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Introduction: Liver disease deaths are rising, but specialist palliative care services for hepatology are limited. Expansion across the NHS is required., Methods: We surveyed clinicians, patients and carers to design an 'ideal' service. Using standard NHS tariffs, we calculated the cost of this service. In hospitals where specialist palliative care was available for liver disease, patient-level costs and bed utilisation in last year of life (LYOL) were compared between those seen by specialist palliative care before death and those not., Results: The 'ideal' service was described. Costs were calculated as whole time equivalent for a minimal service, which could be scaled up. From a hospital with an existing service, patients seen by specialist palliative care had associated costs of £14 728 in LYOL, compared with £18 558 for those dying without. Savings more than balanced the costs of introducing the service. Average bed days per patient in LYOL were reduced (19.4 vs 25.7) also intensive care unit bed days (1.1 vs 1.8). Despite this, time from first admission in LYOL to death was similar in both groups (6 months for the specialist palliative care group vs 5 for those not referred)., Conclusions: We have produced a template business case for an 'ideal' advanced liver disease support service, which self-funds and saves many bed days. The model can be easily adapted for local use in other trusts. We describe the methodology for calculating patient-level costs and the required service size. We present a financially compelling argument to expand a service to meet a growing need., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

While the majority of lesbian, gay, bisexual and transgender (LGBT) adolescents, much like their cis-gendered heterosexual peers, will be confident and healthy young individuals, there are well-known health disparities, particularly within the transgendered community, which may lead to inferior health outcomes. To improve these outcomes, we must empower professionals to feel confident in their interactions with transgender adolescents so they can recognise, discuss and address these disparities. For many healthcare professionals, this may be a novel experience, but following the announcement in 2022 that the Gender Identity Development Service (GIDS) will move towards a regional model, these discussions increasingly frequently be encountered in a general paediatric setting. In this article, we discuss some of the topics which may be relevant to transgender young people during a general paediatric consultation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Palliative care remains suboptimal in advanced cirrhosis, in part relating to a lack of evidence-based interventions. Ascites remains the most common cirrhosis complication resulting in hospitalisation. Many patients with refractory ascites are not candidates for liver transplantation or transjugular intrahepatic portosystemic shunt, and therefore, require recurrent palliative large volume paracentesis in hospital. We review the available evidence on use of palliative long-term abdominal drains in cirrhosis. Pending results of a national trial (REDUCe 2) and consistent with recently published national and American guidance, long-term abdominal drains cannot be regarded as standard of care in advanced cirrhosis. They should instead be considered only on a case-by-case basis, pending definitive evidence. This manuscript provides consensus to help standardise use of long-term abdominal drains in cirrhosis including patient selection and community management. Our ultimate aim remains to improve palliative care for this under researched and vulnerable cohort., Competing Interests: Competing interests: SV: Rocket Medical plc provided the LTAD free of cost for the REDUCe trial. They were not involved in data collection or preparation of manuscript and nor will they be claiming any intellectual property based on the trial., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Compassion is innate in us as human beings. Compassion can be defined as a deep awareness of the suffering of another individual, coupled with the wish to relieve it. It has been increasingly topical, recently, in situations where an apparent breathtaking absence of compassion has allowed great harm to come to patients. So, how do we sustain compassion and prevent this loss? Central to our ability to maintain compassion is how we look after ourselves and those in our teams., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)