Integrating Palliative Principles into Cirrhosis Care: The Effect of Hepatic Encephalopathy

  • Michael Ney
  • Amanda Brisebois
  • Puneeta TandonEmail author


The integration of palliative principles into the management of patients with cirrhosis is a vital, yet often overlooked, component of cirrhosis care. With a focus on symptom control and advance care planning (ACP) discussions, the integration of care using palliative care principles enhances health-related quality of life, decreases healthcare utilization, and improves patient and family satisfaction. The routine use of palliative principles has the potential to optimize effective and comprehensive management of all patients with cirrhosis. These principles have particular relevance in patients with hepatic encephalopathy (HE), with several points of intersection. Most notably, (i) HE itself is perhaps the most debilitating symptom of cirrhosis, requiring early detection and intensive symptom management; (ii) medications given to control other cirrhosis-associated symptoms, such as pain killers, anxiolytics, neuroleptics, benzodiazepines, and antidepressants, may precipitate HE, necessitating dose reduction or avoidance; (iii) the cognitive impairment that defines HE complicates ACP and is a major reason supporting early ACP discussions; and (iv) HE increases caregiver burnout. This chapter outlines the role of integrating palliative principles into cirrhosis care and more specifically the care of patients with HE. We provide an overview of medication management considering the risk for HE and finally we discuss brief strategies for supporting caregivers of patients with cirrhosis, vital members of the healthcare team who are often underappreciated and overworked, at the expense of their own well-being.


Palliative care Caregiver burden De-prescribing Symptom management Quality of life 


  1. 1.
    World Health Organization Definition of Palliative Care. Retrieved from Accessed on March 19, 2018.
  2. 2.
    Brisebois AJ, Tandon P. Working with palliative care services. Clin Liver Dis. 2015;6:37–40.CrossRefGoogle Scholar
  3. 3.
    Sudore RL, Fried TR. Redefining the “planning” in advance care planning: preparing for end-of-life decision making. Ann Intern Med. 2010;153:256–61.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Cohen LM, Moss AH, Weisbord SD, et al. Renal palliative care. J Palliat Med. 2006;9:977–92.CrossRefPubMedGoogle Scholar
  5. 5.
    Schwarz ER, Baraghoush A, Morrissey RP, et al. Pilot study of palliative care consultation in patients with advanced heart failure referred for cardiac transplantation. J Palliat Med. 2012;15:12–5.CrossRefPubMedGoogle Scholar
  6. 6.
    Singer AE, Goebel JR, Kim YS, et al. Populations and interventions for palliative and end-of-life care: a systematic review. J Palliat Med. 2016;19:995–1008.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Lamba S, Murphy P, McVicker S, et al. Changing end-of-life care practice for liver transplant service patients: structured palliative care intervention in the surgical intensive care unit. J Pain Symptom Manag. 2012;44:508–19.CrossRefGoogle Scholar
  8. 8.
    Cordoba J, Flavia M, Jacas C, et al. Quality of life and cognitive function in hepatitis C at different stages of liver disease. J Hepatol. 2003;39:231–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Poonja Z, Brisebois A, van Zanten SV, et al. Patients with cirrhosis and denied liver transplants rarely receive adequate palliative care or appropriate management. Clin Gastroenterol Hepatol. 2014;12:692–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Kathpalia P, Smith A, Lai JC. Underutilization of palliative care services in the liver transplant population. World J Transplant. 2016;6:594–8.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Larson AM. Palliative care for patients with end-stage liver disease. Curr Gastroenterol Rep. 2015;17:440.CrossRefPubMedGoogle Scholar
  12. 12.
    D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol. 2006;44:217–31.CrossRefPubMedGoogle Scholar
  13. 13.
    Jalan R, Gines P, Olson JC, et al. Acute-on chronic liver failure. J Hepatol. 2012;57:1336–48.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Abrams GA, Concato J, Fallon MB. Muscle cramps in patients with cirrhosis. Am J Gastroenterol. 1996;91:1363–6.PubMedGoogle Scholar
  15. 15.
