Patient Experiences and Perspectives of Their Decision-Making to Accept Lung Transplantation Referral: A Qualitative Study

Providing early lung transplantation referral services should be considered to reduce pre-transplant mortality in patients with advanced disease. This study aimed to explore the reasons for lung transplantation referral decisions in patients and provide evidence for the development of transplantation referral services. This was a qualitative, retrospective, and descriptive study involving conventional content analysis. Patients in evaluation, listing, and post-transplant stages were interviewed. A total of 35 participants (25 male and 10 female) were interviewed. Four main themes were defined: (1) expectations for lung transplantation leading to the decision (a gamble for a silver lining, a return to normal life, and occupation); (2) facing uncertain outcomes (personal luck arranging everything; belief in success; incidents leading to "It's decided then"; hesitation when making a decision due to fear); (3) facing various information from peers, doctors, and so on; (4) complex policy and societal support (providing transplantation referral services earlier, family attachment and oral approval responses contribute to the referral decision, and so on). The findings of this study might enrich existing referral services, including training for family members and healthcare providers, a checklist and package of critical events in the patient lung transplantation referral decision-making process, precision services based on behavioral personas, and a curriculum to enhance patient decision self-efficacy.

Pretransplant Patient Education in Solid-organ Transplant: A Narrative Review

Education for pretransplant, solid-organ recipient candidates aims to improve knowledge and understanding about the transplant process, outcomes, and potential complications to support informed, shared decision-making to reduce fears and anxieties about transplant, inform expectations, and facilitate adjustment to posttransplant life. In this review, we summarize novel pretransplant initiatives and approaches to educate solid-organ transplant recipient candidates. First, we review approaches that may be common to all solid-organ transplants, then we summarize interventions specific to kidney, liver, lung, and heart transplant. We describe evidence that emphasizes the need for multidisciplinary approaches to transplant education. We also summarize initiatives that consider online (eHealth) and mobile (mHealth) solutions. Finally, we highlight education initiatives that support racialized or otherwise marginalized communities to improve equitable access to solid-organ transplant. A considerable amount of work has been done in solid-organ transplant since the early 2000s with promising results. However, many studies on education for pretransplant recipient candidates involve relatively small samples and nonrandomized designs and focus on short-term surrogate outcomes. Overall, many of these studies have a high risk of bias. Frequently, interventions assessed are not well characterized or they are combined with administrative and data-driven initiatives into multifaceted interventions, which makes it difficult to assess the impact of the education component on outcomes. In the future, well-designed studies rigorously assessing well-defined surrogate and clinical outcomes will be needed to evaluate the impact of many promising initiatives.

The experiences of adult heart, lung, and heart-lung transplantation recipients: A systematic review of qualitative research evidence

Aim

To review evidence about the experience of being the recipient of a donated heart, lungs, or heart and lungs.

Design

A systematic review (registered with PROSPERO: CRD42017067218), in accordance with PRISMA guidelines.

Data sources

Seven databases and Google Scholar were searched in May 2017 and July 2019 for papers reporting English-language research that had used qualitative methods to investigate experiences of adult recipients.

Review methods

Quality was assessed and results were analysed thematically.

Results

24 papers (reporting 20 studies) were eligible and included. Their results were organised into three chronological periods: pre-transplant (encompassing the themes of ‘dynamic psychosocial impact’, ‘resources and support’), transplant (‘The Call’, ‘intensive care unit’), and post-transplant (‘dynamic psychosocial impact’, ‘management’, ‘rejection’). Sub-themes were also identified. It was evident that contemplating and accepting listing for transplantation entailed or amplified realisation of the precipitating illness’s existential threat. The period surrounding transplantation surgery was marked by profound, often surreal, experiences. Thereafter, although life usually improved, it incorporated unforeseen challenges. The transplantation clinic remained important to the recipient. The meaning of the clinic and its staff could be both reassuring (providing care and support) and threatening (representing onerous medical requirements and potential organ rejection).

Conclusion

This review has implications for the psychosocial care of transplant recipients and indicates the need for further research to gain insight into the experience of receiving a donated heart and/or lung.

Impact

Medical consequences of heart and lung transplantation are well documented; this is the first systematic review of research using qualitative methods to investigate the experience of heart, lung, and heart-and-lung transplantation. The psychosocial impact of transplantation was found to be dynamic and complex, with notable features evident before, during, and after transplantation. Clinic staff remained significant to recipients. It is clear that recipients need continuing psychosocial as well as medical support.

