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Ikumi Okamoto

University of Edinburgh, Schools of Health in Social Science and Divinity, Post-Doc

University of Cambridge, Institute of Public Health, Post-Doc

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Ikumi Okamoto is a medical anthropologist and Research Associate at the Edinburgh Palliative and Supportive Care Group (EPAS), University of Edinburgh. She specialises in qualitative research, and is currently working on a project titled "Mapping the Palliative and End of Life Care Research Workforce in the UK."

Prior to joining EPAS, she held a Research Associate position at the Palliative & End of Life Care Group in Cambridge (PELiCam), University of Cambridge.

Her research interests include:

- Palliative and end of life care
- Death and dying (with a focus on anthropological perspectives)
- Grief, loss, and bereavement

She completed her D.Phil. in Social (Medical) Anthropology at the University of Oxford, where her thesis examined the dying process of cancer patients in a Japanese palliative care unit. Since obtaining her doctorate, she has contributed to several healthcare projects, including palliative/supportive care and multiple long-term conditions in the UK.

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Papers by Ikumi Okamoto

4235 Involving people of diverse ethnicities in cancer research: an exploration of experiences, attitudes and barriers

European Journal of Cancer Supplements, 2009

Overcoming obstacles to conducting trials in the context of palliative care: an exploratory phase II cluster randomised trial to investigate the effectiveness of the Macmillan Approach to Weight Loss and Eating Difficulties (MAWE)

Login. ...

‘It’s Got to Be the Patient’s Decision’ Practicing Shared Decision-making in the U.K. Renal Units

In modern medicine, patient choice and involvement in treatment decision-making are increasingly ... more In modern medicine, patient choice and involvement in treatment decision-making are increasingly recognised as an important issue in improving the quality of healthcare, and in recent years the concept of shared decision-making has attracted attention as a new approach in the medical encounter. This model is particularly appropriate in life-threatening situations in which no best treatment exists and there are trade-offs between benefits and risk of available treatments. In this article, I demonstrate how clinical uncertainty makes shared decision-making difficult in practice, using the case of elderly patients with end-stage renal failure based on data collected by interviewing renal healthcare professionals in the U.K. I then propose the possibility of ‘patient choice’ becoming a burden for some elderly patients and the institutionalisation of shared decision-making and discuss the importance of building a good relationship between healthcare professionals and patients to facilitate shared decision-making.

Reuse of intermittent catheters: a qualitative study of IC users' perspectives

BMJ open, Jan 17, 2018

To explore the views of intermittent catheter (IC) users regarding the advantages and disadvantag... more To explore the views of intermittent catheter (IC) users regarding the advantages and disadvantages of single-use or reuse of catheters. Qualitative study with semi-structured interviews. The interviews were recorded, transcribed and analysed thematically. Participant's own homes in Hampshire and Dorset, UK. A convenience sample of 39 IC users, aged 23-86 years, using IC for at least 3 months. The analysis revealed four main themes: concerns regarding risk of urinary tract infection (UTI); cleaning, preparation and storage; social responsibility; practicalities and location. The main concern was safety, with the fear that reuse could increase risk of UTI compared with single-use sterile catheters. If shown to be safe then around half of participants thought they might consider reusing catheters. The practicalities of cleaning methods (extra products, time and storage) were considered potentially burdensome for reuse; but for single-use, ease of use and instant usability were adv...

Intermittent catheter users’ symptom identification, description and management of urinary tract infection: a qualitative study

BMJ Open, 2017

ObjectivesTo elucidate the views of intermittent catheter (IC) users regarding urinary tract infe... more ObjectivesTo elucidate the views of intermittent catheter (IC) users regarding urinary tract infection (UTI) symptom presentation, terminology for describing signs and symptoms, the cause of UTI and management strategies.DesignQualitative study with semi-structured interviews. The transcribed text was analysed thematically.Setting12 general practitioner (GP) surgeries in Hampshire and Dorset, UK.ParticipantsA convenience sample of 30 IC users, aged over 18, using IC for at least 3 months who had at least one self-reported UTI since starting IC.ResultsParticipants reported a variety of signs and symptoms, such as urine cloudiness and smell, as indicators of UTI. The terms used often differed from those in the modified National Institute on Disability and Rehabilitation Research (NIDRR) symptom set. IC users had difficulty distinguishing possible UTI symptoms from those of their comorbidities. They expressed uncertainty about the cause of UTI, often attributing it to poor hygiene and ...

