McIlvennan Colleen K, Allen Larry A, Nowels Carolyn, Brieke Andreas, Cleveland Joseph C, Matlock Daniel D
From the Section of Advanced Heart Failure and Transplantation, Division of Cardiology (C.K.M., L.A.A., A.B.), Division of General Internal Medicine (C.N., D.D.M.), and Division of Cardiothoracic Surgery (J.C.C.), University of Colorado School of Medicine, Aurora; and Colorado Cardiovascular Outcomes Research Consortium, Denver (C.K.M., L.A.A., D.D.M.).
Circ Cardiovasc Qual Outcomes. 2014 May;7(3):374-80. doi: 10.1161/CIRCOUTCOMES.113.000729. Epub 2014 May 13.
Destination therapy left ventricular assist devices (DT LVADs) are one of the most invasive medical interventions for end-stage illness. How patients decide whether or not to proceed with device implantation is unknown. We aimed to understand the decision-making processes of patients who either accept or decline DT LVADs.
Between October 2012 and September 2013, we conducted semistructured, in-depth interviews to understand patients' decision-making experiences. Data were analyzed using a mixed inductive and deductive approach. Twenty-two eligible patients were interviewed, 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 over-riding desire to live as long as possible: "[LVAD] was the only option I had…that or push up daisies…so I automatically took this." By 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.
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.
目标治疗左心室辅助装置（DT LVADs）是针对终末期疾病最具侵入性的医疗干预措施之一。患者如何决定是否进行装置植入尚不清楚。我们旨在了解接受或拒绝DT LVADs治疗的患者的决策过程。
在2012年10月至2013年9月期间，我们进行了半结构化的深入访谈，以了解患者的决策经历。采用归纳和演绎相结合的方法对数据进行分析。共访谈了22名符合条件的患者，其中15名接受了DT LVADs治疗，7名拒绝了该治疗。我们发现决策过程存在明显的二分法，一些患者（11名接受者）的决策是自动做出的，而另一些患者（3名接受者，7名拒绝者）则是经过深思熟虑的。自动决策组的特点是害怕死亡和极度渴望尽可能长久地活着：“[左心室辅助装置]是我唯一的选择……不然就进坟墓……所以我就自动接受了这个。”相比之下，深思熟虑组则经历了一个权衡风险、益处和负担的理性过程：“有比死亡更糟糕的事情。”无论采用何种方式，大多数患者都将DT LVADs的决策视为一个高度情绪化的过程，许多人寻求家人或精神上的支持。
一些面临DT LVADs治疗决策的患者会通过思考过程并权衡风险和益处来做出决定。而对另一些患者来说，求生的欲望超过了这种深思熟虑的过程。在考虑如何支持面临这一复杂决策的患者时，认识到这种差异很重要。