    Muir AJ. Understanding the complexities of cirrhosis. Clin Ther. 2015;37:1822–36.CrossRefPubMedGoogle Scholar
  16. 16.
    James J, Liou IW. Comprehensive care of patients with chronic liver disease. Med Clin North Am. 2015;99:913–33.CrossRefPubMedGoogle Scholar
  17. 17.
    McPherson S, Lucey MR, Moriarty KJ. Decompensated alcohol related liver disease: acute management. BMJ. 2016;352:i124.CrossRefPubMedGoogle Scholar
  18. 18.
    Larson AM, Curtis JR. Integrating palliative care for liver transplant candidates: “too well for transplant, too sick for life”. JAMA. 2006;295:2168–76.CrossRefPubMedGoogle Scholar
  19. 19.
    Potosek J, Curry M, Buss M, et al. Integration of palliative care in end-stage liver disease and liver transplantation. J Palliat Med. 2014;17:1271–7.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Vilstrup H, Amodio P, Bajaj J, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014;60:715–35.CrossRefPubMedGoogle Scholar
  21. 21.
    Roth K, Lynn J, Zhong Z, et al. Dying with end stage liver disease with cirrhosis: insights from SUPPORT. Study to understand prognoses and preferences for outcomes and risks of treatment. J Am Geriatr Soc. 2000;48:S122–30.CrossRefPubMedGoogle Scholar
  22. 22.
    Schomerus H, Hamster W. Quality of life in cirrhotics with minimal hepatic encephalopathy. Metab Brain Dis. 2001;16:37–41.CrossRefPubMedGoogle Scholar
  23. 23.
    Shaw J, Bajaj JS. Covert hepatic encephalopathy: can my patient drive? J Clin Gastroenterol. 2017;51:118–26.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Agrawal S, Umapathy S, Dhiman RK. Minimal hepatic encephalopathy impairs quality of life. J Clin Exp Hepatol. 2015;5:S42–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Bass NM, Mullen KD, Sanyal A, et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med. 2010;362:1071–81.CrossRefGoogle Scholar
  26. 26.
    Arguedas MR, DeLawrence TG, BM MG. Influence of hepatic encephalopathy on health-related quality of life in patients with cirrhosis. Dig Dis Sci. 2003;48:1622–6.CrossRefPubMedGoogle Scholar
  27. 27.
    McMahan RD, Knight SJ, Fried TR, et al. Advance care planning beyond advance directives: perspectives from patients and surrogates. J Pain Symptom Manag. 2013;46:355–65.CrossRefGoogle Scholar
  28. 28.
    Lum HD, Sudore RL, Bekelman DB. Advance care planning in the elderly. Med Clin North Am. 2015;99:391–403.CrossRefPubMedGoogle Scholar
  29. 29.
    Jackson VA, Jacobsen J, Greer JA, et al. The cultivation of prognostic awareness through the provision of early palliative care in the ambulatory setting: a communication guide. J Palliat Med. 2013;16:894–900.CrossRefPubMedGoogle Scholar
  30. 30.
    van Vliet LM, Lindenberger E, van Weert JC. Communication with older, seriously ill patients. Clin Geriatr Med. 2015;31:219–30.CrossRefPubMedGoogle Scholar
  31. 31.
    Clark K, Lam LT, Agar M, et al. The impact of opioids, anticholinergic medications and disease progression on the prescription of laxatives in hospitalized palliative care patients: a retrospective analysis. Palliat Med. 2010;24:410–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Good P, Richard R, Syrmis W, et al. Medically assisted hydration for adult palliative care patients. Cochrane Database Syst Rev. 2014;(4):Cd006273.Google Scholar
  33. 33.
    Garg RK. Anesthetic considerations in patients with hepatic failure. Int Anesthesiol Clin. 2005;43:45–63.CrossRefPubMedGoogle Scholar
  34. 34.
    Hokka M, Kaakinen P, Polkki T. A systematic review: non-pharmacological interventions in treating pain in patients with advanced cancer. J Adv Nurs. 2014;70:1954–69.CrossRefPubMedGoogle Scholar
  35. 35.
