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Palliative care; Hepatocellular carcinoma; Barriers; Clinicians; Supportive oncology; Multidisciplinary management; Symptom management

Introduction

Hepatocellular carcinoma (HCC), the most prevalent form of primary liver cancer, presents a significant challenge as a complication of chronic liver disease. Its status as the fourth leading cause of cancerrelated death globally highlights the difficulties in achieving a cure. Early detection remains elusive for most cases, limiting access to potentially curative treatments [1]. Age, organ availability, psychosocial factors, and co-morbid illnesses further complicate treatment options, even with timely diagnosis. Additionally, racial and sociodemographic disparities persist in accessing standard treatments. Although overall survival for HCC patients has improved, the complexity of the disease has led to the approval of various treatments, including immunotherapies and combination therapies.

While early palliative care benefits have been established in several solid malignancy populations within the outpatient setting, the integration of supportive oncology practices, including palliative care specialists, has seen significant growth in recent years [2-5]. The American Association for the Study of Liver Diseases recognizes palliative care as a crucial element in the multidisciplinary management of HCC. However, evidence suggests that palliative care may not consistently reach HCC patients and their families until later stages of the illness or, in some cases, not at all. Several factors contribute to inhibiting timely palliative care referral in situations where it could be beneficial to patients and families. Concerns about conveying a loss of hope, uneven availability of palliative care in outpatient settings, and prognostic uncertainty may hinder timely referrals. Addressing these challenges and enhancing the integration of palliative care for HCC patients is crucial. Improving communication and collaboration among healthcare providers, raising awareness about the benefits of early palliative care, and ensuring equitable access to supportive services are essential steps to optimize the care and quality of life for individuals living with HCC. By recognizing the role of palliative care as a valuable complement to disease-focused treatments, healthcare professionals can better support patients and their families throughout their cancer journey. People living with hepatocellular carcinoma (HCC) face a considerable burden of symptoms and an unpredictable disease course. Palliative care has the potential to complement the care provided by HCC specialists by addressing symptom management, supporting family caregivers, facilitating communication, and offering psychosocial assistance [6,7]. However, determining the appropriate time for palliative care intervention can be challenging due to the variable nature of HCC's progression. Existing models have been helpful in illustrating the relevance of palliative care as the disease advances, but they may not fully capture the complexity of HCC, especially considering the impact of cirrhosis. To improve palliative care delivery for individuals with HCC, gaining a deeper understanding of the specific elements of palliative care that are most beneficial and the factors that hinder or delay palliative care referral is crucial. This study aims to explore the perspectives of healthcare professionals from various specialties who provide care to people with HCC. By identifying the facilitators and barriers of palliative care referral, valuable insights can be gained to enhance overall care and support for HCC patients [8]. The study adopted a qualitative cross-sectional design, using constructivist grounded theory methods. Clinicians' perspectives on palliative care referral, their decision-making process, and views on their patients' palliative care needs were explored. The study received ethical approval, and purposive sampling ensured a diverse group of participants from two academic medical centers with specialized liver cancer treatment programs. Participants included clinicians from various disciplines, such as nursing, medicine, and social work, who regularly interact with HCC patients in different practice settings. These settings encompassed medical, surgical, and radiation oncology, as well as palliative care practices [9,10]. The data analysis followed a rigorous process of open coding, axial coding, and selective coding. Quotations from the interviews were linked to specific codes, allowing for an evolving understanding of the factors influencing palliative care referral for HCC patients. Thematic saturation was achieved after the tenth interview, ensuring representation from diverse specialties and disciplines involved in HCC patient care. By delving into the perspectives of clinicians, this study aims to identify opportunities to improve the integration of palliative care for individuals facing HCC [11]. Understanding both the facilitators and barriers of palliative care referral will lead to tailored approaches and ultimately enhance the overall care and support provided to HCC patients and their families.

