Redefining life while forestalling death: living with an implantable cardioverter defibrillator after a sudden cardiac death experience

The experiences of cardiac arrest survivors and their key supporters following cardiac arrest: A systematic review and meta-ethnography

AIM

To review qualitative studies on the experience of sudden cardiac arrest survival from the perspective of both survivors and their key supporters, including family/close friends.

METHODS

A seven-step meta-ethnography and synthesis of qualitative evidence was undertaken, informed by the Meta-Ethnography Reporting Guidelines (eMERGe). Four major databases were searched (Medline, EMBASE, CINAHL, PsycINFO; January 1995-January 2022, updated July 2023) for qualitative studies exploring survivors' and/or key supporters' experiences of cardiac arrest survival. The Critical Appraisal Skills Programme checklist and Grading of Recommendations Assessment, Development and Evaluation - Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQual) were applied to evaluate the overall confidence in research findings. Constructs were identified from each paper, informing theme and sub-theme development.

RESULTS

From 15,917 unique titles/abstracts and 196 full-text articles, 32 met the inclusion criteria. Three themes captured the survivors' experiences: 1) Making sense of my cardiac arrest; 2) Learning to trust my body and mind; and 3) Re-evaluating my life. A further three themes reflected key supporters' experiences: 1) Emotional turmoil; 2) Becoming a carer: same person but different me; and 3) Engaging with a new and unknown world. However, limited data and some methodological weaknesses in included studies reduced confidence in several themes. The findings were conceived within the overarching concept of 'negotiating a new normal'.

CONCLUSIONS

The enduring psychosocial and physical sequelae of cardiac arrest survival substantially impacts the lives of survivors and their key supporters, requiring negotiation of their 'new normality'. The need for sense-making, physical and psychological recovery, and the new roles for key supporters should be strong considerations in the development of future interventions.

The friend within? The implantable cardioverter defibrillator between saving lives and chronically impairing them

This article considers the way in which a medical technology, the implantable cardioverter defibrillator (ICD), by preventing fatal outcomes, in this case sudden death, deriving from cardiac diseases, and specifically hypertrophic cardiomyopathy, contributes to the development of a particular type of chronicity. While biomedicine celebrates technological advances in treatments and naturalises chronicity, focussing on life expectancy as a victory over the 'acute' aspects of the disease, the way in which patients live with the disease is left unquestioned. The article follows Smith-Morris's (2010) perspective in seeing chronicity as the never-ending process of identifying with one's disease, adding a focus on the role played by an embodied technology in relation to it. Based on participant observation in a clinical setting and interviews with clinicians, the article interrogates three key themes in the chronicity of cardiac patients implanted with an ICD: risk, quality of life and choice. The data shows a constant tension between managing a one-off potentially fatal 'acute' risk and life with serious disruptions due to the limitations imposed by the implanted device. The article argues that patients' resources for facing the life and identity disrupted by the disease are limited by ideas of what living a diseased body is, which acritically follow discourses of 'patient choice' and a 'technological imperative' to avoid risk.

Delivering an efficient and effective support group for patients with implantable cardioverter-defibrillators (ICDs): patient perspectives of key concerns and predictors of inclination to attend

BACKGROUND

A subset of patients experience psychological distress following insertion of an implantable cardioverter-defibrillator (ICD) and ICD support groups are recommended, however access to these groups is limited. This study aimed: to gauge a better understanding of patients' key ICD-related concerns; to determine patient interest in a support group and topics deemed helpful to address in a support group; and to examine factors which affect patient inclination to attend.

METHODS

One hundred and thirty nine patients completed the ICD Patient Concerns Questionnaire - Brief (ICDC-B) and a semi-structured survey. Non-parametric tests were used to examine associations and differences in the quantitative data. Qualitative data were analysed using thematic analysis.

RESULTS

42% of respondents said they would attend a support group and inclination to attend was associated with higher ICD concerns and a shorter time since implant. Topics considered important to address in a group were information about heart conditions and devices, the impact of an ICD on daily life and coping with fear of shocks.

CONCLUSION

We concluded that there is interest in further support amongst many patients and that ICD support groups may be delivered efficiently by targeting patients who have higher levels of ICD concerns and within the first few years after implant.

