A randomized controlled trial of a postdischarge nursing intervention for patients with decompensated cirrhosis.

BACKGROUND: Few randomized trials have evaluated the effect of postdischarge interventions for patients with liver cirrhosis. This study assessed the effects of a postdischarge intervention on readmissions and mortality in patients with decompensated liver cirrhosis. METHODS: We conducted a randomized controlled trial at a specialized liver unit. Adult patients admitted with complications of liver cirrhosis were eligible for inclusion. Participants were allocated 1:1 to standard follow-up or a family-focused nurse-led postdischarge intervention between December 1, 2019, and October 31, 2021. The 6-month intervention consisted of a patient pamphlet, 3 home visits, and 3 follow-up telephone calls by a specialized liver nurse. The primary outcome was the number of readmissions due to liver cirrhosis. RESULTS: Of the 110 included participants, 93% had alcohol as a primary etiology. We found no significant differences in effects in the primary outcomes such as time to first readmission, number of patients readmitted, and duration of readmissions or in the secondary outcomes like health-related quality of life and 6- and 12-month mortality. A post hoc exploratory analysis showed a significant reduction in nonattendance rates in the intervention group (RR: 0.28, 95% CI: 0.13-0.54, p=0.0004) and significantly fewer participants continuing to consume alcohol in the intervention group (p=0.003). After 12 months, the total number of readmissions (RR: 0.76, 95% CI: 0.59-0.96, p=0.02) and liver-related readmissions (RR: 0.55, 95% CI: 0.36-0.82, p=0.003) were reduced in the intervention group. CONCLUSIONS: A family-focused postdischarge nursing intervention had no significant effects on any of the primary or secondary outcomes. In a post hoc exploratory analysis, we found reduced 6-month nonattendance and alcohol consumption rates, as well as reduced 12-month readmission rates in the intervention group.

Nursing Care of Patients With Cirrhosis: The LiverHope Nursing Project.

Cirrhosis is a complex disease that is associated with disturbances in different organs besides the liver, including kidneys, heart, arterial circulation, lungs, gut, and brain. As a consequence, patients develop a number of complications that result in frequent hospital admissions and high morbidity and mortality. Patients with cirrhosis require constant and rigorous monitoring both in and outside the hospital. In this context, the role of nurses in the care of patients with cirrhosis has not been sufficiently emphasized and there is very limited information about nursing care of patients with cirrhosis compared with other chronic diseases. The current article provides a review of nursing care for the different complications of patients with cirrhosis. Nurses with specific knowledge on liver diseases should be incorporated into multidisciplinary teams managing patients with cirrhosis, both inpatient and outpatient. Conclusion: Nurses play an important role in the management and prevention of complications of the disease and improvement in patients' quality of life and bridge the gap between clinicians and families, between primary care and hospital care, and provide medical education to patients and caregivers.

Health literacy and liver cirrhosis: testing three screening tools for face validity.

Patients who have liver cirrhosis, which is a chronic and complex disease, have to understand a lot of information, including the nature of the disease and the structure of the healthcare system. It is important for nurses to be able to tailor care to this group of patients. It can therefore be useful to know the level of patients' health literacy (HL). In general, HL is measured through self-administered questionnaires. This study investigated the face validity of three HL questionnaires with a total of 108 outpatients with liver cirrhosis. The patients were allocated to one of 6 groups, within which the questionnaires administered in a different order; the allocation to each groups was random. One-third of patients needed help to complete the questionnaires: these were mostly individuals with alcohol-related liver cirrhosis, low levels of education, who were mostly male. The order of questionnaires was found to be unimportant, as the results were similar across the 6 groups. Measuring HL in patients with liver cirrhosis is a challenge-and the findings of this study indicate that exposing patients to any questionnaire could be used as a rough screening tool.

[Quality of Life of Primary Caregivers of Liver Cirrhosis Patients and Related Factors].