Management of symptoms: In the context of palliative care referral for individuals with hepatocellular carcinoma (HCC), certain symptoms were identified as facilitators. These symptoms included the need for managing cancer-related pain, anxiety, and insomnia. For instance, clinicians pointed out challenges in managing cancer-related pain specifically in liver surgery cases, leading to a preference for referring patients for palliative care assistance in symptom management. On the other hand, non-palliative care participants in the study highlighted a significant barrier to referral - a lack of information or understanding about the services provided by palliative care. Some participants expressed uncertainty about the full scope of palliative care offerings, making it difficult to identify patients who could benefit from these services. Moreover, participants, particularly hepatologists, mentioned barriers related to symptom management [12]. They believed that they or other specialists could adequately manage symptoms related to underlying liver disease, and therefore, may not consider palliative care necessary in such cases. Additionally, they observed that symptoms requiring palliative care support, such as severe pain, tend to manifest only in the advanced stages of the disease. Another barrier identified was concerns about palliative care potentially conflicting with curative therapies. Clinicians worried that patients might interpret palliative care as a loss of hope on the part of the treating team, leading to ambivalence about treatments. This concern was particularly significant in transplant programs where patient dedication is crucial, and introducing ambivalence could be detrimental to their journey. Furthermore, skepticism about palliative care was also mentioned by some participants, highlighting the different interpretations patients and providers may have regarding its role in HCC care. Overall, these findings shed light on the complex factors influencing the referral of HCC patients to palliative care. Addressing these facilitators and barriers will be vital in ensuring timely and appropriate palliative care interventions for individuals facing HCC, ultimately enhancing their overall care and support.

Results

The selective coding of data from our study yielded eight distinct categories that either facilitated or hindered the referral process to palliative care for individuals with HCC. Among the facilitators, four key factors emerged: Transitional Care Support: Palliative care was found to be helpful during critical periods of the HCC journey, providing support and guidance to patients and their families during transitions between different stages of care. Specialized Symptom Management: Clinicians recognized the need for expert assistance in managing symptoms such as pain, anxiety, and insomnia, where specialized knowledge and skills are essential for effective management.

Psychosocial Support: There was a demand for additional resources to address the psychosocial needs of HCC patients, emphasizing the importance of addressing emotional and psychological well-being.

Positive past experiences: Positive experiences with previous palliative care referrals led to subsequent referrals, indicating the perceived benefits and value of palliative care by both clinicians and patients. On the other hand, four barriers or inhibitory factors were identified:

Feasibility concerns: Some clinicians expressed concerns about the practicality and logistics of palliative care referral, possibly due to limited availability of palliative care services in certain practice settings.

Lack of information: A lack of information and understanding about palliative care among HCC-treating clinicians led to uncertainty about when and how to make appropriate referrals.

Perceived lack of need: In some cases, the primary treating team felt capable of managing symptom-related issues, leading to a lack of perceived need for palliative care assistance.

Concerns about loss of hope: There were concerns that palliative care referrals might convey a sense of hopelessness or resignation, potentially impacting patient perceptions and emotional well-being. Understanding these facilitating and inhibitory factors is crucial for improving the integration of palliative care into HCC management. By addressing the identified barriers, enhancing awareness, and emphasizing the benefits of early palliative care involvement, we can foster a more comprehensive and patient-centered approach to HCC treatment. Ultimately, optimizing palliative care referral for people with HCC can lead to improved quality of life, better symptom management, and enhanced support for patients and their families throughout their HCC journey.