Experiences of adults living with an implantable cardioverter defibrillator for cardiovascular disease: a systematic review of qualitative evidence

OBJECTIVE

The objective of this review was to synthesize the best available qualitative evidence on the everyday life experiences of adults living with an implantable cardioverter defibrillator for cardiovascular disease.

INTRODUCTION

Cardiovascular disease is a rising concern worldwide. The efficacy of the implantable cardioverter defibrillator as a successful treatment for cardiovascular disease has been well documented. Research suggests that living with an implantable cardioverter defibrillator is complex and can cause substantial psychosocial distress that can manifest itself at various intervals over time. The first step to developing evidence-based recommendations related to the management of implantable cardioverter defibrillator-related distress is a critical appraisal and synthesis of relevant literature to gain a more comprehensive understanding of this phenomenon.

INCLUSION CRITERIA

The participants of interest were adults 18 years or older who had an implantable cardioverter defibrillator for the management of cardiovascular disease (e.g. ischemic heart disease, angina, cardiomyopathy, myocardial infarction, congenital defect, arrhythmias, heart failure). The phenomenon of interest was the everyday life experience of adults living with an implantable cardioverter defibrillator. The review considered all qualitative research related to the phenomenon of interest.

METHODS

Key databases searched were PubMed, CINAHL, PsycINFO, Embase, International Bibliography of the Social Sciences, Sociological Abstracts, OpenGrey, MedNar, ProQuest Dissertations and Theses Global, Google, and Google Scholar. Published and unpublished papers and articles from 1990 to July 2018 were included in the search. The JBI approach to critical appraisal, study selection, data extraction, and synthesis for qualitative research was used throughout the review.

RESULTS

Twenty-seven papers were included in the review that yielded 143 findings and 13 categories. The methodological quality of the 27 included studies was moderate to strong. Based on ConQual scores, confidence in the synthesized findings was moderate. From this, three synthesized findings were extracted: i) living under the shadow of uncertainty, ii) orchestrating a new normal, and iii) crafting a positive vision for the future.

CONCLUSIONS

Evidence suggests that while implantable cardioverter defibrillator recipients do experience psychosocial distress, they gradually positively embrace the device as part of their everyday norm. Recommendations for practice and education point to the further development of best practice guidelines for implantable cardioverter defibrillator management, continuing education programs for health care providers, and strategies to support implantable cardioverter defibrillator recipients and their families to cope with the device. Research that examines onset, level, and duration of implantable cardioverter defibrillator psychosocial distress is needed to target specific interventions reflective of this population's needs. While findings suggest the experiences of women living with an implantable cardioverter defibrillator are similar to men, the low number of women in included studies limits the strength of this conclusion.

Factors associated with body image among patients with an implanted left ventricular assist device

BACKGROUND

Among Left Ventricular Assist Device (LVAD) implanted patients, body image modifications might occur.

OBJECTIVES

To explore the associations between sexual functioning, confidence in LVAD technology, personal wellbeing, and body image.

METHODS

The cross-sectional study included 30 conveniently recruited LVAD implanted patients who completed Body Image Scale, sexual functioning, confidence in LVAD technology, and Personal Wellbeing Index questionnaires. The associations between the research variables were examined with multiple regression analyses.

RESULTS

The mean age of the participants was 63 (SD=10), 90% were men. The mean scores were: sexual functioning - 2.43 (SD=1.20, range 1-5); confidence in LVAD technology - 2.63 (SD=1.04, range 1-5); Well-Being Index - 6.61 (SD=1.53, range 0-10); and body image - 14.5 (SD=4.17, range 5-20). Sexual functioning (p<.01) and LVAD technology confidence (p=.04) significantly predicted body image.

CONCLUSIONS

Healthcare professionals should be aware of challenges regarding body image faced by LVAD implanted patients and to address related factors.

