Decisional regret in left ventricular assist device patient-caregiver dyads

Patient-related decisional regret: An evolutionary concept analysis

BACKGROUND

Health-related decision-making is a complex process given the variability of treatment options, conflicting treatment plans, time constraints and variable outcomes. This complexity may result in patients experiencing decisional regret following decision-making. Nonetheless, literature on decisional regret in the healthcare context indicates inconsistent characterization and operationalization of this concept.

AIM(S)

To conceptually define the phenomenon of decisional regret and synthesize the state of science on patients' experiences with decisional regret.

DESIGN

A concept analysis.

METHODS

Rodgers' evolutionary method guided the conceptualization of this review. An interdisciplinary literature search was conducted from 2003 until 2023 using five databases, PubMed, CINAHL, Embase, PsycINFO and Web of Science. The search informed how the concept manifested across health-related literature. We used PRISMA-ScR checklist to guide the reporting of this review.

RESULTS

Based on the analysis of 25 included articles, a conceptual definition of decisional regret was proposed. Three defining attributes underscored the negative cognitive-emotional nature of this concept, post-decisional experience relating to the decision-making process, treatment option and/or treatment outcome and an immediate or delayed occurrence. Antecedents preceding decisional regret comprised initial psychological or emotional status, sociodemographic determinants, impaired decision-making process, role regret, conflicting treatment plans and adverse treatment outcomes. Consequences of this concept included positive and negative outcomes influencing quality of life, health expectations, patient-provider relationship and healthcare experience appraisal. A conceptual model was developed to summarize the concept's characteristics.

CONCLUSION

The current knowledge on decisional regret is expected to evolve with further exploration of this concept, particularly for the temporal dimension of regret experience. This review identified research, clinical and policy gaps informing our nursing recommendations for the concept's evolution.

NO PATIENT OR PUBLIC CONTRIBUTION

This concept analysis examines existing literature and does not require patient-related data collection. The methodological approach does not necessitate collaboration with the public.

Prevalence of long-term decision regret and associated risk factors in a large cohort of ICU surrogate decision makers

BACKGROUND

Whether surrogate decision makers regret decisions about the use of life support for incapacitated, critically ill patients remain uncertain. We sought to determine the prevalence of decision regret among surrogates of adult ICU patients and identify factors that influence regret.

METHODS

We conducted a secondary analysis of data from the PARTNER 2 trial, which tested a family support intervention for surrogates of critically ill adults. At 6-month follow-up, surrogates rated their regret about life support decisions using the Decision Regret Scale (DRS), scored from 0 to 100, with higher scores indicating more regret. We used multiple linear regression to identify covariates associated with decision regret based on a psychological construct of regret. We constructed two models using the full cohort; model 1 included patient outcomes; model 2 focused on covariates known at the time of ICU decision-making. Subgroup analyses were also conducted based on patient survival status at hospital discharge and 6-month follow-up.

RESULTS

748 of 848 surrogates had complete DRS data. The median (IQR) DRS score was 15 (0, 25). Overall, 54% reported mild regret (DRS 5-25), 19% moderate-strong regret (DRS 30-100), and 27% no regret (DRS 0). Poor patient outcome at 6 months (death or severe functional dependence) was associated with more regret in model 1 (β 10.1; 95% C.I. 3.2, 17.0). In model 2, palliative care consultation (3.0; 0.1, 5.9), limitations in life support (LS) prior to death (6.3; 3.1, 9.4) and surrogate black race (6.3; 0.3, 12.3) were associated with more regret. Other modulators of regret in subgroup analyses included surrogate age and education level, surrogate-patient relationship, death in hospital (compared to the post-discharge period), and code status at time of ICU admission.

CONCLUSIONS

One in five ICU surrogate decision makers experience moderate to strong regret about life support decisions in ICU. Poor patient outcomes are linked to more regret. Decisions to limit life support prior to patient death may also increase regret. Future studies are needed to understand how regret relates to decision quality and how to lessen lasting regret.

Bereaved Caregiver Perspectives on the End of Life in Pediatric Patients With Ventricular Assist Devices

OBJECTIVES

Ventricular assist devices (VADs) are increasingly used in pediatric heart failure as bridges to heart transplantation, although 25% will die with VADs. Family experiences in this population are not well-described. The objective is to understand bereaved families' perspectives on VAD and end-of-life decision-making.

