Matlock Dan D, Nowels Carolyn T, Masoudi Frederick A, Sauer William H, Bekelman David B, Main Deborah S, Kutner Jean S
Department of Medicine, School of Medicine, University of Colorado, Aurora, Colorado 80045, USA.
Pacing Clin Electrophysiol. 2011 Dec;34(12):1634-44. doi: 10.1111/j.1540-8159.2011.03237.x. Epub 2011 Oct 5.
Although implantable cardioverter-defibrillators (ICDs) reduce mortality in selected patients, they are also associated with potential risks. Periprocedural decision making requires understanding both benefits and risks.
This qualitative study aims to understand cardiologists' and patients' perspectives about decision making surrounding ICD implantation using semi-structured, in-depth interviews. We interviewed 11 cardiologists (including four electrophysiologists) and 20 patients (14 with ICDs; six who declined ICDs). The data were analyzed through the theoretical lens of patient-centered care using the constant comparative method.
Cardiologists emphasized the benefits of ICD therapy but varied substantially in the extent to which they emphasized the various risks associated with ICD implantation with patients. Cardiologists indicated that they were influenced by the benefits of therapy as presented in published guidelines. Many patients who chose to receive an ICD indicated that they followed the advice of their physician without questioning the risks and benefits of the device. Some ICD recipients described not learning many of the risks until after device implantation or when they experienced these side effects. Patients who declined ICD implantation were concerned that the ICD was unnecessary or believed that the risks related to sudden death without an ICD did not apply to them. Only one patient considered the trade-off between dying quickly versus living longer with progressive heart failure.
In our sample, cardiologists' desire to adhere to published guidelines appears to inhibit shared decision making. The marked variability in the discussions surrounding ICD decisions highlights a need for an improved process of ICD decision making.
尽管植入式心脏复律除颤器（ICD）可降低特定患者的死亡率，但它们也存在潜在风险。围手术期决策需要了解其益处和风险。
这项定性研究旨在通过半结构化的深入访谈，了解心脏病专家和患者对ICD植入决策的看法。我们采访了11位心脏病专家（包括4位电生理学家）和20位患者（14位植入了ICD；6位拒绝植入ICD）。使用持续比较法，通过以患者为中心的护理理论视角对数据进行分析。
心脏病专家强调了ICD治疗的益处，但在向患者强调与ICD植入相关的各种风险的程度上差异很大。心脏病专家表示，他们受到已发表指南中所呈现的治疗益处的影响。许多选择接受ICD的患者表示，他们听从了医生的建议，而没有质疑该设备的风险和益处。一些ICD接受者表示，直到设备植入后或出现这些副作用时才了解到许多风险。拒绝植入ICD的患者担心ICD没有必要，或者认为没有ICD时与猝死相关的风险不适用于他们。只有一位患者考虑了快速死亡与因进行性心力衰竭而活得更长之间的权衡。
在我们的样本中，心脏病专家遵循已发表指南的愿望似乎抑制了共同决策。围绕ICD决策的讨论中存在明显差异，这凸显了改进ICD决策过程的必要性。