    Forrest JA, Adriaenssens P, Finlayson ND, et al. Paracetamol metabolism in chronic liver disease. Eur J Clin Pharmacol. 1979;15:427–31.CrossRefPubMedGoogle Scholar
  36. 36.
    Rhee C, Broadbent AM. Palliation and liver failure: palliative medications dosage guidelines. J Palliat Med. 2007;10:677–85.CrossRefPubMedGoogle Scholar
  37. 37.
    Imani F, Motavaf M, Safari S, et al. The therapeutic use of analgesics in patients with liver cirrhosis: a literature review and evidence-based recommendations. Hepat Mon. 2014;14:e23539.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Amarapurkar DN. Prescribing medications in patients with decompensated liver cirrhosis. Int J Hepatol. 2011;2011:519526.PubMedPubMedCentralGoogle Scholar
  39. 39.
    Dwyer JP, Jayasekera C, Nicoll A. Analgesia for the cirrhotic patient: a literature review and recommendations. J Gastroenterol Hepatol. 2014;29:1356–60.CrossRefPubMedGoogle Scholar
  40. 40.
    Soleimanpour H, Safari S, Shahsavari Nia K, et al. Opioid drugs in patients with liver disease: a systematic review. Hepat Mon. 2016;16:e32636.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Khademi H, Kamangar F, Brennan P, et al. Opioid therapy and its side effects: a review. Arch Iran Med. 2016;19:870–6.PubMedGoogle Scholar
  42. 42.
    Verbeeck RK. Pharmacokinetics and dosage adjustment in patients with hepatic dysfunction. Eur J Clin Pharmacol. 2008;64:1147–61.CrossRefPubMedGoogle Scholar
  43. 43.
    Chandok N, Watt KD. Pain management in the cirrhotic patient: the clinical challenge. Mayo Clin Proc. 2010;85:451–8.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Tegeder I, Lotsch J, Geisslinger G. Pharmacokinetics of opioids in liver disease. Clin Pharmacokinet. 1999;37:17–40.CrossRefPubMedGoogle Scholar
  45. 45.
    Haberer JP, Schoeffler P, Couderc E, et al. Fentanyl pharmacokinetics in anaesthetized patients with cirrhosis. Br J Anaesth. 1982;54:1267–70.CrossRefPubMedGoogle Scholar
  46. 46.
    Navapurkar VU, Archer S, Gupta SK, et al. Metabolism of remifentanil during liver transplantation. Br J Anaesth. 1998;81(6):881.CrossRefPubMedGoogle Scholar
  47. 47.
    Crotty B, Watson KJ, Desmond PV, et al. Hepatic extraction of morphine is impaired in cirrhosis. Eur J Clin Pharmacol. 1989;36:501–6.CrossRefPubMedGoogle Scholar
  48. 48.
    Hasselstrom J, Eriksson S, Persson A, et al. The metabolism and bioavailability of morphine in patients with severe liver cirrhosis. Br J Clin Pharmacol. 1990;29:289–97.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Kotb HI, el-Kabsh MY, Emara SE, et al. Pharmacokinetics of controlled release morphine (MST) in patients with liver cirrhosis. Br J Anaesth. 1997;79(6):804.CrossRefPubMedGoogle Scholar
  50. 50.
    Durnin C, Hind ID, Ghani SP, et al. Pharmacokinetics of oral immediate-release hydromorphone (Dilaudid IR) in subjects with moderate hepatic impairment. Proc West Pharmacol Soc. 2001;44:83–4.PubMedGoogle Scholar
  51. 51.
    Tallgren M, Olkkola KT, Seppala T, et al. Pharmacokinetics and ventilatory effects of oxycodone before and after liver transplantation. Clin Pharmacol Ther. 1997;61:655–61.CrossRefPubMedGoogle Scholar
  52. 52.