Dying a good death at a palliative care unit in Japan. [In: Good Deaths/Bad Deaths:Dilemmas of Death in Comparative Perspective]

Cet article examine la conception de bonne mort dans le Japon contemporain a travers l'experi... more Cet article examine la conception de bonne mort dans le Japon contemporain a travers l'experience de mourrants recevant des soins paliatifs. Pour cela, j'examine tout d'abord la philosophie des hospices et la notion de bonne mort, a la fois dans les centres de soins occidentaux et japonais. Dans un deuxieme temps,j'analyse le type de mort traditionnellemet percue comme bonne au Japon. Avec comme cas d'etude la mort d'un patient dans une unite de soin paliatif japonais (PCU), je tenterai d'approffondir notre comprehension de que signifie la bonne mort dans la societe japonaise contemporaine.

It's Got to Be the Patient's Decision': Practicing Shared Decision-making in the U.K. Renal Units

Anthropology in Action, 2015

Journey from life to death

The kind of diseases affecting Japanese people and the causes of death in Japan have changed a ... more The kind of diseases affecting Japanese people and the causes of death in Japan have changed a great deal in the last several decades due to various factors, most notably the advancement of medical technology and changes in life style. The number of people who die from life style diseases such as cancer, which are chronic and possibly need long-term hospitalization, increases every year. In the 1970s the hospice philosophy was introduced to Japan from the West. It encourages patients and their families to affirm life and to regard dying as a normal process, and offers a support system to help patients live as actively as possible and sustain a sense of selfhood, autonomy, and dignity until they die. In practice, however, the dying process is still not regarded as normal in contemporary Japan and many patients fail to die in the way proposed by the hospice philosophy. There is also disagreement between the patients and the medical professionals regarding their respective idea of go...

The semistructured interview guide followed during staff interviews

Decision-making for people with dementia and advanced kidney disease: a secondary qualitative analysis of interviews from the Conservative Kidney Management Assessment of Practice Patterns Study

BMJ Open

ObjectiveTo explore dialysis decision-making for adults who lack capacity due to cognitive impair... more ObjectiveTo explore dialysis decision-making for adults who lack capacity due to cognitive impairment, a common and under-recognised condition in those with advanced chronic kidney disease (CKD).DesignSecondary analysis of qualitative data collected during the Conservative Kidney Management Assessment of Practice Patterns Study programme of research was performed. Sixty semistructured interviews were conducted with multiprofessional team members from UK renal centres. Staff were asked about local facilities, the value of conservative kidney management (CKM), when and with whom CKM was discussed and how CKM could be improved. Thematic analysis was employed to identify, characterise and report on themes that emerged from the data, focused on the specific issues experienced by people with dementia.SettingA purposive sample of nine UK renal centres differing in the scale of their CKM programmes.ParticipantsClinical directors of renal centres identified staff involved in CKM. Staff were ...

Understanding by Older Patients of Dialysis and Conservative Management for Chronic Kidney Failure

American Journal of Kidney Diseases

Background: Older adults with chronic kidney disease stage 5 may be offered a choice between dial... more Background: Older adults with chronic kidney disease stage 5 may be offered a choice between dialysis and conservative management. Few studies have explored patients' reasons for choosing conservative management and none have compared the views of those who have chosen different treatments across renal units. Study Design: Qualitative study with semi-structured interviews. Settings & Participants: Patients 75 years or older recruited from 9 renal units. Units were chosen to reflect variation in the scale of delivery of conservative management. Methodology: Semi-structured interviews audio recorded and transcribed verbatim. Analytical Approach: Data were analyzed using thematic analysis. Results: 42 interviews were completed, 4 to 6 per renal unit. Patients were sampled from those receiving dialysis, those preparing for dialysis, and those choosing conservative management. 14 patients in each group were interviewed. Patients who had chosen different treatments held varying belief...

