As more and more older patients are offered advanced treatments for chronic diseases, including surgeries and implantable devices, new questions have arisen over how these decisions are made.
In a study published Monday in JAMA Internal Medicine, researchers at the University of Colorado Anschutz Medical Campus examined this question by focusing on the decision making that goes into whether a patient should proceed with a therapy called left ventricular assist device or LVAD.
Expansion of LVAD
They found that shared decision making between patients and clinicians can improve the quality of the final decision in these often high-risk interventions.
“LVAD is growing rapidly among people dying from end-stage heart failure who are unable to get a heart transplant,” said study co-author Larry Allen, MD, associate professor of medicine-cardiology at the University of Colorado School of Medicine. “These patients decide to live out the remainder of their lives dependent on a partial artificial heart — so-called destination therapy (DT). Although patients may live longer with a DT LVAD, it also poses many risks, including stroke, serious infection, and bleeding, and comes with big lifestyle changes.”
Deciding whether to go forward with LVAD is often difficult for patients. Yet until recently, there were few tools available for patients and health care providers to use in LVAD shared decision making.
“Because of this, the Colorado Program for Patient Centered Decisions spent years developing unbiased pamphlet and video decision aids for patients and caregivers, and paired them with training for doctors and nurses,” said study co-author Jocelyn Thompson, MA, of the CU School of Medicine.
The researchers set out to see how well these decision aids worked in routine care to help patients make quality choices around DT LVAD.
Six hospitals across the United States participated in a trial called the Decision Support Intervention for Patients and Caregivers Offered Destination Therapy Heart Assist Device (DECIDE-LVAD).
They switched from their current pre-LVAD education practices — usually consisting of locally made documents and pamphlets from the companies that make the LVADs — to using the formal decision aids and providing decision support training for the staff.
Patients were surveyed during the hospitals’ usual process, called the control period, and during the time the formal decision aids were used, called the intervention period. Researchers wanted to see how the new process changed LVAD decision making.
A total of 248 patients were enrolled in the study. Some 95 percent of those in the intervention period received the formal decision aids. When compared to those in the control period, patients exposed to the decision aids had an improved understanding of the DT LVAD decision. This was demonstrated by a 5.5% increase in correct answers on a knowledge test.
The decision aids also improved values-choice agreement. In the intervention period, patients who said they were willing to undergo risky surgery for a chance to extend life were more likely to get an LVAD while those who didn’t want to be dependent on a machine were more likely to turn down LVAD.
Overall, patients who received the decision aids were more likely not to get an LVAD.
Allen said the DECIDE-LVAD trial shows that the use of formal, unbiased, patient decision aids for LVADs can help patients dying from heart failure improve the quality of decision making. It may also change the rate at which they decide to proceed with such high-risk, high-reward treatment.
The study was funded by the Patient-Centered Outcomes Research Institute (PCORI).