    Bosilkovska M, Walder B, Besson M, et al. Analgesics in patients with hepatic impairment: pharmacology and clinical implications. Drugs. 2012;72:1645–69.CrossRefPubMedGoogle Scholar
  53. 53.
    Shull HJ, Wilkinson GR, Johnson R, et al. Normal disposition of oxazepam in acute viral hepatitis and cirrhosis. Ann Intern Med. 1976;84:420–5.CrossRefPubMedGoogle Scholar
  54. 54.
    Kraus JW, Desmond PV, Marshall JP, et al. Effects of aging and liver disease on disposition of lorazepam. Clin Pharmacol Ther. 1978;24:411–9.CrossRefPubMedGoogle Scholar
  55. 55.
    Ghabrial H, Desmond PV, Watson KJ, et al. The effects of age and chronic liver disease on the elimination of temazepam. Eur J Clin Pharmacol. 1986;30:93–7.CrossRefPubMedGoogle Scholar
  56. 56.
    Haussinger D, Schliess F. Pathogenetic mechanisms of hepatic encephalopathy. Gut. 2008;57:1156–65.CrossRefPubMedGoogle Scholar
  57. 57.
    Prabhakar S, Management BR. Management of agitation and convulsions in hepatic encephalopathy. Indian J Gastroenterol. 2003;22(Suppl 2):S54–8.PubMedGoogle Scholar
  58. 58.
    Lewis J, Stine J. Prescribing medications in patients with cirrhosis–a practical guide. Aliment Pharmacol Ther. 2013;37:1132–56.CrossRefPubMedGoogle Scholar
  59. 59.
    Holliday SM, Benfield P. Venlafaxine. A review of its pharmacology and therapeutic potential in depression. Drugs. 1995;49:280–94.CrossRefPubMedGoogle Scholar
  60. 60.
    Suri A, Reddy S, Gonzales C, et al. Duloxetine pharmacokinetics in cirrhotics compared with healthy subjects. Int J Clin Pharmacol Ther. 2005;43:78–84.CrossRefPubMedGoogle Scholar
  61. 61.
    Hrdina PD, Lapierre YD, Koranyi EK. Altered amitriptyline kinetics in a depressed patient with porto-caval anastomosis. Can J Psychiatr. 1985;30:111–3.CrossRefGoogle Scholar
  62. 62.
    Mullish BH, Kabir MS, Thursz MR, et al. Review article: depression and the use of antidepressants in patients with chronic liver disease or liver transplantation. Aliment Pharmacol Ther. 2014;40:880–92.CrossRefPubMedGoogle Scholar
  63. 63.
    Joffe P, Larsen FS, Pedersen V, et al. Single-dose pharmacokinetics of citalopram in patients with moderate renal insufficiency or hepatic cirrhosis compared with healthy subjects. Eur J Clin Pharmacol. 1998;54:237–42.CrossRefPubMedGoogle Scholar
  64. 64.
    Demolis JL, Angebaud P, Grange JD, et al. Influence of liver cirrhosis on sertraline pharmacokinetics. Br J Clin Pharmacol. 1996;42:394–7.CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Spahr L, Coeytaux A, Giostra E, et al. Histamine H1 blocker hydroxyzine improves sleep in patients with cirrhosis and minimal hepatic encephalopathy: a randomized controlled pilot trial. Am J Gastroenterol. 2007;102:744–53.CrossRefPubMedGoogle Scholar
  66. 66.
    Montagnese S, De Pittà C, De Rui M, et al. Sleep-wake abnormalities in patients with cirrhosis. Hepatology. 2014;59:705–12.CrossRefPubMedGoogle Scholar
  67. 67.
    Verbeeck RK, Patwardhan RV, Villeneuve JP, et al. Furosemide disposition in cirrhosis. Clin Pharmacol Ther. 1982;31:719–25.CrossRefPubMedGoogle Scholar
  68. 68.
    Abshagen U, Rennekamp H, Luszpinski G. Disposition kinetics of spironolactone in hepatic failure after single doses and prolonged treatment. Eur J Clin Pharmacol. 1977;11:169–76.CrossRefPubMedGoogle Scholar
  69. 69.
