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But They Don't Always Come to Appointments!

Nicole Dubyk
Mazankowski Heart Institute
Edmonton, AB, Canada

Pamela Combs, PhD, RN
University of Chicago
Chicago, IL, USA

"But they don't come to all of their appointments," is an occasionally heard statement in selection meetings when discussing patient candidacy for VAD implantation. Psychosocial factors, like adherence to medical appointments, form evidence of whether the team typically feels a patient is an "ideal candidate" for VAD therapy. This week, I wondered how much weight should be placed on a patient's attendance record.

Gravlee et al. (2016) stresses the importance of candidate selection and warns healthcare teams to exercise caution in offering VAD therapy to patients who have a history of appointment non-adherence. Consistently attending clinic appointments is viewed as a strong predictor of how adherent a patient will be to other key aspects of VAD therapy-anti-coagulation, driveline management and follow up medical visits to name a few. In a review of psychosocial factors and its subsequent implications for VAD patient candidacy, it is often noted that the ability to select candidates from these factors can be problematic based on a lack of standardized assessment tools (Grogan et al. 2015). If there is a lack of standardized assessment, is it appropriate to use appointment attendance as a means of compliance? Being one of the few tangible psychosocial factors that can be measured, tracked and quantified, is it a justified and ethical means to determine candidacy in all potential clients?

A patient was admitted to the Coronary Intensive Care Unit (CICU) for an exacerbation of Heart failure (HF). He was diagnosed with an acute kidney injury and an acute liver injury during his admission to the hospital. The patient had severe bilateral pitting edema to the knees and bilateral pleural effusions on a chest x-ray. The CICU started to optimize his HF medications along with diuretics, but found that they could not support his end organ function without the aid of inotropes. After failing to wean inotropes, a consult was placed both to the transplant team and the VAD team. The patient's past medical history included Type II Diabetes Mellitus and HIV. Etiology of the HIV was thought to be from a blood transfusion he had during the 1980s. The patient had a strong support system in his wife and children whom he lived with outside the city. His finances were stable. He denied the use of all drugs, tobacco and alcohol. As our team social worker started her assessment of the patient, it was noted from colleagues in the transplant team that the patient had "no showed" numerous medical appointments. During discussion of the patient's candidacy in our weekly meeting, many colleagues felt that the patient was not a good candidate for transplant due to the severity of his illness at the time. His VAD candidacy was taking heavy scrutiny because of the multiple missed appointments with transplant. His absenteeism was probing at a metric of compliance for adherence to VAD therapy. But, we believed there to be a better measure of compliance that could be quantified-CD4 counts. In reviewing the patient's blood work, it was noted that his CD4 counts had been stable for years. Upon talking to the physician following his CD4 counts and managing his anti-retroviral therapy, the patient had in our minds demonstrated compliance. Our physician advocated that since the patient had a stable CD4 count and has complied with his current HIV regime, this was a stronger predictor of future compliance with a VAD. His multiple missed appointments stemmed from the family going through financial hardship at the time and making the drive into the urban center multiple times a week was not feasible. The patient, in his mind, chose to attend appointments that were offering therapy to him now instead of a mere glimpse of his future self.

Petty and Bauman (2015) argue that "[psychosocial] evaluation isn't simply a matter of evaluating compliance history...but rather to ensure that the appropriate resources are available to care for the patient as a whole" (p. 2182-2183). In the context of the case study provided above, if as teams we only quantify compliance as attendance to medical appointments, it could be argued that we are not being judicial in our final decision to offer VAD as a therapy option. Additionally, the authors would contend that circumstances surrounding non-adherence to clinic visits must be explored and the patient needs to be provided with adequate support from the interdisciplinary team to correct/demonstrate compliance. Furthermore, due to the lack of VAD specific psychosocial assessment tools, it is difficult to quantify how much weight should be placed on attendance versus other factors determining outcomes such as income and social support. As VADs become more widely used within the heart failure community, research and predictors such as clinic adherence need to be evaluated to observe if they are indeed an objective measurement of future compliance with VAD therapy. ■

Disclosure Statement: The authors have no conflicts of interest to disclose.


  1. Clevland, J.C. (2016). Long term uses of mechanical circulatory support devices. In Gravlee, Davis, Hammon & Kussman (Eds.), Cardiopulomary bypass and mechanical circulatory support: principles and practice fourth edition. (pp. 6954). Philadelphia, PA: Wolters Kluwer.
  2. Grogan, S., Kostick, K., Delgado,E., Bruce,C. (2015). Ventricular assist devices as destination therapy: psychosocial and ethical implications. Methodist Debakey Cardiovascular Journal, 11(1), 9-11. doi: 10.14797/mdcj-11-1-9.
  3. Petty, M., Bauman, L. (2015). Psychosocial issues in ventricular assist device implantation and management. Journal of Thoracic Diseases, 7(12), 2181-2187. Doi: 10.3978/j.issn.2072-1439.2015.09.10

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