Posttraumatic stress disorder after implantation of a Mechanical Assist Device Followed by Heart Transplantation: Evaluation of Patients and Partners

Association Between Caregiver Burden and Patient Recovery After Left Ventricular Assist Device Implantation: Insights From Sustaining Quality of Life of the Aged: Heart Transplant or Mechanical Support

INTRODUCTION

After left ventricular assist device (LVAD) implantation, caregivers may experience increasing burden because of new roles and responsibilities. We examined the association between caregiver burden at baseline and patient recovery after long-term LVAD implantation in patients ineligible for heart transplantation.

METHODS

Between October 1, 2015, and December 31, 2018, data from 60 patients with a long-term LVAD (age, 60-80 years) and caregivers through 1 postoperative year were analyzed. Caregiver burden was measured using the Oberst Caregiving Burden Scale, a validated instrument used for measuring caregiver burden. Patient recovery post-LVAD implantation was defined by change in Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) overall summary score and rehospitalizations over 1 year. Multivariable regression models (least-squares for change in KCCQ-12 and Fine-Gray cumulative incidence for rehospitalizations) were used to assess for association with caregiver burden.

RESULTS

Patients were 69.4 ± 5.5 years old, 85% men, and 90% White. Over the first year post-LVAD implantation, there was a 32% cumulative probability of rehospitalization; 72% (43/60) of patients had an improvement of ≥5 points in KCCQ-12 scores. Caregivers were 61.2 ± 11.5 years old, 93% women, 81% White, and 85% married. Median Oberst Caregiving Burden Scale Difficulty and Time scores at baseline were 1.13 and 2.27, respectively. Higher caregiver burden was not significantly associated with hospitalizations or change in patient health-related quality of life during the first year post-LVAD implantation.

CONCLUSIONS

Higher caregiver burden at baseline was not associated with patient recovery in the first year after LVAD implantation. Understanding the associations between caregiver burden and patient outcomes after LVAD implantation is important as excessive caregiver burden is a relative contraindication for LVAD implantation.

Posttraumatic stress disorder prevalence in medical populations: A systematic review and meta-analysis

OBJECTIVE

PTSD is increasingly recognized following medical traumas although is highly heterogeneous. It is difficult to judge which medical contexts have the most traumatic potential and where to concentrate further research and clinical attention for prevention, early detection and treatment. The objective of this study was to compare PTSD prevalence in different medical populations.

METHODS

A systematic review of the literature on PTSD following medical traumas was conducted as well as a meta-analysis with final pooled result and 95% confidence intervals presented. A meta-regression was used to investigate the impact of potential effect modifiers (PTSD severity, age, sex, timeline) on study effect size between prevalence studies.

RESULTS

From 3278 abstracts, the authors extracted 292 studies reporting prevalence. Using clinician-administered reports, the highest 24 month or longer PTSD prevalence was found for intraoperative awareness (18.5% [95% CI=5.1%-36.6%]) and the lowest was found for epilepsy (4.5% [95% CI=0.2%-12.6%]). In the overall effect of the meta-regression, only medical events or procedures emerged as significant (p = 0.006) CONCLUSION: This review provides clinicians with greater awareness of medical contexts most associated with PTSD, which may assist them in the decision to engage in more frequent, earlier screening and referral to mental health services.

Relationship quality, dyadic coping, and depression in couples with left ventricular assist device implantation

AIMS

Living with a left ventricular assist device (LVAD) can be associated with many burdens and worries for patients. They are often dependent on the support of their spouses. This can also be a burden on the spouses and the relationship. However, the relationships quality of LVAD couples has so far scarcely been investigated. Couple's mutual coping with stress (dyadic coping, DC), as well as depression are important factors influencing relationship quality. To examine patients' with an LVAD and their partners' ability to cope with stress and levels of depression, and the impact these have on relationship quality.

METHODS AND RESULTS

The study investigates relationship satisfaction in couples after LVAD implantation as well as influencing factors such as DC or depression. Differences in relationship quality, DC, and depression between patients and spouses are examined using validated questionnaires. N = 39 heterosexual couples with male patients participated. Relationship quality of patients was higher than that of their spouses. The actor-partner-interdependence model provided for spouses actor effects on relationship satisfaction of their own DC, partner DC, and depression. For patients, actor effects of partner DC and depression as well as a partner effect of depression were found. In addition, DC of patients was estimated by both partners to be lower than DC of spouses.

CONCLUSION

The results indicate a high rate of depression among LVAD patients and spouses. This study contributes to the knowledge about the mental state of LVAD couples and demonstrates that the spouses should be considered during treatment.