Conservative care for end-stage kidney disease in the UK: a national survey

Clinical Journal of the American Society of Nephrology

Background and objectives: Conservative Kidney Management (CKM) has developed in the UK as an alt... more Background and objectives: Conservative Kidney Management (CKM) has developed in the UK as an alternative to dialysis for older patients with stage 5 chronic kidney disease (CKD5) and multiple comorbidities. We report on a national survey which aims to describe the current scale and pattern of delivery of conservative care in UK renal units and identify their priorities for its future development. Design, setting, participants, and measurements: A survey on practice patterns of CKM for patients aged over 75 years with CKD5 was sent to clinical directors of all 71 adult renal units in the UK in March 2013. Results: Sixty-seven units (94%) responded. All but one unit reported providing CKM for some patients. Terminology varied, although ‘conservative management’ was the most frequently used term (46%). Lack of an agreed definition of when a patient is receiving CKM made it difficult to obtain meaningful data on the numbers of such patients. 52% provided the number of CKM patients aged...

A national study of practice patterns in UK renal units in the use of dialysis and conservative kidney management to treat people aged 75 years and over with chronic kidney failure

Background: Conservative kidney management (CKM) is recognised as an alternative to dialysis for ... more Background: Conservative kidney management (CKM) is recognised as an alternative to dialysis for a significant number of older adults with multi-morbid chronic kidney disease stage 5 (CKD5). However, little is known about the way CKM is delivered or how it is perceived. Aim: To determine the practice patterns for CKM of older patients with CKD5, to inform service development and future research. Objectives: i) To describe the differences between renal units in the extent and nature of CKM. ii) To explore how decisions are made about treatment options for older patients with CKD5. iii) To explore clinicians willingness to randomise patients with CKD5 to CKM versus dialysis. iv) To describe the interface between renal units and primary care in managing CKD5. v) To identify the resources involved and potential costs of CKM. Methods: Mixed methods study. Interviews with 42 patients aged >75 with CKD5 and 60 renal unit staff in a purposive sample of nine UK renal units. Interviews inf...

Using the Clinical Research Network for psychosocial cancer research: lessons learned from two observational studies

BMJ supportive & palliative care, Jan 19, 2013

Patient recruitment to psychosocial oncology research has increased but the many studies have bee... more Patient recruitment to psychosocial oncology research has increased but the many studies have been single-site or small-scale. The National Institute for Health Research Clinical Research Network, supports National Institute for Health Research portfolio studies through provision of research staff for recruitment and follow-up. These studies are usually clinical trials of an investigational medicinal product. Psychosocial researchers have little used this resource. We report the processes followed and experiences of two psychosocial research teams who recently used the Clinical Research Network, to undertake patient recruitment to two prospective observational studies: electronic Patient-reported Outcomes from Cancer Survivors study (ePOCS) and the ColoREctal Wellbeing study (CREW). Both research groups employed different approaches to using Clinical Research Network support. ePOCS secured Comprehensive Local Research Networks funding to appoint ePOCS-specific study research nurses....

Lessons learnt recruiting to a multi-site UK cohort study to explore recovery of health and well-being after colorectal cancer (CREW study)

BMC Medical Research Methodology, 2013

Dying a good death at a palliative care unit in Japan

Tairyoku as a belief system of health and illness: a study of cancer patients in Japan

Anthropology and Medicine, Jan 1, 2008

Impact of cancer on everyday life: a systematic appraisal of the research evidence

Health Expectations

What to eat when off treatment and living with involuntary weight loss and cancer: a systematic search and narrative review

by Ikumi Okamoto and Jane Hopkinson

Supportive Care in Cancer, 2011

Purpose The aim of this study was to report a systematic search and narrative review of the evide... more Purpose The aim of this study was to report a systematic search and narrative review of the evidence base that can inform dietary advice for patients off treatment living with cancer cachexia syndrome (CCS). Methods Searches were conducted in MEDLINE, EMBASE, PsycINFO and CINAHL databases for publications about diet and cancer patients off treatment with symptoms of CCS. The following limits were applied: English language, from September 1998 to September 2008 and adults. In addition, a hand search included the reference lists of papers identified. Seven hundred and eighteen abstracts were assessed against inclusion/exclusion criteria and 88 were selected for full text independent examination by two researchers. Information from 48 papers was extracted, quality assessed, thematically analyzed and presented as a narrative synthesis. Results Two dominant perspectives emerged on what should be eaten by weight-losing cancer patients. The majority of authors advocated a nutrient-dense diet, facilitated by nutritional counselling. The alternative approach was to advise the patient to ‘eat what they want’. There is little robust evidence to justify either approach as able to deliver on the range of physical and psychosocial objectives that they aim to achieve. Conclusion A new model for the delivery of nutritional care may benefit cancer patients (off treatment) living with weight loss. The proposed model integrates the two identified perspectives to facilitate optimal food intake taking into account the patient's (1) disease symptoms and treatment side effects (2) emotional adaptation to illness and (3) social circumstances. Research is needed to establish which of these obstacles to eating can be changed for which patient groups to improve patient outcomes.