Heideggerian hermeneutic phenomenology as method: modelling analysis through a meta-synthesis of articles on Being-towards-death

While the richness of Heideggerian philosophy is attractive as a healthcare research framework, its density means authors rarely utilise its fullest possibilities as an hermeneutic analytic structure. This article aims to clarify Heideggerian hermeneutic analysis by taking one discrete element of Heideggerian philosophy (Being-towards-death), and using it's clearly defined structure to conduct a meta-synthesis of Heideggerian phenomenological studies on the experience of living with a potentially life-limiting illness. The findings richly illustrate Heidegger's philosophy that there is either an inauthentic positioning towards death, or an authentic positioning towards death with a proposition that (1) death is certain; (2) death is indefinite; (3) death is non-relational; and (4) death is not-to-be-outstripped. None of the 29 included studies on the experience of a confrontation with death fully utilised this framework, despite claiming a grounding in Heideggerian thought. This demonstrates the value in modelling how Heideggerian existential structures can be used proactively as analytical 'hooks' for data in research claiming a basis in this philosophy and/or method. By modelling the potential application of an important Heideggerian philosophical construct to published qualitative data, this meta-synthesis has revealed new domains and more nuanced understandings of the temporal structure of Being-towards-death. Such an approach helps to more fully unveil the existential concerns of people at the core of interpretative phenomenological enquiry and may provide a blueprint to map either primary or synthesised data to other key ontological existentials.

Living With Prophylactic ICD Therapy and the Risk of Sudden Cardiac Death: How Patients Negotiate Solutions and Problems

Prophylactic implantable cardioverter defibrillator (ICD) therapy treats potentially lethal cardiac arrhythmias in patients who have not previously experienced such but are at considerable risk due to underlying heart disease. Most patients are unaware of their risk of sudden cardiac death (SCD) until the ICD is introduced to them. Thus, the problem of risk of death and the solution of ICD therapy are presented simultaneously. Based on ethnographic fieldwork in Danish hospitals, this article illustrates how clinicians narrate prophylactic ICD therapy as a benign therapy preventing risk of death and providing the good life. However, risk of SCD is not the most pressing problem for the patients. The article argues that the solution of ICD therapy ignores patients' experience of living with severe heart disease and introduces the risk of shock therapy. For patients, a good life does not equal absence of risk of death but a life without heart disease.

Clinical life: expectation and the double edge of medical promise

This article introduces the concept of clinical life to capture a form of life produced in the pursuit and wake of medically achieved longevity. Relying on the retrospective accounts of 28 individuals over age 70 who have undergone cardiac bypass surgery, angioplasty or a stent procedure, as well as interviews with their families and with clinicians, we examine three features of clinical life. First, patients do not distinguish between clinical possibility and clinical promise, and thus assume that life can and will be improved by medical intervention in late life. Rather than anticipating a range of potential treatment outcomes, patients therefore expect the best-case scenario: that medical procedures will reverse aging, disease and the march of time. Second, patients then assess the value of their post-procedure lives in accordance with that expectation. Norms regarding what life ‘should be like’ at particular ages are continually recalibrated to the horizon of what is clinically possible. And third, the price of living longer entails a double-edged relationship with the clinic – it generates opportunities for bodily restoration and increased self-worth but also creates ambivalence about the value of life. This latter feature of clinical life is rarely publicly acknowledged in an environment that emphasizes medical promise.

Living with an implantable cardiac defibrillator: a model of chronic uncertainty

Over the last two decades, the number of patients receiving implantable cardiac defibrillators (ICDs) for the prevention of sudden cardiac death has grown significantly. This growth is largely the result of broadened indication for ICD use because of the success of trials demonstrating efficacy. Early ICD indication centered on secondary prevention, which then advanced to primary prevention in high-risk patients. Nurses delivering care to these patients not only manage this complex technology but also patients' uncertainty about their survival and related psychosocial adjustment to receiving an ICD. To inform practice, theoretical models such as Mishel's (1988) uncertainty in illness model provide insight into such acute phases of illness. This article proposes expansion of the uncertainty in illness model to advance knowledge in this field for nurses caring for patients with ICD.

Sudden cardiac death: a critical appraisal of the implantable cardioverter defibrillator

IMPORTANCE

Approximately 350,000 Americans still die of sudden cardiac death each year. This exceeds the number of patients who die annually from stroke, lung cancer, breast cancer and AIDS combined.

OBJECTIVE

This review aims to trace the history of implantable cardioverter defibrillators (ICD) with reference to landmark trials and their influence on the formulation of Medicare guidelines for ICD implantation criteria. This paper will also discuss the cost-effectiveness of ICDs and the quality of life after implantation. The reasons for the disparity between guidelines for implantation and actual clinical practice will be elucidated, with suggestions for improving overall clinical performance.