Depression, anxiety, fear of progression, and emotional arousal in couples after left ventricular assist device implantation

AIMS

Left ventricular assist device (LVAD) is a common treatment option for patients with heart failure waiting for a donor heart. Living with an LVAD is associated with many burdens and worries. Patients often depend on the support of their relatives, usually their spouses. This can also put a strain on the spouses and be associated with psychological stress for both. In couples, communication proves to be an important form of emotional support. Besides verbal aspects of communication, the extent of emotional arousal (f₀ ) that is vocally encoded plays an essential role as a non-verbal aspect of communication. This study aims to investigate the psychological impact of LVAD on couples in investigating to what extent depression, anxiety, and fear of progression (FoP) differ between patients and partners, the intrapersonal and interpersonal associations of anxiety, depression, and FoP, and differences in emotional arousal.

METHODS AND RESULTS

In this cross-sectional study, male LVAD patients and their female partners (N = 21 couples) responded to self-report questionnaires on depression, anxiety, and FoP. Emotional arousal (f₀ ) was evaluated during social support interactions between both spouses. Female partners experienced more anxiety than male patients (P = 0.016). No differences occurred in depression (P = 0.967) and FoP (P = 0.084). Regarding intrapersonal associations, for patients, correlations appeared between anxiety and depression (r = 0.859, P = 0.000), anxiety and FoP (r = 0.730, P = 0.000), and depression and FoP (r = 0.608, P = 0.004). For caregivers, correlations appeared between anxiety and depression (r = 0.906, P = 0.000), anxiety and FoP (r = 0.665, P = 0.001), and depression and FoP (r = 0.734, P = 0.000). Regarding interpersonal associations, correlations were found between patient's anxiety and caregiver's anxiety (r = 0.461, P = 0.041), caregiver's depression (r = 0.510, P = 0.018), and caregiver's FoP (r = 0.524, P = 0.015). Non-significant correlations were found for caregiver's anxiety and patient's FoP (r = 0.404, P = 0.078) and patient's depression (r = 0.286, P = 0.236). Patient's depression was associated with caregiver's FoP (r = 0.526, P = 0.017), but not with caregiver's depression (r = 0.337, P = 0.146). No significant correlations were found between caregiver's depression and patient's FoP (r = 0.386, P = 0.084) and patient's depression (r = 0.337, P = 0.146). Patient's and caregiver's FoP showed significant associations (r = 0.482, P = 0.027). Patient's and partner's f₀ were interrelated. Patient's f₀ was positively related with his own and his partner's psychological distress. Partner's f₀ showed associations to her own depression and FoP.

CONCLUSIONS

Findings indicate that women of LVAD patients are burdened similarly or even to a greater extent than men themselves. Women's psychological distress has an impact on patients' psychological distress and vice versa. Early interventions for both patient and partner represent a necessary intervention target.

Nursing Challenges in Interactions With Patients Receiving Mechanical Circulatory and Respiratory Support

BACKGROUND

Mechanical circulatory and respiratory support (MCRS) systems provide short- to long-term life support for patients with severe cardiac or respiratory failure. Whereas the challenges of patients with these lifesaving systems are well understood, the challenges faced by nurses of patients receiving MCRS remain relatively unidentified.

OBJECTIVES

In this study, we investigated the challenges and experiences of MCRS nurses, with the aim of informing the design of future interventions.

DESIGN

A qualitative approach was taken to develop an in-depth understanding of the emotional issues nurses experience in their daily interactions with patients.

PARTICIPANTS AND SETTING

Nine MCRS nurses ranging in clinical experience were recruited from Australian hospitals.

METHODS

Participants were divided into 3 focus groups, with design prompts being used in the focus groups to facilitate discussion. Data from these focus groups were analyzed through a thematic analysis protocol.

RESULTS

The nurses' accounts were clustered around 2 themes, including (1) patient connection and (2) compassion vitality and fatigue. Each theme elicits a conflicting compromise that MCRS nurses face daily.

CONCLUSION

The challenges of nurses who support patients with MCRS are complex, multifaceted, emotionally stimulating, and exhausting. We therefore contributes a set of design criteria to support such nurses, setting a direction for future research.

Human Factors and User Experience Issues with Ventricular Assist Device Wearable Components: A Systematic Review

Ventricular Assist Devices (VADs) provide continuous mechanical circulatory support during in- and out-of-hospital care. However, limitations of the external wearable components influence patient quality of life. There is insufficient understanding of the issues with such components that combines a holistic viewpoint from both human factors and user (including patient and caregiver) experience perspectives. This paper comprehensively details the issues with VAD wearable systems and proposes a way for human-centered design to bridge the gap, addressing such issues synergistically. Through the review the authors investigated: the user issues caused by wearable components of VADs, and how human factors issues correlate to the VAD user experience. A Boolean search ("ventricular assist" AND "human factors" AND "experience") for peer-reviewed studies published between 2008 and 2018 returned 338 titles, with 35 relevant studies selected using a PRISMA process for inclusion in cross-study analysis and synthesis. This paper provides design recommendations for the issues found in the literature. Four key focus areas to inform the future design of VAD wearable components were identified-'Power Supply', 'Wearability and Travel Freedom', 'The Female Experience' and 'Intuitive Handling'. Using design to drive innovation could result in VAD wearable components which better meet or exceed users' quality of life goals.