The Effectiveness of Patient-Family Carer (Couple) Intervention for the Management of Symptoms and Other Health-Related Problems in People Affected by Cancer: A Systematic Literature Search and Narrative Review

Journal of Pain and Symptom Management

4235 Involving people of diverse ethnicities in cancer research: an exploration of experiences, attitudes and barriers

European Journal of Cancer Supplements, 2009

Overcoming obstacles to conducting trials in the context of palliative care: an exploratory phase II cluster randomised trial to investigate the effectiveness of the Macmillan Approach to Weight Loss and Eating Difficulties (MAWE)

Login. ...

‘It’s Got to Be the Patient’s Decision’ Practicing Shared Decision-making in the U.K. Renal Units

In modern medicine, patient choice and involvement in treatment decision-making are increasingly ... more In modern medicine, patient choice and involvement in treatment decision-making are increasingly recognised as an important issue in improving the quality of healthcare, and in recent years the concept of shared decision-making has attracted attention as a new approach in the medical encounter. This model is particularly appropriate in life-threatening situations in which no best treatment exists and there are trade-offs between benefits and risk of available treatments. In this article, I demonstrate how clinical uncertainty makes shared decision-making difficult in practice, using the case of elderly patients with end-stage renal failure based on data collected by interviewing renal healthcare professionals in the U.K. I then propose the possibility of ‘patient choice’ becoming a burden for some elderly patients and the institutionalisation of shared decision-making and discuss the importance of building a good relationship between healthcare professionals and patients to facilitate shared decision-making.

Reuse of intermittent catheters: a qualitative study of IC users' perspectives

BMJ open, Jan 17, 2018

To explore the views of intermittent catheter (IC) users regarding the advantages and disadvantag... more To explore the views of intermittent catheter (IC) users regarding the advantages and disadvantages of single-use or reuse of catheters. Qualitative study with semi-structured interviews. The interviews were recorded, transcribed and analysed thematically. Participant's own homes in Hampshire and Dorset, UK. A convenience sample of 39 IC users, aged 23-86 years, using IC for at least 3 months. The analysis revealed four main themes: concerns regarding risk of urinary tract infection (UTI); cleaning, preparation and storage; social responsibility; practicalities and location. The main concern was safety, with the fear that reuse could increase risk of UTI compared with single-use sterile catheters. If shown to be safe then around half of participants thought they might consider reusing catheters. The practicalities of cleaning methods (extra products, time and storage) were considered potentially burdensome for reuse; but for single-use, ease of use and instant usability were adv...

Intermittent catheter users’ symptom identification, description and management of urinary tract infection: a qualitative study

BMJ Open, 2017

ObjectivesTo elucidate the views of intermittent catheter (IC) users regarding urinary tract infe... more ObjectivesTo elucidate the views of intermittent catheter (IC) users regarding urinary tract infection (UTI) symptom presentation, terminology for describing signs and symptoms, the cause of UTI and management strategies.DesignQualitative study with semi-structured interviews. The transcribed text was analysed thematically.Setting12 general practitioner (GP) surgeries in Hampshire and Dorset, UK.ParticipantsA convenience sample of 30 IC users, aged over 18, using IC for at least 3 months who had at least one self-reported UTI since starting IC.ResultsParticipants reported a variety of signs and symptoms, such as urine cloudiness and smell, as indicators of UTI. The terms used often differed from those in the modified National Institute on Disability and Rehabilitation Research (NIDRR) symptom set. IC users had difficulty distinguishing possible UTI symptoms from those of their comorbidities. They expressed uncertainty about the cause of UTI, often attributing it to poor hygiene and ...

Dying a good death at a palliative care unit in Japan. [In: Good Deaths/Bad Deaths:Dilemmas of Death in Comparative Perspective]

Cet article examine la conception de bonne mort dans le Japon contemporain a travers l'experi... more Cet article examine la conception de bonne mort dans le Japon contemporain a travers l'experience de mourrants recevant des soins paliatifs. Pour cela, j'examine tout d'abord la philosophie des hospices et la notion de bonne mort, a la fois dans les centres de soins occidentaux et japonais. Dans un deuxieme temps,j'analyse le type de mort traditionnellemet percue comme bonne au Japon. Avec comme cas d'etude la mort d'un patient dans une unite de soin paliatif japonais (PCU), je tenterai d'approffondir notre comprehension de que signifie la bonne mort dans la societe japonaise contemporaine.