RESULTS AND CONCLUSION

The ICD has been shown to be cost-effective in reducing sudden cardiac death and all-cause mortality. However, the existing recommendations for ICD implantation have yet to translate completely into clinical practice. Barriers to implementation of existing guidelines include knowledge gaps in the referring physician practices, lack of validated screening tools to assess patient candidacy for the device and patient understanding of the need for the device. Future strategies to increase compliance with the existing guidelines and improve clinical performance are areas of potential research focus.

Ethical issues in the reuse of qualitative data: perspectives from literature, practice, and participants

In this article, we explore ethical issues in qualitative secondary analysis through a comparison of the literature with practitioner and participant perspectives. To achieve this, we integrated critical narrative review findings with data from two discussion groups: qualitative researchers and research users/consumers. In the literature, we found that theoretical debate ran parallel to practical action rather than being integrated with it. We identified an important and novel theme of relationships that was emerging from the perspectives of researchers and users. Relationships were significant with respect to trust, sharing data, transparency and clarity, anonymity, permissions, and responsibility. We provide an example of practice development that we hope will prompt researchers to re-examine the issues in their own setting. Informing the research community of research practitioner and user perspectives on ethical issues in the reuse of qualitative data is the first step toward developing mechanisms to better integrate theoretical and empirical work.

The weather-stains of care: interpreting the meaning of bad weather for front-line health care workers in rural long-term care

This paper addresses the gap in health services and policy research about the implications of everyday weather for health care work. Building on previous research on the weather-related challenges of caregiving in homes and communities, it examines the experiences of 'seasonal bad weather' for health care workers in long-term care institutions. It features a hermeneutic phenomenology analysis of six transcripts from interviews with nurses and personal support workers from a qualitative study of institutional long-term care work in rural Canada. Focussing on van Manen's existential themes of lived experience (body, relations, space, time), the analysis reveals important contradictions between the lived experiences of health care workers coping with bad weather and long-term care policies and practices that mitigate weather-related risk and vulnerability. The findings contribute to the growing concern for rural health issues particularly the neglected experiences of rural health providers and, in doing so, offer insight into the recent call for greater attention to the geographies of health care work.

COPE-ICD: patient experience of participation in an ICD specific rehabilitation programme

PURPOSE

Evaluating rehabilitation programmes from the patient's perspective is much needed, as the patients are the most important stakeholders in the health care system. A comprehensive rehabilitation programme, COPE-ICD programme, consists of exercise training and nursing consultations during a one year period post ICD implantation. The purpose of this paper is to describe the experience and meaning of participating in a comprehensive ICD-specific rehabilitation programme.

METHODS

Qualitative interviews were conducted with 10 patients representing the participating population, and later transcribed. The analysis was inspired by Ricoeur's theory of interpretation, which consists of three levels: naive reading, structured analysis and critical interpretation and discussion.

RESULTS

The overall concept was that participating in the COPE-ICD programme meant feeling inspired and secure through individualized care. Four themes emerged: Knowledge: patients gained much needed understanding; Physical attention: patients interpreted body signals and adjusted their exercise behaviour; Trust: patients regained trust, felt secure and dared to live again; Strategies of living: patients' coping was supported through reflection and professional dialogue, and they dealt with the risk of shock or death.

CONCLUSION

Participating in an ICD-specific rehabilitation programme can make patients feel inspired and secure through individualized care. They discover that they have to rethink some of their strategies of living and they gain support in the reflection and coping needed for that. Patients gain insight and they develop a special physical attention whereby they continue healthy activities through interpreting body signals and adjusting exercise behaviour. They learn to trust their body again.

Patients, intimate partners and family experiences of implantable cardioverter defibrillators: qualitative systematic review

AIM

This paper is a report of an interpretive review of qualitative research on how an implantable cardioverter defibrillator affects adult recipients and their significant others.

BACKGROUND

An implantable cardioverter defibrillator detects pathological cardiac rhythms and automatically converts the rhythm with electrical counter shocks.

DATA SOURCES

A systematic literature search was conducted for qualitative research papers published between January 1999 and January 2009. PubMed, Medline, ISI Web of Knowledge and CINAHL databases were searched with the following key words: internal defibrillator, implantable defibrillator and qualitative research.