DESIGN

Semistructured interviews with bereaved caregivers of pediatric VAD patients.

SETTING

Tertiary children's hospital.

PATIENTS

Families of six pediatric VAD patients who died from 2014 to 2020.

INTERVENTIONS

Not available.

MEASUREMENTS AND MAIN RESULTS

Applying a grounded theory framework, interviews were coded by two independent readers using qualitative software. Themes were discussed in iterative multidisciplinary meetings. Participants were interviewed at a median 2.4 years after their child died. Three major themes emerged: 1) "lack of regret" for VAD implantation despite the outcome; 2) "caregiver-child accord" (via patient's verbal assent or physical cues) at implantation and end-of-life was important in family decision-making; and 3) development of a "local surrogate family" (medical team and peer families) provided powerful support.

CONCLUSIONS

Bereaved families' perspectives provide insight into quality decision-making for major interventions and end-of-life care in pediatric patients with chronic illness who face decisions regarding technology dependence.

Factors Associated With Health-Related Quality of Life 2 Years After Left Ventricular Assist Device Implantation: Insights From INTERMACS

Background

Factors related to health‐related quality of life (HRQOL) 2 years after left ventricular assist device (LVAD) implantation are unknown. We sought to determine whether preimplant intended goal of LVAD therapy (heart transplant candidate [short‐term group], uncertain heart transplant candidate [uncertain group], and heart transplant ineligible [long‐term group]) and other variables were related to HRQOL 2 years after LVAD implantation.

Methods and Results

Our LVAD sample (n=1620) was from INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support). Using the EuroQol‐5 Dimension Questionnaire (EQ‐5D‐3L), a generic HRQOL measure, and the Kansas City Cardiomyopathy Questionnaire (KCCQ‐12), a heart failure–specific HRQOL measure, multivariable linear regression modeling was conducted with the EQ‐5D‐3L Visual Analog Scale (VAS) score and KCCQ‐12 overall summary score (OSS) as separate dependent variables. Two years after LVAD implant, the short‐term group had a significantly higher mean VAS score versus the uncertain and long‐term groups (short‐term: 75.18 [SD, 20.62]; uncertain: 72.27 [SD, 20.33]; long‐term: 70.87 [SD, 22.09], P=0.01); differences were not clinically meaningful. Two‐year mean scores did not differ by group for the KCCQ‐12 OSS (short‐term, 67.85 [SD, 20.61]; uncertain, 67.79 [SD, 19.31]; long‐term, 67.08 [SD, 21.49], P=0.80). Factors associated with a worse VAS score 2 years postoperatively (n=1205) included not working; not having a short‐term LVAD; and postoperative neurological dysfunction, greater health‐related stress, coping poorly, less VAD self‐care confidence, and less satisfaction with VAD surgery, explaining 28% of variance (P<0.001). Factors associated with a worse KCCQ‐12 OSS 2 years postoperatively (n=1250) included not working; history of high body mass index and diabetes mellitus; and postoperative renal dysfunction, greater health‐related stress, coping poorly, less VAD self‐care confidence, less satisfaction with VAD surgery, and regret regarding VAD implantation, accounting for 36% of variance (P<0.001).

Conclusions

Factors related to HRQOL 2 years after LVAD implantation include demographic, clinical, and psychological variables.

The relational dynamics of caregivers of patients with a left ventricular assist device for destination-therapy: A qualitative investigation

BACKGROUND

Caregivers are critical to the recovery and management of patients with destination-therapy left ventricular assist devices (DT-LVADs).

OBJECTIVE

To explore the needs and impacts of caregiving for patients with DT-LVAD relative to the various relationships caregivers navigate from the shared perspectives of patients, caregivers, and healthcare providers.

METHODS

Qualitative descriptive secondary analysis. Patients with a DT-LVAD (n = 3), caregivers (n = 2), and healthcare providers (n = 13) from all DT-LVAD programs in Ontario, Canada were invited to participate in semi-structured interviews. We used thematic analysis to identify, analyze, organize, describe, and report caregiver-related themes.

RESULTS

Eighteen participants were interviewed. The needs and impact of caregiving for patients with DT-LVADs were characterized by connection with others (relational), and drastic and ongoing changes from normalcy within established and new relationships (dynamics).

CONCLUSIONS

DT-LVAD caregivers' unique needs may be a result of multi-leveled and compounding relational dynamics within and across established and new relationships. These could be considered to inform the content of targeted support strategies.