    Oliveira L, Ferreira MO, Rola A, et al. Deprescription in advanced cancer patients referred to palliative care. J Pain Palliat Care Pharmacother. 2016;30:201–5.CrossRefPubMedGoogle Scholar
  70. 70.
    Maltoni M, Scarpi E, Rosati M, et al. Palliative sedation in end-of-life care and survival: a systematic review. J Clin Oncol. 2012;30:1378–83.CrossRefPubMedGoogle Scholar
  71. 71.
    Chari AV, Engberg J, Ray KN, et al. The opportunity costs of informal elder-care in the United States: new estimates from the American Time Use Survey. Health Serv Res. 2015;50:871–82.CrossRefPubMedGoogle Scholar
  72. 72.
    Hollander MJ, Liu G, Chappell NL. Who cares and how much? The imputed economic contribution to the Canadian healthcare system of middle-aged and older unpaid caregivers providing care to the elderly. Healthc Q. 2009;12:42–9.CrossRefPubMedGoogle Scholar
  73. 73.
    Smith CE, Piamjariyakul U, Yadrich DM, et al. Complex home care: part III—economic impact on family caregiver quality of life and patients’ clinical outcomes. Nurs Econ. 2010;28:393–9. 414PubMedPubMedCentralGoogle Scholar
  74. 74.
    Adelman RD, Tmanova LL, Delgado D, et al. Caregiver burden: a clinical review. JAMA. 2014;311:1052–60.CrossRefPubMedGoogle Scholar
  75. 75.
    Rakoski MO, McCammon RJ, Piette JD, et al. Burden of cirrhosis on older Americans and their families: analysis of the health and retirement study. Hepatology. 2012;55:184–91.CrossRefPubMedPubMedCentralGoogle Scholar
  76. 76.
    Golics CJ, Basra MK, Salek MS, et al. The impact of patients' chronic disease on family quality of life: an experience from 26 specialties. Int J Gen Med. 2013;6:787–98.CrossRefPubMedPubMedCentralGoogle Scholar
  77. 77.
    Jeffs L, Dhalla I, Cardoso R, et al. The perspectives of patients, family members and healthcare professionals on readmissions: preventable or inevitable? J Interprof Care. 2014;28:507–12.CrossRefPubMedGoogle Scholar
  78. 78.
    Cameron JI, Chu LM, Matte A, et al. One-year outcomes in caregivers of critically ill patients. N Engl J Med. 2016;374:1831–41.CrossRefPubMedGoogle Scholar
  79. 79.
    Morimoto T, Schreiner AS, Asano H. Caregiver burden and health-related quality of life among Japanese stroke caregivers. Age Ageing. 2003;32:218–23.CrossRefPubMedGoogle Scholar
  80. 80.
    Pinquart M, Sörensen S. Correlates of physical health of informal caregivers: a meta-analysis. J Gerontol Ser B Psychol Sci Soc Sci. 2007;62:P126–37.CrossRefGoogle Scholar
  81. 81.
    Schulz R, Beach SR. Caregiving as a risk factor for mortality: the Caregiver Health Effects Study. JAMA. 1999;282:2215–9.CrossRefPubMedPubMedCentralGoogle Scholar
  82. 82.
    Bajaj JS, Wade JB, Gibson DP, et al. The multi-dimensional burden of cirrhosis and hepatic encephalopathy on patients and caregivers. Am J Gastroenterol. 2011;106:1646–53.CrossRefPubMedPubMedCentralGoogle Scholar
  83. 83.
    Montagnese S, Amato E, Schiff S, et al. A patients’ and caregivers’ perspective on hepatic encephalopathy. Metab Brain Dis. 2012;27:567–72.CrossRefPubMedGoogle Scholar
  84. 84.
    Cohen M, Katz D, Baruch Y. Stress among the family caregivers of liver transplant recipients. Prog Transplant. 2007;17:48–53.CrossRefPubMedGoogle Scholar
  85. 85.