REVIEW METHODS

Twenty-two papers were included. The critical appraisal skills programme and prompts were used to appraise studies. Thematic analysis and synthesis approaches were used to interpret evidence.

FINDINGS

People with an implantable cardioverter defibrillator were found to experience physical, psychological and social changes. Shocks produce fear and anxiety, affecting relationships and sexual relations. The use of support groups and the use of the Internet are important in helping adjustment to an implantable cardioverter defibrillator. Women's responses to an implantable cardioverter defibrillator appear different than men's responses and include concerns about physical appearance and relationship issues. Postdischarge follow-up and educational programmes are still underdeveloped.

CONCLUSION

Patients need additional education, support and follow-up care after hospital discharge. Patients and significant others benefit from collaboration between patient associations and healthcare professional societies. Future research is needed to identify the specific challenges that women recipients face.

Authoritative knowledge, the technological imperative and women's responses to prenatal diagnostic technologies

Theories about authoritative knowledge (AK) and the technological imperative have received varying levels of interest in anthropological, feminist and science and technology studies. Although the anthropological literature abounds with empirical considerations of authoritative knowledge, few have considered both theories through an empirical, inductive lens. Data extracted from an earlier study of 30 women's responses to termination for fetal anomaly are reanalyzed to consider the women's views of, and responses to, prenatal diagnostic technologies (PNDTs). Findings indicate that a small minority embrace the societal portrayal of technology as univalently positive, while the majority have nuanced and ambivalent responses to the use of PNDTs. Further, the interface of authoritative knowledge and the technological imperative suggests that AK derives not only from medical provider status and technology use, but also from the adequacy and trustworthiness of the information. The issue of timing and uncertainty of the information also are interrogated for their impact on women's lives and what that can illuminate about the theories of AK and the technological imperative.

Ironic technology: Old age and the implantable cardioverter defibrillator in US health care

We take the example of cardiac devices, specifically the implantable cardioverter defibrillator, or ICD, to explore the complex cultural role of technology in medicine today. We focus on persons age 80 and above, for whom ICD use is growing in the U.S. We highlight an ironic feature of this device. While it postpones death and 'saves' life by thwarting a lethal heart rhythm, it also prolongs living in a state of dying from heart failure. In that regard the ICD is simultaneously a technology of life extension and dying. We explore that irony among the oldest age group -- those whose considerations of medical interventions are framed by changing societal assumptions of what constitutes premature death, the appropriate time for death and medicine's goals in an aging society. Background to the rapidly growing use of this device among the elderly is the 'technological imperative' in medicine, bolstered today by the value given to evidence-based studies. We show how evidence contributes to standards of care and to the expansion of Medicare reimbursement criteria. Together, those factors shape the ethical necessity of physicians offering and patients accepting the ICD in late life. Two ethnographic examples document the ways in which those factors are lived in treatment discussions and in expectations about death and longevity.

[The daily experience of the patient with an implantable cardioverter defibrillator]

OBJECTIVE

To describe the daily experience of patients with an automatic defibrillator (AD) implant and the adaptive changes of the patient.

METHOD

Qualitative and phenomenological research. Collection of data through; initially unstructured interview with half of the informants, semi-structured interviews through an open questions guide after the initial unstructured interviews and use of personal narratives of the informants. Analysis of the data using the Van Manen proposal.

RESULTS

We analysed the interviews of 10 participants. We collected socio-demographic variables and identified the following themes, which respond to the question "How is life with an AD": It is life "with the two sides of the coin," living in constant wait and uncertainty, accepting change, developing adaptation strategies, renegotiating relationships and sexuality and it is to live transformed.

CONCLUSIONS

The results of this study can be integrated into nurse clinical practice in areas such as valuation after discharge, changes in habits, control of treatment, notification of shocks, masking detection of symptoms and strategies that can jeopardise the bearer. Research needs to be developed that looks closer into the influence of other technological devices in people.

[The basics and development of a phenomenological research protocol in nursing]

The use of qualitative methodology has been increasing over recent years. The application of different theoretical and methodological qualitative approaches makes it necessary to identify the characteristics of qualitative designs when developing research protocols and projects.

OBJECTIVES

To show the steps for the development of a phenomenological research protocol.