BACKGROUND: The prognosis of patients with liver cirrhosis often involves multiple complications and repeated admissions, which may significantly burden and reduce the quality of life of the primary caregivers of these patients. PURPOSE: The purpose of this correlational study was to explore the relationship between the burden of caregivers of liver cirrhosis patients and their quality of life. METHODS: A structured questionnaire, which included the Primary Caregiver Burden Scale, Coping Behaviors Scale, the WHOQOL-BREF, and a caregiver demographic datasheet, was used to collect data. Descriptive and inferential statistics (independent t-test, one-way ANOVA, Pearson's product-moment correlation, and stepwise regression analysis) were used to analyze data. RESULTS: A total of 113 participants were recruited from a medical center in northern Taiwan. The results revealed: (1) The highest average scores for caregiver burden were in the financial domain, while the lowest average scores were in the physical domain. The highest average scores for quality of life were observed in the environment domain, while the lowest average scores were in the physical health domain. (2) Most of the caregivers adopted a problem-solving oriented strategy to care for their patient. (3) Overall care burden correlated negatively with overall quality of life (r = -.223, p < .05). The caregivers' "self-assessed health", "financial load", and "daily care hours" were significant factors affecting overall quality of life (F = 52.78, p < .05), accounting for 58% of the total variance in the results. CONCLUSIONS: The results of this study may help nurses better understand and work to reduce the burden of caregivers in order to enhance their quality of life. Nurses should assess caregiver burden, especially in cases where caregivers themselves are in a poor financial situation or have poor self-assessed health, in order to provide necessary support and assistance.

Prevalence and Severity of Nonalcoholic Fatty Liver Disease Among Caregivers of Patients With Nonalcoholic Fatty Liver Disease Cirrhosis.

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, affecting nearly 1 in 3 Americans.1 Nonalcoholic steatohepatitis (NASH), the clinically aggressive variant of NAFLD, has a propensity of fibrosis progression and increased risk of cirrhosis and hepatocellular carcinoma. NASH-related cirrhosis is now the most rapidly growing indication for liver transplantation (LT).2 Disease recurrence and progression to advanced fibrosis after LT are high3; however, the key contributors of these are unknown. We hypothesized that patients with NASH cirrhosis reside in a microenvironment conducive to not only development of NASH but also fibrosis progression, which likely persist after LT and contribute to disease recurrence. The hypothesis was tested by performing vibration-controlled transient elastography (VCTE) in primary caregivers and cohabitants of patients with decompensated cirrhosis awaiting LT.

Nurse-led clinic for patients with liver cirrhosis-effects on health-related quality of life: study protocol of a pragmatic multicentre randomised controlled trial.

INTRODUCTION: Liver cirrhosis affects health-related quality of life (HRQoL) even in its early stages. Morbidity is especially high when the disease decompensates and self-care actions become essential. Nurse involvement in secondary prevention in other chronic diseases has contributed to better symptom control, less need of inpatient care and improved HRQoL. In order to evaluate the impact of nurse involvement in the follow-up of patients with liver cirrhosis, we decided to compare structured nurse-led clinics, inspired by Dorothea Orem's nursing theory and motivational strategies, with a group of patients receiving standard care. The primary outcome is HRQoL and the secondary outcomes are quality of care, visits to outpatient clinics or hospitals, disease progress and health literacy. METHODS AND ANALYSIS: This is a pragmatic, multicentre randomised controlled study conducted at six Swedish hepatology departments. Eligible patients are adults with diagnosed cirrhosis of the liver (n=500). Participants are randomised into either an intervention with nurse-led follow-up group or into a standard of care group. Recruitment started in November 2016 and is expected to proceed until 2020. Primary outcomes are physical and mental HRQoL measured by RAND-36 at enrolment, after 1 and 2 years. ETHICS AND DISSEMINATION: The study is ethically approved by the Regional Ethical Review Board in Uppsala. The results shall be disseminated in international conferences and peer-reviewed articles. TRIAL REGISTRATION NUMBER: NCT02957253; Pre-results.

Palliative Care and Hospice Interventions in Decompensated Cirrhosis and Hepatocellular Carcinoma: A Rapid Review of Literature.

BACKGROUND: Patients with decompensated cirrhosis (DC) and/or hepatocellular carcinoma (HCC) have a high symptom burden and mortality and may benefit from palliative care (PC) and hospice interventions. OBJECTIVE: Our aim was to search published literature to determine the impact of PC and hospice interventions for patients with DC/HCC. METHODS: We searched electronic databases for adults with DC/HCC who received PC, using a rapid review methodology. Data were extracted for study design, participant and intervention characteristics, and three main groups of outcomes: healthcare resource utilization (HRU), end-of-life care (EOLC), and patient-reported outcomes. RESULTS: Of 2466 results, eight were included in final results. There were six retrospective cohort studies, one prospective cohort, and one quality improvement study. Five of eight studies had a high risk of bias and seven studied patients with HCC. A majority found a reduction in HRU (total cost of hospitalization, number of emergency department visits, hospital, and critical care admissions). Some studies found an impact on EOLC, including location of death (less likely to die in the hospital) and resuscitation (less likely to have resuscitation). One study evaluated survival and found hospice had no impact and another showed improvement of symptom burden. CONCLUSION: Studies included suggest that PC and hospice interventions in patients with DC/HCC reduce HRU, impact EOLC, and improve symptoms. Given the few number of studies, heterogeneity of interventions and outcomes, and high risk of bias, further high-quality research is needed on PC and hospice interventions with a greater focus on DC.

