21 May How Do Patients Decide to Accept a LVAD – Left Ventricular Assist Device?
MedicalResearch.com Interview with:
Colleen K. McIlvennan, DNP, ANP
Assistant Professor of Medicine
University of Colorado, Division of Cardiology
Section of Advanced Heart Failure and Transplantation
MedicalResearch: What are the main findings of the study?
Answer: We interviewed 22 patients who were offered destination therapy left ventricular assist devices (DT LVAD), 15 with DT LVADs and 7 who declined. We found a strong dichotomy between decision processes with some patients (11 accepters) being automatic and others (3 accepters, 7 decliners) being reflective in their approach to decision making. The automatic group was characterized by a fear of dying and an overriding desire to live as long as possible: [LVAD] was the only option I had…that or push up daisies…so I automatically took this. In contrast, the reflective group went through a reasoned process of weighing risks, benefits, and burdens: There are worse things than death. Irrespective of approach, most patients experienced the DT LVAD decision as a highly emotional process and many sought support from their families or spiritually.
MedicalResearch: Were any of the findings unexpected?
Answer: There is a scarcity of literature on how people make decisions around any major procedure for advanced heart failure and also for other non-cardiac terminal diseases. Our study demonstrates that for many people, major interventions designed to delay impending death appeal directly to their primal desire for self-preservation and help alleviate their fear of death. This is so strong that many patients do not necessarily wish to know the extent to which the DT LVAD actually accomplishes this stated goal. This is discordant with the current paradigm for informed consent for LVAD, which requires that patients understand the risks of therapy and are offered a description of reasonable alternatives. While information is essential for informed consent and helpful to some patients, our results show that cognitive weighing of theoretical risks and benefits played a secondary role in most of the patients’ decision-making process.
MedicalResearch: What should clinicians and patients take away from your report?
Answer: To improve decision making for patients with end-stage chronic disease, much work remains to be done. Our findings show that some patients offered a DT LVAD face the decision by reflecting on a process and reasoning through risks and benefits. For others, the desire to live supersedes such reflective processing. Acknowledging this difference is important when considering how to support patients who are faced with this complex decision.
MedicalResearch: What recommendations do you have for future research as a result of this study?
Answer: Future research aiming to support DT LVAD decision making should explore the degree to which addressing the fear and emotion associated with this decision can help automatic patients traverse a more reflective process – and whether a more reflective process is even a good thing for patients in this situation. Further, future research should test whether a reflective process leads to patients and caregivers who are better informed and better prepared for downstream consequences. Finally, we know that patients resolve cognitive dissonance over time; a prospective study aiming to explore patients’ decision processes at the time of decision making for DT LVAD and then follow their reactions over time would validate or refute our findings.
Decision Making for Destination Therapy Left Ventricular Assist Devices: “There Was No Choice” Versus “I Thought About It an Awful Lot”
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Circ Cardiovasc Qual Outcomes. 2014;CIRCOUTCOMES.113.000729published online before print May 13 2014, doi:10.1161/CIRCOUTCOMES.113.000729