METHOD AND CONCLUSIONS

Developing a phenomenological research protocol entails a series of steps and elements that must be consistent, this mainly being the development of the research question with an adequate qualitative proposal. This methodological approach will determine the data, the method of collection and analysis. The phenomenological studies are aimed at studying the experience of the patient regarding a disease or circumstance.

Almost normal: experiences of adolescents with implantable cardioverter defibrillators

PURPOSE

The purpose of this study was to describe the experiences of adolescents with implantable cardioverter defibrillators (ICDs).

DESIGN AND METHODS

This qualitative study explored the lived experiences of 14 adolescents with ICDs using face-to-face, semistructured interviews.

RESULTS

Six themes were identified: life interrupted; still the same, except; sometimes it's tough; it cuts both ways; unique joule; and living life regular.

PRACTICE IMPLICATIONS

These findings suggest that nurses could make a significant impact on the lives of adolescents with ICDs by focusing their efforts away from viewing the adolescent through an illness lens and more toward a normalization lens.

To survive out-of-hospital cardiac arrest: a search for meaning and coherence

The primary responsibility of prehospital emergency personnel at out-of-hospital cardiac arrests (OHCA) is to provide lifesaving care. Ethical considerations, decisions, and actions should be based in the patient's beliefs about health and well-being. In this article, we describe patients' experiences of surviving OHCA. By using a phenomenological approach, we focus on how OHCA influences patients' well-being over time. Nine survivors were interviewed. Out-of-hospital cardiac arrest is described as a sudden and elusive threat, an awakening in perplexity, and the memory gap as a loss of coherence. Survival means a search for coherence with distressing and joyful understanding, as well as existential insecurity exposed by feelings of vulnerability. Well-being is found through a sense of coherence and meaning in life. The study findings show survivors' emotional needs and a potential for prehospital emergency personnel to support them as they try to make sense of what has happened to them.

A concept analysis of self-monitoring

AIM

This paper reports a concept analysis delineating and clarifying the concept of self-monitoring to facilitate development and evaluation of interventions to enhance self-monitoring.

BACKGROUND

The concepts of self-monitoring, self-management, self-care and symptom management are often used in similar or interchangeable ways. Clarification of the concept of self-monitoring is needed for research and theory development.

METHOD

Rodgers and Knafl's evolutionary concept analysis process was used to delineate and clarify the concept. The PubMed and CINAHL databases were searched using keywords 'self-monitoring', 'self-management' and 'self-care' (with and without the hyphen) for the years 1998-2005, to update a previous study (not published). Later, searching was refined and the keyword 'self-monitoring' was paired with 'awareness' and 'self-regulation' was added. Approximately half the papers were from nursing (n = 34) and half from other disciplines (n = 32). The sample from 1998 to 2005 was further stratified by chronic condition. Definition, exemplars, usage, attributes, antecedents/consequences and implications for further study were identified.

FINDINGS

Self-monitoring was composed of two complementary components (attributes): (1) awareness of bodily symptoms, sensations, daily activities, and cognitive processes and (2) measurements, recordings and observations that inform cognition or provide information for independent action or consultation with care providers.

CONCLUSION

Self-monitoring may be an important concept for understanding how people self-manage chronic conditions. This concept analysis may be useful for researchers who wish to measure this dimension and to develop nursing theory in this area.

Costs and quality-of-life effects of implantable cardioverter-defibrillators

Although the clinical efficacy of implantable cardioverter-defibrillators (ICDs) has been convincingly demonstrated in clinical trials, the impact of ICDs on health care costs and recipients' quality of life (QOL) is less certain. The existing medical research on the health care costs and QOL effects of ICDs was reviewed and summarized. Medline and the Institute for Scientific Information's Web of Knowledge were searched for publications reporting costs of care and QOL assessments of ICD recipients. Unpublished and non-peer-reviewed "gray" publications were excluded. Reports were included if they reported primary, original patient data that were collected after 1993, when nonthoracotomy defibrillators entered clinical practice. Two reviewers independently evaluated publications for relevance and quality, abstracted study data, and summarized the findings. Excessive heterogeneity among studies prevented formal meta-analysis, so a narrative synthesis was performed, and key themes were identified from the published research. There were limited published data on the costs of ICD care, especially for the primary prevention of sudden cardiac death. The published research on ICD QOL lacked large, multicenter, longitudinal studies. Many ICD QOL studies were performed in small numbers of patients at single centers. Initial ICD implantation costs ranged (in 2006 United States dollars) from $28,500 to $55,200, with annual follow-up costs ranging from $4,800 to $17,000. QOL was higher for ICD recipients than for patients treated with antiarrhythmic drugs, but there was a substantial prevalence of anxiety, depression, and "loss of control" in ICD recipients, particularly in those who had received ICD shocks. In conclusion, ICD implantation remains costly but may be becoming less expensive over time, and ICD recipients' QOL is significantly affected by their devices.