It's Got to Be the Patient's Decision': Practicing Shared Decision-making in the U.K. Renal Units

Anthropology in Action, 2015

Journey from life to death

The kind of diseases affecting Japanese people and the causes of death in Japan have changed a ... more The kind of diseases affecting Japanese people and the causes of death in Japan have changed a great deal in the last several decades due to various factors, most notably the advancement of medical technology and changes in life style. The number of people who die from life style diseases such as cancer, which are chronic and possibly need long-term hospitalization, increases every year. In the 1970s the hospice philosophy was introduced to Japan from the West. It encourages patients and their families to affirm life and to regard dying as a normal process, and offers a support system to help patients live as actively as possible and sustain a sense of selfhood, autonomy, and dignity until they die. In practice, however, the dying process is still not regarded as normal in contemporary Japan and many patients fail to die in the way proposed by the hospice philosophy. There is also disagreement between the patients and the medical professionals regarding their respective idea of go...

The semistructured interview guide followed during staff interviews

Decision-making for people with dementia and advanced kidney disease: a secondary qualitative analysis of interviews from the Conservative Kidney Management Assessment of Practice Patterns Study

BMJ Open

ObjectiveTo explore dialysis decision-making for adults who lack capacity due to cognitive impair... more ObjectiveTo explore dialysis decision-making for adults who lack capacity due to cognitive impairment, a common and under-recognised condition in those with advanced chronic kidney disease (CKD).DesignSecondary analysis of qualitative data collected during the Conservative Kidney Management Assessment of Practice Patterns Study programme of research was performed. Sixty semistructured interviews were conducted with multiprofessional team members from UK renal centres. Staff were asked about local facilities, the value of conservative kidney management (CKM), when and with whom CKM was discussed and how CKM could be improved. Thematic analysis was employed to identify, characterise and report on themes that emerged from the data, focused on the specific issues experienced by people with dementia.SettingA purposive sample of nine UK renal centres differing in the scale of their CKM programmes.ParticipantsClinical directors of renal centres identified staff involved in CKM. Staff were ...

Understanding by Older Patients of Dialysis and Conservative Management for Chronic Kidney Failure

American Journal of Kidney Diseases

Background: Older adults with chronic kidney disease stage 5 may be offered a choice between dial... more Background: Older adults with chronic kidney disease stage 5 may be offered a choice between dialysis and conservative management. Few studies have explored patients' reasons for choosing conservative management and none have compared the views of those who have chosen different treatments across renal units. Study Design: Qualitative study with semi-structured interviews. Settings & Participants: Patients 75 years or older recruited from 9 renal units. Units were chosen to reflect variation in the scale of delivery of conservative management. Methodology: Semi-structured interviews audio recorded and transcribed verbatim. Analytical Approach: Data were analyzed using thematic analysis. Results: 42 interviews were completed, 4 to 6 per renal unit. Patients were sampled from those receiving dialysis, those preparing for dialysis, and those choosing conservative management. 14 patients in each group were interviewed. Patients who had chosen different treatments held varying belief...

Conservative care for end-stage kidney disease in the UK: a national survey

Clinical Journal of the American Society of Nephrology

Background and objectives: Conservative Kidney Management (CKM) has developed in the UK as an alt... more Background and objectives: Conservative Kidney Management (CKM) has developed in the UK as an alternative to dialysis for older patients with stage 5 chronic kidney disease (CKD5) and multiple comorbidities. We report on a national survey which aims to describe the current scale and pattern of delivery of conservative care in UK renal units and identify their priorities for its future development. Design, setting, participants, and measurements: A survey on practice patterns of CKM for patients aged over 75 years with CKD5 was sent to clinical directors of all 71 adult renal units in the UK in March 2013. Results: Sixty-seven units (94%) responded. All but one unit reported providing CKM for some patients. Terminology varied, although ‘conservative management’ was the most frequently used term (46%). Lack of an agreed definition of when a patient is receiving CKM made it difficult to obtain meaningful data on the numbers of such patients. 52% provided the number of CKM patients aged...