Dyadic Coping of Kidney Transplant Recipients and Their Partners: Sex and Role Differences

Background: Coping with stressful health issues - e.g., organ transplantation - can affect interpersonal relationships. Objective: The study examines individual and dyadic coping (DC) in kidney transplant recipients and their partners under consideration of sex and role differences. The Dyadic Coping Inventory allows analyzing partners' perception of their own DC and also of their partner's behavior and investigating different perspectives with three discrepancy indexes (similarity, perceived similarity, congruence). Methods: Fifty-six kidney transplant recipients and their partners completed self-report questionnaires (N = 112) on DC, depression, anxiety, and relationship satisfaction. The average age of the patients was 58.1 years and of the partners 57.2 years; 64.3% of the patients were male; time since transplantation was on average 9.7 years. Results: (1) Individual and dyadic functioning: In couples with male patients female caregivers showed higher own supportive DC than the males. In couples with female patients, women reported higher own stress communication, supportive DC, total positive DC and total DC as well as depression compared to men. (2) Regarding the discrepancy indexes, in couples with male patients lower levels of similarity in DC reactions of the couple was associated with higher depression of the males as well as higher anxiety of the females. Moreover, lower comparability of the own DC with partner-perception was correlated with higher depression in males. In couples with female patients, higher comparability was associated with higher DC. Higher DC of the males was associated with lower own anxiety and better similarity in DC reactions. Lower levels of similarity of the male spouse showed correlations with higher depression and anxiety of the females. (3) Sex and role differences occurred. No significant differences between male patients and male partners occurred whereas female patients showed higher own stress communication, supportive DC, common DC, total positive DC, total DC and relationship satisfaction compared to female caregivers (role differences). The same differences were found comparing female with male patients. No differences occurred between male and female caregivers (sex differences). (4) Regarding male's relationship quality, male's DC total score and similarity index seem to be important predictors in couples with male patients. Discussion: The results demonstrate the relevance of DC in couples with kidney transplantation and show differences between males and females as well as between patients and partners.

Sexual activity in patients with left ventricular assist devices and their partners: impact of the device on quality of life, anxiety and depression

OBJECTIVES

Prolonged support with a left ventricular assist device (LVAD) has evolved as an alternative treatment strategy for patients with end-stage heart disease. This requires a shift in focus on sexual activity and psychosocial outcomes in patients with an LVAD and their partners.

METHODS

This cross-sectional study was designed to capture Sexual Activities in Left Ventricular Assist Device Patients Or PaRtners (SALVADOR) perceptions on illness-related changes in the quality of sexual activity and its impact on quality of life, anxiety and depression using standardized patient-reported outcome scales (Sexual Adjustment Scale, 36-Item Short Form Health Survey, Hospital Anxiety and Depression Scale). A total of 72 patients with LVADs (50% response rate) along with 48 partners participated.

RESULTS

For patients with an LVAD (median age 60 years; 84.7% male), median time on the device was 650 days; 69.5% stayed in long-term partnerships (median 23 years). Prevalence rates for illness-related changes in the quality of sexual activity were 58.3% for patients and 52.1% for partners. Device-related disturbances in sexual activities occurred due to battery pockets (patients/partners: 59.2%/37.6%; P = 0.006) and the driveline (46.3%/37.5%; P = 0.033) and led to significantly increased distress in patients/partners (battery pockets: 53.5%/41.3%; P = 0.006; driveline 54.9%/37.5%; P = 0.004). Disturbances in sexual activity were independently associated with higher rates of depression (odds ratio 1.33, 95% confidence interval 1.14-1.55; P = 0.001) in patients and lower mental quality of life (odds ratio 6.18, 95% confidence interval 1.13-33.98; P = 0.036) in partners.

CONCLUSIONS

Disturbances in sexual activity are common in patients with an LVAD and their partners while the patients are on durable long-term support. Counselling on long-term adjustment should provide a platform for information seeking on illness-related changes in the quality of sexual activity.

The Relationship Between Psychological Symptoms and Ventricular Assist Device Implantation

CONTEXT

Ventricular assist devices (VADs) improve quality of life in advanced heart failure patients, but there are little data exploring psychological symptoms in this population.

OBJECTIVE

This study examined the prevalence of psychiatric symptoms and disease over time in VAD patients.

METHODS

This prospective multicenter cohort study enrolled patients immediately before or after VAD implant and followed them up to 48 weeks. Depression and anxiety were assessed with Patient-Reported Outcomes Measurement Information System Short Form 8a questionnaires. The panic disorder, acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) modules of the Structured Clinical Interview for the DSM were used.