"Is there life on dialysis?": time and aging in a clinically sustained existence

Increasingly, in the United States, lives are being extended at ever-older ages through the implementation of routine medical procedures such as renal dialysis. This paper discusses the lives and experiences of a number of individuals 70 years of age and older at two dialysis units in California. It considers what kind of life it is that is being sustained and prolonged in these units, the meanings of the time gained through (and lost to) dialysis for older people, and the relationship of "normal" life outside the units to an exceptional state on the inside that some patients see as not-quite-life. Highlighting the unique dimensions of gerontological time on chronic life support, the article offers a phenomenology of the end of life as that end is drawn out, deferred by technological means, and effaced by the ethos and experiential course of dialysis treatment.

Technology-patient interactions: Internet use for gaining a healthy context for living with an implantable cardioverter defibrillator

OBJECTIVE

The purpose of this study was to understand the practical knowledge gained from Internet use by implantable cardioverter defibrillator (ICD) recipients through hermeneutic interpretation of narrative stories.

METHODS

The study took place through an online virtual focus group and e-mail interviews. Thirteen participants attended the ongoing 4-week virtual focus group, and 8 followed up with individual interviews.

RESULTS

Five related themes and 1 constitutive pattern emerged. Themes included getting past fear with knowledge and support; gaining context through a window to the future; Internet as mountain of information; and Internet as social interaction and becoming informed consumers. The constitutive pattern was gaining a context for living a healthy life with an ICD.

IMPLICATIONS

Providers must be aware of the value added when patients use the Internet for self-care management of their chronic illness. Through information searches and sharing stories, patients gain insight into possibilities and potential outcomes of living with an ICD.

ICD: a qualitative study of patient experience the first year after implantation

BACKGROUND

The experiences of how patients live with an implantable cardioverter defibrillator are still poorly understood. Only a few qualitative studies have investigated this phenomenon. This paper was undertaken as part of a larger project to evaluate quality of life and psychological well-being in those survivors of cardiac arrest who have received an implantable cardioverter defibrillator.

AIMS AND OBJECTIVES

The aim of this qualitative study was to explore how implantable cardioverter defibrillator recipients perceive their lives during the first year after implantation of the device.

METHODS

A sample of 21 patients who received an implantable cardioverter defibrillator was interviewed during three consecutive periods: one, six and 12 months postdischarge from the hospital. The semi-structured interviews were based on insights gained from a literature review. The transcripts were subjected to content analysis.

RESULTS

Analysis of the data revealed seven major categories: physical deterioration, cognitive changes, perceived social support, dependency, contact with the doctor, confrontation with mortality and uncertainty surrounding having a shock. Anxiety, uncertainty, disappointment, frustration, unexpected barriers, acceptance of and dependency on the implantable cardioverter defibrillator played a major role in the lives of implantable cardioverter defibrillator recipients. Well-being improved throughout the year. During the first months after discharge from the hospital the focus was on regaining physical health. During the early postimplantation period both the implantable cardioverter defibrillator recipient and family members had adapted to the situation. Reflection on the impact and consequences of the cardiac arrest was reported more often in the late postimplantation period.

CONCLUSIONS

Content analysis is a resourceful approach giving answers to questions that have hardly been addressed within the domain of cardiology. Implantable cardioverter defibrillator recipients face a complex first year, especially the first 6 months. Cognitive deterioration and confrontation with mortality are problems that need to be researched further.

RELEVANCE TO CLINICAL PRACTICE

Caregivers are able to explain to future patients what they can expect in the first year after implantation. Caregivers may become more receptive to physical, psychological and social limitations and to emotional and social problems that occur in implantable cardioverter defibrillator recipients, enabling them to act upon them.