Discussion

In our study, our primary aim was to gain comprehensive insights into the perspectives of clinicians treating hepatocellular carcinoma (HCC) patients regarding palliative care referral, their perceived needs related to palliative care, and their experiences in managing individuals with HCC. Through qualitative research methods, we collected valuable data that shed light on the factors influencing the decisionmaking process for palliative care referrals and the challenges faced by clinicians in this regard. The findings of our study revealed both facilitators and barriers to palliative care referral for people with HCC, as perceived by the clinicians [13]. The facilitators encompassed specific aspects of palliative care that were deemed helpful at various points along the course of HCC. Clinicians acknowledged that palliative care could offer valuable support during critical transitions in care, assistance in managing cancer-related symptoms such as pain, anxiety, and insomnia, and provision of much-needed psychosocial support [14]. Moreover, positive experiences with prior palliative care referrals emerged as an encouraging factor. These findings underscore the potential benefits of integrating palliative care into the comprehensive management of HCC and its potential positive impact on patients' quality of life. On the other hand, our study also identified barriers that impede palliative care referral for individuals with HCC. These barriers were evident at both the individual and systems levels. A significant hurdle was the lack of information and understanding about the full scope of palliative care services. Clinicians indicated a need for more clarity on when and whom to refer for palliative care, which could optimize the identification of appropriate patients who could benefit from these specialized services.

Additionally, concerns related to symptom management played a role in inhibiting referrals. Clinicians felt competent in managing certain symptoms themselves, particularly those associated with underlying liver disease, leading them to question the necessity of involving palliative care for symptom relief. Furthermore, concerns about palliative care were raised, with worries that referral might be perceived as giving up hope or causing ambivalence in patients [15]. This highlights the importance of addressing misconceptions and enhancing communication between clinicians and patients to foster a better understanding of palliative care's role in HCC management. To provide a clear overview of the factors identified, we have presented. By recognizing and understanding these factors, we can work towards promoting effective palliative care referral practices for individuals facing HCC. Importantly, we have also drawn insights from experiences with other serious illnesses, which can inform potential strategies to address these facilitators and barriers effectively in the context of HCC. Overall, our study significantly contributes to the field of palliative care for individuals with HCC. By gaining a deeper understanding of the perspectives of HCC-treating clinicians, we can develop targeted interventions to overcome barriers and capitalize on facilitators to enhance the integration of palliative care in HCC management. This, in turn, can lead to improved patient outcomes and overall quality of life for individuals living with HCC.

Conclusion

In conclusion, the qualitative study investigating the perspectives of HCC-treating clinicians on palliative care referral and related needs has provided valuable insights into the facilitators and barriers in this context. The findings underscore the potential benefits of palliative care, such as its usefulness during transitional care, effective symptom management, and provision of psychosocial support. However, certain barriers, including lack of information, concerns about symptom management, and fears of introducing ambivalence, hinder the referral process. Recognizing these factors is essential for optimizing palliative care integration in HCC management. By addressing the lack of information and providing clarity on referral criteria, we can enhance clinicians' understanding of the scope and benefits of palliative care, enabling them to identify suitable patients for referral. Moreover, promoting open communication between clinicians and patients can help alleviate concerns about palliative care and foster a better understanding of its role in HCC treatment. Our study has also drawn insights from experiences with other serious illnesses, offering potential strategies to overcome these facilitators and barriers in the context of HCC. This comprehensive approach to understanding palliative care referral in HCC is crucial for improving patient outcomes and quality of life. Moving forward, efforts should focus on implementing targeted interventions to promote palliative care referral for people with HCC. By fostering a collaborative approach among HCC-treating clinicians, palliative care specialists, and patients, we can optimize the timing and delivery of palliative care services to provide comprehensive support throughout the course of the disease. In conclusion, our study serves as a stepping stone towards enhancing palliative care delivery for individuals facing HCC. By addressing the identified facilitators and barriers, we can work towards ensuring that palliative care becomes an integral part of HCC management, offering patients and their families the support and comfort they need during this challenging journey. Through a patient-centered approach, we can ultimately improve the overall quality of care and quality of life for individuals with HCC, fostering a sense of comfort and well-being throughout their journey.

Acknowledgement

Not applicable.

Conflict of Interest

Author declares no conflict of interest.

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