RESULTS

Eighty-seven patients were enrolled. After implant, depression and anxiety scores decreased significantly over time (P = 0.03 and P < 0.001, respectively). Two patients met criteria for panic disorder early after implantation, but symptoms resolved over time. None met criteria for ASD or PTSD.

CONCLUSIONS

Our study suggests VADs do not cause serious psychological harms and may have a positive impact on depression and anxiety. Furthermore, VADs did not induce PTSD, panic disorder, or ASD in this cohort.

New role of ventricular assist devices as bridge to transplantation: European perspective

PURPOSE OF REVIEW

Progress of ventricular assist devices (VAD) technology led to improved survival and apparently low morbidity. However, from the European perspective, updated analysis of EUROMACS reveals a somewhat less impressive picture with respect to mortality and morbidity.

RECENT FINDINGS

We describe the great demand of cardiac allografts versus the lack of donors, which is larger in Europe than in the United States. Technical progress of VADs made it possible to work out a modern algorithm of bridge-to-transplant, which is tailored to the need of the particular patient. We analyze the burden of patients undergoing bridge-to-transplant therapy. They are condemned to an intermediate step, coupled with additional major surgery and potential adverse events during heart transplantation.

SUMMARY

Based on current registry data, we do have to question the increasingly popular opinion, that the concept of heart transplantation is futureless, which seems to be for someone who treats and compares both patients (VAD and heart transplantation) in daily practice, questionable. Up to now, left ventricular assist device therapy remains a bridge to a better future, which means a bridge to technical innovations or to overcome the dramatic lack of donors in Europe.

Cardiac Disease-Induced Post-traumatic Stress Symptoms (CDI-PTSS) Among Patients' Partners

It is well established that a patient's partner can be deeply affected by the traumatizing nature of the patient's illness. Yet, no study to date has focused on post-traumatic stress symptoms (PTSS) among partners of patients coping with an acute coronary syndrome (ACS). The current study's main aims were to address this gap and to evaluate cardiac disease-induced (CDI) PTSS prevalence in partners of patients who experienced ACS. Patients who experienced ACS and their partners were interviewed by telephone 2 to 6 months after patients' hospitalization. All patients and partners were screened for CDI-PTSS. Demographic and medical variables as well as partners' level of exposure to the cardiac event were assessed. Prevalence of CDI-PTSS was higher among partners than among patients. Partners' number of CDI-PTSS was not significantly associated with patients' number of CDI-PTSS or with any of the other explanatory factors measured, except for education level. The preliminary results that arose from the current study point to the vast number of individuals who must act as caregivers for their ill partners while having to cope with their own PTSS. Much effort should be channelled into integrating partners into cardiac recovery programmes. Copyright © 2016 John Wiley & Sons, Ltd.

The Perceptions of Important Elements of Caregiving for a Left Ventricular Assist Device Patient: A Qualitative Meta-Synthesis

BACKGROUND

The use of a left ventricular assist device (LVAD) is becoming increasingly common in patients with end-stage heart failure. Many LVAD programs require patients to have a caregiver before receiving a device. There are few studies exploring the experience, burden, and impacts on caregivers of patients with LVADs.

OBJECTIVES

The aim of this study was to synthesize the qualitative literature regarding caregiver's perceptions about caring for an adult LVAD patient.

METHODS

We searched MEDLINE, CINAHL, PsychInfo, and Web of Science to find English articles on the topic of LVAD caregiver's perceptions. The articles were then synthesized using a formal process of qualitative meta-synthesis.

RESULTS

Eight articles met criteria for inclusion. The meta-synthesis across the articles resulted in 8 themes categorized under 3 domains. Many of the articles suggested a longitudinal process of caregiving with perceptions largely dependent upon the time of interview in relation to the LVAD. The first domain of caregiving is the "early" stage, covering the life before the LVAD through the procedure. This phase is characterized by the pre-LVAD "emotional rollercoaster," the decision seen as "no option," and the thought of "leave it [the LVAD] at the hospital." The second domain is the "middle" stage, covering the time frame after discharge from the hospital. This phase is characterized by fragility of the patient, recognition of a need to adapt, and a transformed life. The final domain is "late LVAD" and describes how late in the LVAD process the LVAD indication (bridge to transplant or destination therapy) brings in to focus what is important to caregivers.

CONCLUSIONS

Existing literature indicates that the LVAD caregiver experience is intense as well as burdensome and entails the need to adapt to a new life. Given the burdens caregivers experience, clinicians and future research should explore strategies to support these important individuals.

The Experience of Family Caregivers of Patients With a Left Ventricular Assist Device

Objective:

The purpose of this review is to understand the experience of caregivers of patients with left ventricular assist device (LVAD) and to evaluate how health professionals can support them properly.

Background:

Left ventricular assist device can improve quality of life, enhance functional status, and prolong survival in patients with advanced heart failure. Nonetheless, LVAD can adversely influence quality of life for their family caregivers.

Methods:

An integrative literature review was conducted using scientific databases between January to March 2015.

