Skaar Elisabeth, Ranhoff Anette Hylen, Nordrehaug Jan Erik, Forman Daniel E, Schaufel Margrethe Aase
Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.
Department of Heart Disease, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway; Kavli Research Centre for Geriatrics and Dementia, Haraldsplass Deaconess Hospital, Bergen, Norway.
J Geriatr Cardiol. 2017 Jan;14(1):42-48. doi: 10.11909/j.issn.1671-5411.2017.01.007.
Patient autonomy is a leading principle in bioethics and a basis for shared decision making. This study explores conditions for an autonomous choice experienced by older adults who recently underwent trans-catheter aortic valve replacement (TAVR).
Qualitative study entailing semi-structured interviews of a purposive sample of ten older (range 73-89, median 83.5 years) adults after TAVR (median 23 days). The study setting was a cardiac department at a university hospital performing TAVR since 2010. Analysis was by systematic text condensation.
Even when choice seemed hard or absent, TAVR-patients deliberately took the chance offered them by processing risk assessment, ambivalence and fate. They regarded declining the treatment to be worse than accepting the risk related to the procedure. The experience of being thoroughly advised by their physician formed the basis of an autonomous trust. The trust they felt for the physicians' recommendations mitigated ambivalence about the procedure and risks. TAVR patients expressed feelings consistent with self-empowerment and claimed that it had to be their decision. Even so, choosing the intervention as an obligation to their family or passively accepting it was also reported.
Older TAVR patients' experience of an autonomous decision may encompass frank tradeoff; deliberate physician dependency as well as a resilient self-view. Physicians should be especially aware of how older adults' subtle cognitive declines and inclinations to preserve their identities which can influence their medical decision making when obtaining informed consent. Cardiologists and other providers may also use these insights to develop new strategies that better respond to such inherent complexities.
患者自主权是生物伦理学的一项首要原则，也是共同决策的基础。本研究探讨了近期接受经导管主动脉瓣置换术（TAVR）的老年人自主选择的条件。
定性研究，对10名年龄较大（73 - 89岁，中位数83.5岁）的TAVR术后成年人（中位数23天）进行有目的抽样的半结构式访谈。研究地点是一所自2010年起开展TAVR手术的大学医院的心脏科。采用系统文本浓缩法进行分析。
即使选择似乎困难或不存在，TAVR患者仍通过处理风险评估、矛盾心理和命运来刻意把握提供给他们的机会。他们认为拒绝治疗比接受与手术相关的风险更糟糕。医生给予充分建议的经历构成了自主信任的基础。他们对医生建议的信任减轻了对手术和风险的矛盾心理。TAVR患者表达了与自我赋权一致的感受，并声称这必须是他们自己的决定。即便如此，也有报告称患者将选择干预视为对家人的义务或被动接受。
老年TAVR患者自主决策的体验可能包括坦率的权衡；对医生的刻意依赖以及坚韧的自我认知。医生在获取知情同意时应特别注意老年人细微的认知衰退以及维护自身身份的倾向如何影响他们的医疗决策。心脏病专家和其他医疗服务提供者也可以利用这些见解制定新策略，以更好地应对此类内在复杂性。