Advanced nurse practitioner-led abdominal therapeutic paracentesis.

Liver disease is a common cause of death in England and Wales, and ascites is associated with a 50% mortality rate. Most patients who present with ascites have underlying liver cirrhosis, and often require therapeutic paracentesis for symptomatic relief. This article describes a competency framework that was developed to enable advanced nurse practitioners to perform therapeutic paracentesis in an ambulatory care unit.

Nurse-led hepatocellular carcinoma surveillance clinic provides an effective method of monitoring patients with cirrhosis.

The aim of this study is to examine the acceptability and effectiveness of a nurse-led hepatocellular carcinoma (HCC) surveillance clinic in high-risk patients with cirrhosis/advanced fibrosis. Early detection of HCC is associated with better treatment outcomes and improved survival. International guidelines recommend 6-monthly surveillance of patients at risk of developing HCC. A nurse-led HCC surveillance protocol was established to support patients in adherence to surveillance protocols. The design used was retrospective document analysis. Retrospective analysis of healthcare records of patients referred to the clinic between August 2009 and December 2015. Extracted data included attendance of clinic visits, blood testing, ultrasound or other imaging, and outcomes. Ultrasound was attended within 6 months in 30.3% of cases and within 7 months in 71.2% of cases. The median time between Nurse-Led Clinic appointments, ultrasound scans and blood testing did not exceed 9 months. First year FibroScans were attended by 82.9% (63/76) patients; endoscopy was indicated for 42 and attended by 35 (83.3%) patients. Lesions were identified in 16 patients (21.5%) and HCC diagnosed in two patients. One patient died because of HCC and one to sub-dural haematoma. Nurse-led HCC surveillance was an effective method of monitoring patients with cirrhosis at high risk of developing HCC. Well-defined protocols enable timely identification of patients with HCC or hepatic decompensation so that management strategies can be implemented without delay. The potential benefits identified by this study warrant further, rigorous evaluation.

Being an informal caregiver for a relative with liver cirrhosis and overt hepatic encephalopathy: a phenomenological study.

AIMS AND OBJECTIVES: To explore the experiences of being an informal caregiver for a relative with liver cirrhosis and overt hepatic encephalopathy. BACKGROUND: Overt hepatic encephalopathy is a common complication in patients with liver cirrhosis. It is associated with decreased quality of life for patients, and presents a major burden for caregivers. The involvement of informal caregivers in medical care is recommended, but it has not been clearly described. An understanding of the experience of caregivers is needed to improve the support provided to them by healthcare professionals. DESIGN: A qualitative, interpretative, phenomenological approach was used. METHODS: Twelve informal caregivers participated in qualitative interviews. The analysis followed the six steps of the interpretative phenomenological approach. RESULTS: Caregivers' experiences were described using five themes: (1) feeling overwhelmed by their loved one having unexplainable symptoms and behaviours; (2) learning that this and previous experiences were complications of liver disease; (3) becoming aware of the symptoms of hepatic encephalopathy; (4) having feelings of being tied down and (5) experiencing and overcoming obstacles in working with healthcare professionals. CONCLUSIONS: This study provides insight into caregivers' experiences and the consequences for their lives. The first occurrence of symptoms was a shock, but receiving the diagnosis was seen as an important step in understanding and learning. Caregivers provide daily assessments of their relatives' conditions, and they feel responsible for medication management. Over time, the caregivers impressively showed how they were able to incorporate their personal experiences into caregiving and to accept more accountability in managing the disease. RELEVANCE TO CLINICAL PRACTICE: Nurses should acknowledge caregivers as experts in caring for their loved ones. Nurses can assist caregivers in managing an episode of hepatic encephalopathy and can provide individualised interventions to ease the future burden.

Factors associated with medication adherence in patients living with cirrhosis.