Results:

A total of 15 studies are included in the final review. Three major themes emerged “emotional distress,” “responsibility,” and “coping strategies” that characterize family caregivers’ experiences with care of patients with LVAD.

Conclusion:

Health care providers should understand the pivotal role of caregivers in promoting and maintaining patients’ well-being and be able to help the caregiver to moderate the impact being overloaded. Research should be addressed to create interventions that motivate the caregivers to engage in activities that promote their health.

PTSD in solid organ transplant recipients: Current understanding and future implications

PTSS are quite prevalent in transplant recipients, although full-scale PTSD may not be that common. Those symptoms have been linked to poor transplant outcomes, perhaps owing to non-adherence to medications and other recommendations, brought about by the avoidance dimension of the PTSD/PTSS construct (patients may avoid taking their medications because they serve as reminder of the emotionally traumatic event--the transplant). It is possible to treat PTSD via specific psychotherapeutic techniques, and the treatment has been shown to be safe and likely effective in other populations. Therefore, practitioners who treat transplant recipients should be familiar with the presentation and treatment of those symptoms. This manuscript provides a systematic literature review of the PTSD/PTSS presentation in the pediatric transplant setting, a synthesis of available research findings, and suggestions for current care and future research.

Assessment of patients' and caregivers' informational and decisional needs for left ventricular assist device placement: Implications for informed consent and shared decision-making

BACKGROUND

Several organizations have underscored the crucial need for patient-centered decision tools to enhance shared decision-making in advanced heart failure. The purpose of this study was to investigate the decision-making process and informational and decisional needs of patients and their caregivers regarding left ventricular assist device (LVAD) placement.

METHODS

In-depth, structured interviews with LVAD patients, candidates and caregivers (spouse, family members) (n = 45) were conducted. We also administered a Decisional Regret Scale.

RESULTS

Participants reported LVAD decision-making to be quick and reflexive (n = 30), and deferred heavily to clinicians (n = 22). They did not perceive themselves as having a real choice (n = 28). The 2 most prevalent informational domains that participants identified were lifestyle issues (23 items), followed by technical (drive-line, battery) issues (14 items). Participants easily and clearly identified their values: life extension; family; and mobility. Participants reported the need to meet other patients and caregivers before device placement (n = 31), and to have an involved caregiver (n = 28) to synthesize information. Some participants demonstrated a lack of clarity regarding transplant probability: 9 of 15 patients described themselves as on a transplant trajectory, yet 7 of these were destination therapy patients. Finally, we found that decisional regret scores were low (1.307).

CONCLUSIONS

Informed consent and shared-decision making should: (a) help patients offered highly invasive technologies for life-threatening disease get past the initial "anything to avoid thinking about death" reaction and make a more informed decision; (b) clarify transplant status; and (c) focus on lifestyle and technical issues, as patients have the most informational needs in these domains.

Posttraumatic stress disorder in organ transplant recipients: a systematic review

OBJECTIVE

To summarize and critically review the existing literature on the prevalence of posttraumatic stress disorder (PTSD) following organ transplantation, risk factors for posttransplantation PTSD and the relationship of posttransplant PTSD to other clinical outcomes including health-related quality of life (HRQOL) and mortality.

METHODS

We conducted a systematic literature review using PubMed, CINAHL Plus, the Cochrane Library and PsycInfo and a search of the online contents of 18 journals.

RESULTS

Twenty-three studies were included. Posttransplant, the point prevalence of clinician-ascertained PTSD ranged from 1% to 16% (n=738), the point prevalence of questionnaire-assessed substantial PTSD symptoms ranged from 0% to 46% (n=1024) and the cumulative incidence of clinician-ascertained transplant-specific PTSD ranged from 10% to 17% (n=482). Consistent predictors of posttransplant PTSD included history of psychiatric illness prior to transplantation and poor social support posttransplantation. Posttransplant PTSD was consistently associated with worse mental HRQOL and potentially associated with worse physical HRQOL.

CONCLUSIONS

PTSD may impact a substantial proportion of organ transplant recipients. Future studies should focus on transplant-specific PTSD and clarify potential risk factors for, and adverse outcomes related to, posttransplant PTSD.

Clinical psychological and neuropsychological issues with left ventricular assist devices (LVADs)

BACKGROUND

Left ventricular assist devices (LVADs) are increasingly being used to treat patients in end-stage heart failure (HF) as bridge-to-transplantation, lifetime support or destination therapy. However, the importance of this newer technique for chronic cardiac support compared to heart transplantation is still open to discussion. To date, there are few studies that extensively explore the psychological and cognitive profiles of patient with ventricular assist devices (VADs).

METHODS

We studied the psychological aspects, quality of life (QOL) and cognitive profiles of 19 patients with HF before VAD implantation and then at two, five and 16 months post-implantation.

