**9.1 Psychosocial aspects in family and advanced liver disease**

Emotions are stressful for the patient and also for the family and can lead to physical and emotional exhaustion (Nickel, 2002). Family members usually have emotional troubles, sometimes overlapping those presented by the patient. The most common are: fear, anxiety, sleep disturbances, difficulty concentrating, loss of appetite, and fatigue (Sanders, 2008). When the patient gets all the attention, a feeling of isolation among other family members may appear (Pérez San Gregorio, 2008; Stilley, 2010). Moreover, other perceptions have been observed, such as guilt, when the patient is left alone, or fear of not doing enough or not doing something correctly, etc..,

It is also important to mention two phenomena that may affect the whole family, and they are: the conspiracy of silence and family claudication (Miyazaki, 2010). The conspiracy of silence attempts to prevent that the parties involved become aware of the diagnosis and prognosis of the disease. The results are the emergence of mistrust, isolation, limited emotional expression and isolation which can create family-physician-patient misleading relationships (Bolkhir, 2007). To avoid the conspiracy of silence we must always take into account the real needs and desires of the patient information that can change with the time (Carr, 2001).

Family claudication: expresses the absence of the family's ability to respond adequately to the demands and needs of the patient due to a state of exhaustion and an overwhelming feeling that results in difficulties in maintaining a positive communication between the patient, family members, and the healthcare team (Szeifert, 2010; Kramer, 2011).
