title: Managing uncertainty in advanced liver disease: a qualitative, multiperspective, serial interview study.
abstract: OBJECTIVE
  To understand the experiences and support needs of people with advanced liver disease and those of their lay and professional carers to inform improvements in the supportive and palliative care of this rapidly growing but currently neglected patient group.
  
  
  METHODS
  Multiperspective, serial interviews. We conducted up to three qualitative in-depth interviews with each patient and lay carer over 12 months and single interviews with case-linked healthcare professionals. Data were analysed using grounded theory techniques.
  
  
  METHODS
  Patients with advanced liver disease of diverse aetiologies recruited from an inpatient hepatology ward, and their lay carers and case-linked healthcare professionals nominated by the patients.
  
  
  METHODS
  Primary and secondary care in South-East Scotland.
  
  
  RESULTS
  37 participants (15 patients, 11 lay and 11 professional carers) completed 51 individual and 13 joint patient-carer interviews. Nine patients died during the study. Uncertainty dominated experiences throughout the course of the illness, across patients' considerable physical, psychological, social and existential needs and affected patients, lay carers and professionals. This related to the nature of the condition, the unpredictability of physical deterioration and prognosis, poor communication and information-sharing, and complexities of care. The pervasive uncertainty also shaped patients' and lay carers' strategies for coping and impeded care planning. While patients' acute medical care was usually well coordinated, their ongoing care lacked structure and focus.
  
  
  CONCLUSIONS
  Living, dying and caring in advanced liver disease is dominated by pervasive, enduring and universally shared uncertainty. In the face of high levels of multidimensional patient distress, professionals must acknowledge this uncertainty in constructive ways that value its contribution to the person's coping approach. Pervasive uncertainty makes anticipatory care planning in advanced liver disease challenging, but planning 'just in case' is vital to ensure that patients receive timely and appropriate supportive and palliative care alongside effective management of this unpredictable illness.
authors.affiliation: Primary Palliative Care Research Group, Centre of Population Health Sciences, The University of Edinburgh, Edinburgh, UK.
authors.forename: Barbara
authors.initials: B
authors.lastname: Kimbell
authors.affiliation: Royal Infirmary of Edinburgh, Edinburgh, UK.
authors.forename: Kirsty
authors.initials: K
authors.lastname: Boyd
authors.affiliation: Primary Palliative Care Research Group, Centre of Population Health Sciences, The University of Edinburgh, Edinburgh, UK.
authors.forename: Marilyn
authors.initials: M
authors.lastname: Kendall
authors.affiliation: The University of Edinburgh, Edinburgh, UK.
authors.forename: John
authors.initials: J
authors.lastname: Iredale
authors.affiliation: Primary Palliative Care Research Group, Centre of Population Health Sciences, The University of Edinburgh, Edinburgh, UK.
authors.forename: Scott A
authors.initials: SA
authors.lastname: Murray
mesh_terms: D000223:Adaptation, Psychological; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017028:Caregivers / Q000523:psychology*; D019468:Disease Management; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008107:Liver Diseases / Q000523:psychology*; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000379:methods*; D036301:Qualitative Research; D012606:Scotland; D012944:Social Support; D035501:Uncertainty
keywords: PALLIATIVE CARE; QUALITATIVE RESEARCH