    Miyazaki ET, Dos Santos R Jr, Miyazaki MC, et al. Patients on the waiting list for liver transplantation: caregiver burden and stress. Liver Transpl. 2010;16:1164–8.CrossRefPubMedGoogle Scholar
  86. 86.
    Rodrigue JR, Dimitri N, Reed A, et al. Quality of life and psychosocial functioning of spouse/partner caregivers before and after liver transplantation. Clin Transpl. 2011;25:239–47.CrossRefGoogle Scholar
  87. 87.
    Nguyen DL, Chao D, Ma G, et al. Quality of life and factors predictive of burden among primary caregivers of chronic liver disease patients. Ann Gastroenterol. 2015;28:124–9.PubMedPubMedCentralGoogle Scholar
  88. 88.
    Kunzler-Heule P, Beckmann S, Mahrer-Imhof R, et al. Being an informal caregiver for a relative with liver cirrhosis and overt hepatic encephalopathy: a phenomenological study. J Clin Nurs. 2016;25:2559–68.CrossRefPubMedGoogle Scholar
  89. 89.
    Hasselkus BR, Murray BJ. Everyday occupation, well-being, and identity: the experience of caregivers in families with dementia. Am J Occup Ther. 2007;61:9–20.CrossRefPubMedGoogle Scholar
  90. 90.
    Abernethy AP, Currow DC, Fazekas BS, et al. Specialized palliative care services are associated with improved short-and long-term caregiver outcomes. Support Care Cancer. 2008;16:585–97.CrossRefPubMedGoogle Scholar
  91. 91.
    Madigan K, Egan P, Brennan D, et al. A randomised controlled trial of carer-focussed multi-family group psychoeducation in bipolar disorder. Eur Psychiatry. 2012;27(4):281.CrossRefPubMedGoogle Scholar
  92. 92.
    Hepburn K, Lewis M, Tornatore J, et al. The Savvy Caregiver program: the demonstrated effectiveness of a transportable dementia caregiver psychoeducation program. J Gerontol Nurs. 2007;33:30–6.PubMedGoogle Scholar
  93. 93.
    Grant JS, Elliott TR, Weaver M, et al. Telephone intervention with family caregivers of stroke survivors after rehabilitation. Stroke. 2002;33:2060–5.CrossRefPubMedGoogle Scholar
  94. 94.
    Chien LY, Chu H, Guo JL, et al. Caregiver support groups in patients with dementia: a meta-analysis. Int J Geriatr Psychiatry. 2011;26:1089–98.CrossRefPubMedGoogle Scholar
  95. 95.
    Bajaj JS, Ellwood M, Ainger T, et al. Mindfulness-based stress reduction therapy improves patient and caregiver-reported outcomes in cirrhosis. Clin Transl Gastroenterol. 2017;8:e108.CrossRefPubMedPubMedCentralGoogle Scholar
  96. 96.
    Medici V, Rossaro L, Wegelin JA, et al. The utility of the model for end-stage liver disease score: a reliable guide for liver transplant candidacy and, for select patients, simultaneous hospice referral. Liver Transpl. 2008;14:1100–6.CrossRefPubMedGoogle Scholar
  97. 97.
    Organization NHaPC. NHPCO’s facts and figures: hospice care in America; 2015.Google Scholar
  98. 98.
    Christakis NA, Escarce JJ. Survival of Medicare patients after enrollment in hospice programs. N Engl J Med. 1996;335:172–8.CrossRefPubMedGoogle Scholar
  99. 99.
    Fukui N, Golabi P, Otgonsuren M, et al. Demographics, resource utilization, and outcomes of elderly patients with chronic liver disease receiving hospice care in the United States. Am J Gastroenterol. 2017;112:1700–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of GastroenterologyUniversity of AlbertaEdmontonCanada
  2. 2.Division of Palliative Care and General Internal MedicineUniversity of AlbertaEdmontonCanada
  3. 3.Cirrhosis Care Clinic, Division of GastroenterologyUniversity of AlbertaEdmontonCanada

Personalised recommendations