AIMS AND OBJECTIVES: Medication adherence in people with cirrhosis is largely unknown. This study aims to determine adherence patterns and factors associated with adherence in patients with cirrhosis. BACKGROUND: Prescribed medications are a pivotal component in the clinical management of cirrhosis with potential to retard disease progression and reduce complication risks. Medication adherence is necessary to optimise health outcomes. Understanding why medications are missed may help to develop strategies and inform nursing practice. DESIGN: Prospective cohort study. METHODS: Participants (n = 29) diagnosed with cirrhosis attending a tertiary hospital consented to complete a self-reported survey. Demographic information, adherence to medications, patient knowledge and quality of life data were collected, collated, checked and analysed using SPSS version 21. RESULTS: Less than half of the 28 patients who completed the adherence questionnaire (n = 13, 46%) reported that they had never missed medication. Being forgetful, being away from home and falling asleep contributed to nonadherence. Having less abdominal symptoms, less fatigue and increased emotional well-being were significantly associated with patients never missing medications. CONCLUSIONS: To our knowledge this is the first published study to describe adherent behaviour and the reasons medications are missed in this population. The percentage of nonadherent participants is of concern considering the potential morbidity risk that is associated with missed medications and rebound symptoms of cirrhosis. Strategies to improve and sustain adherence levels are required including enhanced adherence counselling offered to patients who are deteriorating or experience periodic exacerbation of symptoms. RELEVANCE TO CLINICAL PRACTICE: Study findings have the potential to change clinical practice especially the way nurses target motivational adherence counselling, key treatment messages, education and adherence monitoring. The results presented here provide a basis for developing adherence strategies and nursing management plans to improve adherence and health outcomes in people with cirrhosis.

Nursing Assessment Tool for People With Liver Cirrhosis.

The aim of this study was to describe the process of developing a nursing assessment tool for hospitalized adult patients with liver cirrhosis. A descriptive study was carried out in three stages. First, we conducted a literature review to develop a data collection tool on the basis of the Conceptual Model of Wanda Horta. Second, the data collection tool was assessed through an expert panel. Third, we conducted the pilot testing in hospitalized patients. Most of the comments offered by the panel members were accepted to improve the tool. The final version was in the form of a questionnaire with open-closed questions. The panel members concluded that the tool was useful for accurate nursing diagnosis. Horta's Conceptual Model assisted with the development of this data collection tool to help nurses identify accurate nursing diagnosis in hospitalized patients with liver cirrhosis. We hope that the tool can be used by all nurses in clinical practice.

Experiences of Individuals With Liver Cirrhosis: A Qualitative Study.

Liver cirrhosis is one of the main causes of mortality and morbidity worldwide. Health-related quality of life in cirrhotic patients is affected by the disease's complications. The purpose of this article was to describe the experiences of individuals with liver cirrhosis during critical illness. The aim was to investigate the disease experiences of liver cirrhosis. The authors conducted a phenomenological qualitative study, using a Colaizzi's seven-step method. Ten participants with liver cirrhosis participated in in-depth interviews. The data from this analysis were transformed into 119 codes, 11 subthemes, and 4 main themes including (1) confronting tension, (2) needs, (3) spirituality, and (4) interaction and effective communication. Findings could be used as a basis for information and emotional and social support interventions, as these can be effective in promoting adjustment to complications of cirrhosis by suitable interventions. Adequate adjustment through adaptation leads to successful completion of treatment and improved quality of life.

Outpatient interventions for hepatology patients with fluid retention: a review and synthesis of the literature.

Cirrhosis of the liver was the 12th leading cause of death in the United States, according to the 2010 Vital Statistics Report. Cirrhosis is responsible for more than 150,000 hospitalizations each year. Similar to heart failure, severe fluid retention in cirrhotic patients leads to hospitalizations and increase in resource utilization. Outpatient interventions can be used to decrease preventable hospitalizations. The existing literature was explored to determine what interventions can be implemented in an outpatient setting that may reduce or prevent hospital admissions for cirrhotic patients with fluid retention. Seventeen articles were included in the review of the literature. There were 9 randomized controlled trials that yielded a total of 1,694 patients. One meta-analysis yielded 5 randomized controlled trials with 330 patients. Three cohort studies yielded 86 patients. One systematic review yielded 2,115 articles and 2 literature reviews yielded 110 articles. One report from an expert committee was included in the review. Findings from the studies identified 6 main interventions that can be used for outpatient management of cirrhotic patients with fluid retention and may prevent related hospitalizations. These include dietary sodium restriction, diuretics, daily weights, albumin infusions and paracentesis, placement of a transjugular intrahepatic portosystemic shunt, and telephone management.

Management of patients with complications of cirrhosis.

Cirrhosis results from repeated hepatocellular injury over time, leading to portal hypertension and the development of ascites, hepatic encephalopathy, and varices. Despite improvements in medical care for patients with cirrhosis, mortality from infection, renal failure, and hepatocellular carcinoma remain high.