A national study of practice patterns in UK renal units in the use of dialysis and conservative kidney management to treat people aged 75 years and over with chronic kidney failure

Background: Conservative kidney management (CKM) is recognised as an alternative to dialysis for ... more Background: Conservative kidney management (CKM) is recognised as an alternative to dialysis for a significant number of older adults with multi-morbid chronic kidney disease stage 5 (CKD5). However, little is known about the way CKM is delivered or how it is perceived. Aim: To determine the practice patterns for CKM of older patients with CKD5, to inform service development and future research. Objectives: i) To describe the differences between renal units in the extent and nature of CKM. ii) To explore how decisions are made about treatment options for older patients with CKD5. iii) To explore clinicians willingness to randomise patients with CKD5 to CKM versus dialysis. iv) To describe the interface between renal units and primary care in managing CKD5. v) To identify the resources involved and potential costs of CKM. Methods: Mixed methods study. Interviews with 42 patients aged >75 with CKD5 and 60 renal unit staff in a purposive sample of nine UK renal units. Interviews inf...

Using the Clinical Research Network for psychosocial cancer research: lessons learned from two observational studies

BMJ supportive & palliative care, Jan 19, 2013

Patient recruitment to psychosocial oncology research has increased but the many studies have bee... more Patient recruitment to psychosocial oncology research has increased but the many studies have been single-site or small-scale. The National Institute for Health Research Clinical Research Network, supports National Institute for Health Research portfolio studies through provision of research staff for recruitment and follow-up. These studies are usually clinical trials of an investigational medicinal product. Psychosocial researchers have little used this resource. We report the processes followed and experiences of two psychosocial research teams who recently used the Clinical Research Network, to undertake patient recruitment to two prospective observational studies: electronic Patient-reported Outcomes from Cancer Survivors study (ePOCS) and the ColoREctal Wellbeing study (CREW). Both research groups employed different approaches to using Clinical Research Network support. ePOCS secured Comprehensive Local Research Networks funding to appoint ePOCS-specific study research nurses....

Lessons learnt recruiting to a multi-site UK cohort study to explore recovery of health and well-being after colorectal cancer (CREW study)

BMC Medical Research Methodology, 2013

Dying a good death at a palliative care unit in Japan

Tairyoku as a belief system of health and illness: a study of cancer patients in Japan

Anthropology and Medicine, Jan 1, 2008

Impact of cancer on everyday life: a systematic appraisal of the research evidence

Health Expectations

What to eat when off treatment and living with involuntary weight loss and cancer: a systematic search and narrative review

by Ikumi Okamoto and Jane Hopkinson

Supportive Care in Cancer, 2011

Purpose The aim of this study was to report a systematic search and narrative review of the evide... more Purpose The aim of this study was to report a systematic search and narrative review of the evidence base that can inform dietary advice for patients off treatment living with cancer cachexia syndrome (CCS). Methods Searches were conducted in MEDLINE, EMBASE, PsycINFO and CINAHL databases for publications about diet and cancer patients off treatment with symptoms of CCS. The following limits were applied: English language, from September 1998 to September 2008 and adults. In addition, a hand search included the reference lists of papers identified. Seven hundred and eighteen abstracts were assessed against inclusion/exclusion criteria and 88 were selected for full text independent examination by two researchers. Information from 48 papers was extracted, quality assessed, thematically analyzed and presented as a narrative synthesis. Results Two dominant perspectives emerged on what should be eaten by weight-losing cancer patients. The majority of authors advocated a nutrient-dense diet, facilitated by nutritional counselling. The alternative approach was to advise the patient to ‘eat what they want’. There is little robust evidence to justify either approach as able to deliver on the range of physical and psychosocial objectives that they aim to achieve. Conclusion A new model for the delivery of nutritional care may benefit cancer patients (off treatment) living with weight loss. The proposed model integrates the two identified perspectives to facilitate optimal food intake taking into account the patient's (1) disease symptoms and treatment side effects (2) emotional adaptation to illness and (3) social circumstances. Research is needed to establish which of these obstacles to eating can be changed for which patient groups to improve patient outcomes.

The Effectiveness of Patient-Family Carer (Couple) Intervention for the Management of Symptoms and Other Health-Related Problems in People Affected by Cancer: A Systematic Literature Search and Narrative Review

Journal of Pain and Symptom Management