McIlvennan Colleen K, Matlock Daniel D, Allen Larry A, Thompson Jocelyn S, Ranby Krista W, Sannes Timothy S
Adult and Child Consortium for Health Outcomes Research and Delivery Science (C.K.M., D.D.M., L.A.A., J.S.T.), University of Colorado School of Medicine, Aurora, CO.
Division of Cardiology (C.K.M., L.A.A.), University of Colorado School of Medicine, Aurora, CO.
Circ Cardiovasc Qual Outcomes. 2020 Mar;13(3):e006155. doi: 10.1161/CIRCOUTCOMES.119.006155. Epub 2020 Mar 9.
The decision to pursue a left ventricular assist device (LVAD) commits loved ones to major caregiving responsibilities and, often, medical decision-making. How emotional domains overlap within patients and their caregivers and contribute to conflict around the decision to pursue LVAD remains largely unexplored.
The associations within and between individuals in patient-caregiver dyads considering LVAD were estimated in a specific type of structural equation model known as the Actor-Partner Interdependence Model. This model tested whether each person's depression and stress predicted their own decisional conflict (actor effects), as well as their partner's decisional conflict (partner effects). At the time of study enrollment when a formal LVAD evaluation was initiated, 162 patient-caregiver dyads completed assessments of decisional conflict using the Decisional Conflict Scale, depressive symptoms using the Patient Health Questionnaire-2, and stress using the Perceived Stress Scale. Across both models, decisional conflict was significantly correlated within patient-caregiver dyads (β=0.47 and 0.44, for depression and perceived stress models, respectively, <0.001). Greater perceived stress in both the patient (β=0.18; 0.05) and caregiver (β=0.28; 0.001) was significantly related to greater decisional conflict (both actor effects). Greater patient depressive symptoms were related to greater patient decisional conflict (β=0.16; 0.05), whereas caregiver depression symptoms was not related to their own decisional conflict (β=0.07; =0.37). There were no partner effects identified between decisional conflict and perceived stress or depressive symptoms.
Patient and caregiver conflict over the decision to pursue an LVAD was highly correlated in this sample, with greater perceived stress significantly predicting greater decisional conflict in both patients and caregivers. Depressive symptoms in patients also predicted greater patient decisional conflict. No partner effects were identified in predicting decisional conflict. These results contribute to a larger body of work acknowledging the importance of patient-caregiver well-being in serious illness. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02344576.
决定使用左心室辅助装置（LVAD）会使患者的亲人承担主要的护理责任，并且常常涉及医疗决策。患者及其护理人员的情感领域如何相互重叠，以及如何导致围绕使用LVAD决策的冲突，在很大程度上仍未得到探索。
在一种特定类型的结构方程模型（称为“行为者-伙伴相互依赖模型”）中，估计了考虑使用LVAD的患者-护理人员二元组中个体内部和个体之间的关联。该模型测试了每个人的抑郁和压力是否预测了他们自己的决策冲突（行为者效应），以及他们伴侣的决策冲突（伙伴效应）。在开始正式的LVAD评估的研究入组时，162个患者-护理人员二元组使用决策冲突量表完成了决策冲突评估，使用患者健康问卷-2完成了抑郁症状评估，并使用感知压力量表完成了压力评估。在两个模型中，患者-护理人员二元组内的决策冲突均显著相关（抑郁模型和感知压力模型的β分别为0.47和0.44，<0.001）。患者（β=0.18；P=0.05）和护理人员（β=0.28；P=0.001）中更高的感知压力均与更大的决策冲突显著相关（均为行为者效应）。患者更严重的抑郁症状与患者更大的决策冲突相关（β=0.16；P=0.05），而护理人员的抑郁症状与他们自己的决策冲突无关（β=0.07；P=0.37）。在决策冲突与感知压力或抑郁症状之间未发现伙伴效应。
在这个样本中，患者和护理人员在是否使用LVAD决策上的冲突高度相关，更高的感知压力显著预测了患者和护理人员中更大的决策冲突。患者的抑郁症状也预测了患者更大的决策冲突。在预测决策冲突方面未发现伙伴效应。这些结果为大量承认患者-护理人员福祉在重病中的重要性的研究工作做出了贡献。注册：网址：https://www.clinicaltrials.gov；唯一标识符：NCT02344576。