RESULTS

Our results showed that after VAD implantation, patients did not show any psychopathological problems such as anxiety and/or depression. More interestingly, despite the constant risk of neurological events determined by the continuous-blood-flow pump (CBFP), patients' cognitive functioning did not worsen. In fact, significant enhancements were observed over time.

CONCLUSIONS

Psychological and cognitive deficits are common in advanced HF and often worsen over time. Appropriately designed and randomized studies are needed to demonstrate whether earlier VAD implantation is warranted to arrest cognitive decline and encourage better post-implantation adaptation.

Heart transplants: Identity disruption, bodily integrity and interconnectedness

Of heart transplant recipients, 30 per cent report ongoing or episodic emotional issues post-transplant, which are not attributable to medications or pathophysiological changes. To this end, our team theorized that cardiac transplantation introduces pressing new questions about how patients incorporate a transplanted heart into their sense of self and how this impacts their identity. The work of Merleau-Ponty provided the theoretical underpinning for this project as it rationalizes how corporeal changes affect one’s self and offer an innovative framework to access these complex aspects of living with a transplanted heart. We used visual methodology and recorded 25 semi-structured interviews videographically. Both visual and verbal data were analyzed at the same time in an iterative process. The most common theme was that participants expressed a disruption to their own identity and bodily integrity. Additionally, participants reported interconnectedness with the donor, even when the transplanted heart was perceived as an intruder or stranger. Finally, transplant recipients were very vivid in their descriptions and speculation of how they imagined the donor. Receiving an anonymous donor organ from a stranger often leaves the recipient with questions about who they themselves are now. Our study provides a nuanced understanding of heart transplant recipients’ embodied experiences of self and identity. Insights gained are valuable to educate transplant professionals to develop new supportive interventions both pre- and post-transplant, and to improve the process of informed consent. Ultimately, such insights could be used to enable heart transplant recipients to incorporate the graft optimally over time, easing distress and improving recovery.

Psychological distress in patients with a left ventricular assist device and their partners: an exploratory study

BACKGROUND

Left ventricular assist device (LVAD) therapy is increasingly used in patients with advanced heart failure, and may have a significant psychological impact on both patients and their partners. Hence, we examined the distress levels of LVAD patients and their partners.

METHODS

Anxiety, depression and post-traumatic stress disorder (PTSD) were assessed at 3-4 weeks after implantation, and at 3 and 6 months follow-up in 33 LVAD patients (73% men; mean age=54±10 years) and 33 partners (27% men; mean age=54±11 years).

RESULTS

The prevalence of anxiety in LVAD partners was significantly higher compared to LVAD patients at baseline (48% vs. 23%, p=0.03) and 3 months follow-up (44% vs. 15%, p=0.02), but not at 6 months follow-up (p=0.43). No differences were found for depression and PTSD (ps>0.05). Scores between the LVAD patients and partners showed only a significant correlation at baseline between the anxiety, depression and PTSD score of the patient and the depression score of the partner (r anx=0.40, p=0.04; rdep=.40, p=0.04; r PSTD=0.46, p=0.05). Multivariable analyses showed no significant association between the role (patient vs. partner) and anxiety, depression and PTSD over time after correction for age, gender and clinical covariates. However, after correction for Type D personality and the use of psychotropic medication the LVAD partners showed significantly higher anxiety (F=6.95, p=0.01) and depression (F=3.94, p=0.04) scores over time compared to LVAD patients.

CONCLUSION

LVAD partners had significantly higher levels of anxiety than LVAD patients. Emotional distress of LVAD partners should gain more attention, as partners are an essential source of support for LVAD patients.

Prolegomena to any future mereology of the body

Many bioethical arguments rely implicitly on the assumption that the concept of "human part" is one on which everyone must agree, because it is unambiguous. But various parties interpret this "unambiguous" term in incompatible ways, leading to contention. This article is an informal presentation of a topomereological system on whose preferred interpretation several distinct but related meanings of "human part" can be isolated: part of a human body, part of the completion of a human body, and part of a human being. A case is analyzed (the first total artificial heart (TAH) implantation), demonstrating in the process much of the apparatus of the system. By means of a casuistic methodology, the analysis is translated into recommendations for the ethical conduct of future TAH research. The more general conclusion, however, is that formal methods may provide useful tools for clarifying thought processes and organizing arguments in debates over bioethical issues.

Nursing Patients with Ventricular Assist Devices: An Interpretive Description

Context

Although researchers have studied the experience of caring for patients with ventricular assist devices from the perspective of family caregivers, few reports address the experience of nursing patients with such devices.

Objective

To investigate the experience of nursing patients who have a ventricular assist device.

Design

A qualitative approach called interpretive description was used to conduct semistructured, 1-on-1 interviews.

Participants

Six registered nurses with a range of clinical experiences were interviewed in a 1-year period from 2009 to 2010. Data were transcribed and analyzed by the researcher in conjunction with a research team.

Results

Four distinct themes were interpreted from the interview data: exclusive knowledge, human connection, ethics, and interdisciplinary stress and technology.

