutics,46(1), 16-25. doi:10.1111/apt.14078

Colantuoni, E., Scharfstein, D. O., Wang, C., Hashem, M. D., Leroux, A., Needham, D. M., & Girard, T. D. (2018). Statistical methods to compare functional outcomes in randomized controlled trials with high mortality. Bmj. doi:10.1136/bmj.j5748

De, J., Wand, A. P., Smerdely, P. I., & Hunt, G. E. (2016). Validating the 4A's test in screening for delirium in a culturally diverse geriatric inpatient population. International Journal of Geriatric Psychiatry,32(12), 1322-1329. doi:10.1002/gps.4615

Denvir, M. A., Cudmore, S., Highet, G., Robertson, S., Donald, L., Stephen, J., . . . Boyd, K. (2016). Phase 2 randomised controlled trial and feasibility study of future care planning in patients with advanced heart disease. Scientific Reports,6(1). doi:10.1038/srep24619

Haun, M. W., Estel, S., Rücker, G., Friederich, H., Villalobos, M., Thomas, M., & Hartmann, M. (2017). Early palliative care for adults with advanced cancer. Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.cd011129.pub2

Kimbell, B., & Murray, S. A. (2013). What is the patient experience in advanced liver disease? A scoping review of the literature. BMJ Supportive & Palliative Care,5(5), 471-480. doi:10.1136/bmjspcare-2012-000435

Kimbell, B., Boyd, K., Kendall, M., Iredale, J., & Murray, S. A. (2015). Managing uncertainty in advanced liver disease: A qualitative, multiperspective, serial interview study: Table 1. BMJ Open,5(11). doi:10.1136/bmjopen-2015-009241

Kimbell, B., Murray, S. A., Byrne, H., Baird, A., Hayes, P. C., Macgilchrist, A., . . . Boyd, K. (2018). Palliative care for people with advanced liver disease: A feasibility trial of a supportive care liver nurse specialist. Palliative Medicine,32(5), 919-929. doi:10.1177/0269216318760441

Low, J., Vickerstaff, V., Davis, S., Bichard, J., Greenslade, L., Hopkins, K., . . . Jones, L. (2015). Palliative care for cirrhosis: A UK survey of health professionals’ perceptions, current practice and future needs. Frontline Gastroenterology,7(1), 4-9. doi:10.1136/flgastro-2015-100613

Mokdad, A. A., Lopez, A. D., Shahraz, S., Lozano, R., Mokdad, A. H., Stanaway, J., . . . Naghavi, M. (2014). Liver cirrhosis mortality in 187 countries between 1980 and 2010: A systematic analysis. BMC Medicine,12(1). doi:10.1186/s12916-014-0145-y

Murray, S. A., Kendall, M., Mitchell, G., Moine, S., Amblàs-Novellas, J., & Boyd, K. (2017). Palliative care from diagnosis to death. BMJ Open. doi:10.1136/bmj.j878

Salamanca-Balen, N., Seymour, J., Caswell, G., Whynes, D., & Tod, A. (2017). The costs, resource use and cost-effectiveness of Clinical Nurse Specialist–led interventions for patients with palliative care needs: A systematic review of international evidence. Palliative Medicine,32(2), 447-465. doi:10.1177/0269216317711570

Siouta, N., Beek, K. V., Eerden, M. E., Preston, N., Hasselaar, J. G., Hughes, S., . . . Menten, J. (2016). Integrated palliative care in Europe: A qualitative systematic literature review of empirically-tested models in cancer and chronic disease. BMC Palliative Care,15(1). doi:10.1186/s12904-016-0130-7

Tassinari, D., Drudi, F., Monterubbianesi, M. C., Stocchi, L., Ferioli, I., Marzaloni, A., . . . Sartori, S. (2016). Early palliative care in advanced oncologic and non-oncologic chronic diseases: A systematic review of literature. Reviews on Recent Clinical Trials,11(1), 63-71. doi:10.2174/1574887110666151014141650

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