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Shared Decision-Making: Its Involvement in the World of VADs


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Pamela S. Combs, PhD, RN
MCS Clinical Manager
Seton Medical Center
Austin, Texas, USA
pscombs@seton.org




The traditional style of medical decision-making has primarily been the physician making the final selection of the appropriate treatment for the patient's condition. This approach is being challenged by the concept of "shared decision-making" [1,2]. Shared decision-making incorporates education provided to the patient and the caregiver by the health care team, along with the patient's perspective of his/her health care, resulting in the implementation of the agreed-upon plan of care [3]. The following is a reflection about the existence of shared decision-making in the world of VADs.

Over the past 30 years, VADs have been a standard therapy at many world-wide centers treating patients with advanced heart failure [4]. Additionally, the implantation of these devices is rapidly increasing [4]. Along with this well-documented increase in the use of VADs, does evidence exist that shared decision-making is already taking place?

This author has witnessed various situations that the VAD team recognizes and adheres to shared decision-making with the following examples of 1) timing of daily medications, 2) planning independent activities such as travelling, 3) the options of how to wear VAD equipment, and 4) end-of-life decisions. With such life decisions being made, trust has to be the basis for this type of collaboration between the patient, caregiver and the team members with open discussions being conducted in a dynamic process throughout the VAD patient's journey [3]. Building trust starts with the early solicitation of the patient's beliefs, values and goals at the beginning of the VAD evaluation. Trust continues to be fostered by the team's use an iterative process of communication with the patient and caregiver.

Throughout the VAD journey, the VAD Coordinator maintains communication during clinical visits by providing constant and repetitive education before and after the device implant. This dynamic informational process is accomplished while always keeping in mind the possibility of potential obstacles in achieving the patient's goals. Examples of such obstacles might be the VAD patient's anxiety, limited health literacy, language differences and family dynamics [3].

To ensure that the journey is aligned with the VAD patient's defined goals, the VAD team continues to communicate through engaging, clarifying and querying the patient about the ongoing treatments being administered. Literature suggests that a "decision coach", a trained professional, often a nurse, assists with decision-making by encouraging the patient to ask questions [3]. Is this not what the VAD Coordinator executes in his/her role? This author encourages research regarding the VAD team's use of this particular model with the inclusion of patient and caregiver satisfaction, examples of shared decision-making and patient outcomes.

In conclusion, this author proposes that shared decision-making is already being utilized in various aspects of VAD patient care. However, the need exists to research this model and its application with this very complex population. The VAD Coordinator is an expert in constantly communication with the VAD patient and caregiver and is responsible for ensuring that the patient's wishes are known to the rest of the VAD team. Therefore, this author offers a challenge to VAD team members to research the area of implementing this decision-making model with VAD patients. In exploring what shared decision-making processes and/or techniques are more effective, VAD teams may tailor their care to improve the patient's outcomes.

Disclosure Statement: The author has no conflicts of interest to disclose.


References:

  1. Coulter A. (1997). Partnerships with patients: The pros and cons of shared clinical decision-making. Journal of Health Services Research & Policy, 2(2); pp. 112-121.
  2. Elwyn, G., Edwards, A. & Kinnersely, P. (1999). Shared decision-making in primary care: The neglected second half of the consultation. British Journal of General Practice, 49, pp. 477-482.
  3. Allen, L., et al. (2012). 2012"Decision Making in Advanced Heart Failure: A scientific statement from the American Heart Association. Circulation, 125, pp. 1928-1952.
  4. Slaughter, M., et al. (2010) "Clinical management of continuous-flow left ventricular assist devices in advanced heart failure." The Journal of Heart and Lung Transplantation 29(4), S1-S39.



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