Conclusion

Nursing patients who have a ventricular assist device is a complex experience. Nurses develop expert knowledge that is related to direct exposure to patients; this unique knowledge should be formally considered in team decision making. Nursing care of patients who have a ventricular assist device also has features that might result in overconnected nurse-patient relationships. Closely connected nurse-patient relationships intensified the emotional difficultly of experiences of exposure to illness or suffering, or exposure to an unpredictable dying trajectory. Nursing patients with ventricular assist devices can be difficult, and nursing leaders should be aware of the emotional reactions that can result from direct exposure to patients who might be perceived as very ill or suffering. Institutions with ventricular assist device programs should consider providing emotional support for health care workers who find this type of work emotionally difficult.

Post-traumatic stress disorder in partners of people with epilepsy

AIMS

The objectives of the present study were to examine whether living with an individual who suffered from epilepsy was a potentially traumatizing event and to identify predictive risk factors in developing post-traumatic stress disorder (PTSD).

METHODS

Six hundred fourteen respondents completed the Harvard Trauma Questionnaire, the Crisis Support Scale, the Hopkins Symptom Checklist-25, and the Dyadic Adjustment Scale. In addition, demographic variables were included in order to identify factors that might predict PTSD.

RESULTS

The percentage of the participants that fulfilled the symptom criteria of PTSD was 7.7%, and an additional 43.9% reported a subclinical level of PTSD. Clinical and subclinical anxiety was unveiled in 9.3% of the respondents.

CONCLUSION

Partners were at risk of PTSD when living with a patient with epilepsy. Identified variables that explained PTSD were frequency and types of seizures medication, side effects, and objective and subjective epilepsy severity, anxiety, and depression. High level of social support decreased the level of traumatic stress.

Preparation and Support of Patients through the Transplant Process: Understanding the Recipients' Perspectives

Preparation for heart transplant commonly includes booklets, instructional videos, personalized teaching sessions, and mentorship. This paper explores heart transplant recipients' thoughts on their preparation and support through the transplant process. Twenty-five interviews were audio-/videotaped capturing voice and body language and transcribed verbatim. Coding addressed language, bodily gesture, volume, and tone in keeping with our visual methodology. Recipients reported that only someone who had a transplant truly understands the experience. As participants face illness and life-altering experiences, maintaining a positive attitude and hope is essential to coping well. Healthcare professionals provide ongoing care and reassurance about recipients' medical status. Mentors, family members, and close friends play vital roles in supporting recipients. Participants reported that only heart transplant recipients understood the experience, the hope, and ultimately the suffering associated with living with another persons' heart. Attention needs to be focused not solely on the use of teaching modalities, but also on the development of innovative support networks. This will promote patient and caregiver engagement in self-management. Enhancing clinicians' knowledge of the existential aspects of transplantation will provide them with a nuanced understanding of the patients' experience, which will ultimately enhance their ability to better prepare and support patients and their caregivers.

The experience of parents and children where children have been supported with a ventricular assist device as a bridge to heart transplantation

There is little information to assist in understanding the experience endured by parents and children where children have been supported with a ventricular assist device (VAD) as a bridge to heart transplantation. Consequently, the aims of this study were to gain an understanding of children's and parents' experience where children have been supported with a VAD as a bridge to heart transplantation and to use this information to improve the Royal Children's Hospital (RCH) VAD program. This study employed a qualitative approach using purposive sampling. Semistructured interviews were conducted with children aged 13 years or more and their parents to determine their experience of having required VAD support as a bridge to transplantation. Results demonstrated a lack of information that prepared families and children for the anticipated course of treatment on VAD support. Recommendations to improve the VAD program for parents and children include more information through meetings, as well as in a written format, and speaking to other families who had already experienced VAD. For children in particular, a visual of the VAD, its associated equipment, and an image of where it is placed in the body is vital information that is necessary prior to VAD support. Overall, the recommendations are important and should be made available to improve the experience for children and parents, not only of the RCH VAD program but for all hospitals offering VAD therapy.

Health-related quality of life and exercise tolerance in recipients of heart transplants and left ventricular assist devices: a prospective, comparative study

BACKGROUND

The aim of this study was to evaluate and compare health-related quality of life (HRQoL) and physical exercise tolerance in patients after heart transplantation (HTx) or implantation of a left ventricular assist device (LVAD).

METHODS

A prospective, comparative design was used to characterize changes over time in HRQoL (SF-36) and exercise tolerance in patients after HTx (n = 54) and during LVAD support (n = 36). Nine LVAD patients were lost for follow-up. The majority of patients in both groups were male (97%); the LVAD cohort tended to be younger (p = 0.06).

RESULTS

HRQoL improved significantly in HTx patients in the SF-36 physical (p = 0.02), but not in the psychosocial (p = 0.27) component score during follow-up. In the LVAD group, HRQoL showed improvements for both the SF-36 physical and psychosocial component scores (both p = 0.04). Between-group comparisons revealed better HRQoL for the HTx cohort than the LVAD cohort for 2 of 8 SF-36 subscales. Age-, gender- and body mass index (BMI)-adjusted exercise tolerance (workload; VO(2max)) showed significant improvements for both HTx (p = 0.01) and LVAD (p = 0.01) patients. Adjusted maximum oxygen consumption was higher for HTx patients (p = 0.05) relative to LVAD patients at 8 ± 1 months after implant.

CONCLUSION

HRQoL and exercise capacity increased in both groups over the time-course of the study. After adjusting for relevant variables, HTx patients showed a higher exercise tolerance compared with the LVAD group during follow-up. Thus, future large-scale intervention studies should emphasize the specific needs of these patient cohorts.

Emotional Experiences of Caregivers of Patients with a Ventricular Assist Device

Context

Little is known about the stresses experienced by caregivers of patients discharged home with a ventricular assist device.

Objective

To describe the lived experience of caregivers of patients who were discharged home with a ventricular assist device.

Design

The study used a phenomenological framework to conduct semistructured interviews guided by 2 psychologists using a focus group setting.

Participants

Interviews of 13 caregivers of 9 patients discharged to home with a ventricular assist device between March 2004 and June 2007 were recorded, transcribed, and analyzed.

Results

Four themes emerged during the interviews: anxiety, initially exhibited as profound shock; loss of a loved one, of their lives, of freedom and independence; burden, both the physical burden and the burden of responsibility; and finally coping through faith, acceptance, empathy, and social support.

Conclusion

Caregivers of patients discharged home with a ventricular assist device experienced significant pressures that changed over the duration of support with the ventricular assist device. Caregivers described their coping mechanisms in dealing with shock, loss, and burden. Understanding the fluctuating needs of caregivers will enable teams to provide interventions based on the situation. Future care guidelines should address the significant stresses placed on caregivers of recipients of a ventricular assist device.

Ethical challenges with the left ventricular assist device as a destination therapy

The left ventricular assist device was originally designed to be surgically implanted as a bridge to transplantation for patients with chronic end-stage heart failure. On the basis of the REMATCH trial, the US Food and Drug Administration and the US Centers for Medicare & Medicaid Services approved permanent implantation of the left ventricular assist device as a destination therapy in Medicare beneficiaries who are not candidates for heart transplantation. The use of the left ventricular assist device as a destination therapy raises certain ethical challenges. Left ventricular assist devices can prolong the survival of average recipients compared with optimal medical management of chronic end-stage heart failure. However, the overall quality of life can be adversely affected in some recipients because of serious infections, neurologic complications, and device malfunction. Left ventricular assist devices alter end-of-life trajectories. The caregivers of recipients may experience significant burden (e.g., poor physical health, depression, anxiety, and posttraumatic stress disorder) from destination therapy with left ventricular assist devices. There are also social and financial ramifications for recipients and their families. We advocate early utilization of a palliative care approach and outline prerequisite conditions so that consenting for the use of a left ventricular assist device as a destination therapy is a well informed process. These conditions include: (1) direct participation of a multidisciplinary care team, including palliative care specialists, (2) a concise plan of care for anticipated device-related complications, (3) careful surveillance and counseling for caregiver burden, (4) advance-care planning for anticipated end-of-life trajectories and timing of device deactivation, and (5) a plan to address the long-term financial burden on patients, families, and caregivers.Short-term mechanical circulatory devices (e.g. percutaneous cardiopulmonary bypass, percutaneous ventricular assist devices, etc.) can be initiated in emergency situations as a bridge to permanent implantation of ventricular assist devices in chronic end-stage heart failure. In the absence of first-person (patient) consent, presumed consent or surrogate consent should be used cautiously for the initiation of short-term mechanical circulatory devices in emergency situations as a bridge to permanent implantation of left ventricular assist devices. Future clinical studies of destination therapy with left ventricular assist devices should include measures of recipients' quality of end-of-life care and caregivers' burden.

Palliative care and hospice in advanced heart failure

This paper provides an evidence-based review of the principles underlying palliative care for heart failure (HF), including its pathogenesis, staging, assessment, prognosis, and treatment. Approaches to advanced care planning, symptom management, hospice eligibility, home inotropic infusions, device management and improving the continuum of care in HF are discussed. The reader will be able to recognize advanced HF, use important elements of physical assessment, utilize Web-based prognostic and risk-stratification models, facilitate advance care planning, ensure optimal treatment, manage common symptoms and comorbid conditions, determine hospice eligibility, and consider issues related to withholding or withdrawal of inotropic infusions and devices used in HF refractory to standard treatment. The ultimate goal of palliative care for heart failure is to integrate knowledge of treatment advances and comfort measures and to provide them concurrently in a seamless continuum to patients with late-stage disease.