A Qualitative Study to Explore the Needs of Lung Transplant Caregivers

INTRODUCTION

Providing support throughout the lung transplant process is an intensive task, which requires a dedicated caregiver. The needs of caregivers who must relocate with their loved one receiving the transplant are currently unknown. The objective of this study is to explore experiences and perceptions of lung transplant caregivers identified from a satellite clinic to inform the development of educational resources.

METHODS

A qualitative study with a phenomenology approach was undertaken with individuals who have taken on the role of a caregiver for lung transplant candidates or recipients and must travel to the specialized transplant center. Semistructured interviews were conducted with 12 caregivers. Interviews conducted by phone were audio-recorded and then transcribed verbatim. NVivo software was used to code the data and identify emerging themes.

RESULTS

Ideas were classified into the following 4 themes: (1) the stress of being a caregiver, (2) caregivers undertake a variety of roles, (3) caregivers require support, and (4) satisfaction with health care providers. Even though the caregivers lived an average of 7.1 (standard deviation 2) hours from the surgical transplant center, all expressed satisfaction with the level of care that they received. Caregivers identified several stressors during the transplant process and described various strategies for coping.

CONCLUSION

Caregivers shared their experiences on the transplant process. It was evident that being a caregiver was a stressful and supports were necessary for those undertaking this role. These insights will help inform the development of a new educational resource for patients and caregivers.

Provision of information on transplantation to cystic fibrosis patients and their relatives: Overview of French practices and recommendations

BACKGROUND

How health-care professionals inform cystic fibrosis patients and their relatives about transplantation is not well known. Such information may not be provided in a timely or satisfactory manner. We conducted a survey about patient information practices among professionals from all French cystic fibrosis centers and transplant centers, to determine how they might be improved.

METHODS

This was a national, retrospective, multicenter, descriptive assessment of practices involving health-care professionals, transplant recipients and their relatives, and peer patients who are themselves transplant recipients. Questionnaires were developed by the French working group on cystic fibrosis patient education (GETHEM: Groupe éducation thérapeutique et mucoviscidose). At the end of the questionnaires, respondents were invited to suggest ways to improve the current process.

RESULTS

In all, 216 professionals, 55 patients, 30 relatives of these patients, and 17 peer patients responded to the questionnaires, which addressed topics in chronological order, from neonatal screening or later diagnosis of the illness to the time of the transplant, if one was performed.

CONCLUSIONS

Study findings have allowed us to draft nine recommendations for professionals to improve patient information practices. A booklet now being prepared aims to facilitate the process for professionals, and e-learning modules are also forthcoming.

Lung Transplant Pulmonologists' Views of Specialty Palliative Care for Lung Transplant Recipients

Background: Lung transplant recipients with serious illness may benefit from but rarely receive specialty palliative care (SPC) services. Transplant pulmonologists' views of SPC may be key to understanding SPC utilization but have not been well characterized. Objectives: (1) To understand how transplant pulmonologists view SPC and decide to refer transplant recipients and (2) to identify unique aspects of lung transplantation that may influence referral decisions. Design: We conducted semistructured interviews with transplant pulmonologists at nine geographically diverse high-volume North American transplant centers with SPC services. A multidisciplinary team analyzed interview transcripts using constant comparative methods to inductively develop and refine a coding framework related to SPC views and referral decisions. Results: We interviewed 38 transplant pulmonologists; most (36/38) had referred lung transplant recipients to SPC. Participants described SPC as a medical specialty that aims to improve quality of life and distinguished SPC from hospice care, which was considered end-of-life care. Participants who viewed transplant as a temporary solution (n = 17/38, 45%) described earlier utilization of SPC alongside disease-directed therapies, whereas those who viewed transplant as survival-focused (n = 21/38, 55%) described utilization of SPC after disease-directed therapies were exhausted. Concerns about one-year survival metrics and use of addicting medications for symptom palliation were barriers to referral. Conclusions: Transplant pulmonologists' SPC referral practices may be related to their views of lung transplantation. Optimizing use of SPC in lung transplantation will require improving communication between transplant pulmonology and SPC to ensure a collaborative effort toward patient-centered goals while addressing unique barriers to SPC referral.

The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

Lung Transplant or Bust: Patients' Recommendations for Ideal Lung Transplant Education

Context

Effective lung transplant education helps ensure informed decision making by patients and better transplant outcomes.

Objective

To understand the educational needs and experiences of lung transplant patients.

Design

Mixed-method study employing focus groups and patient surveys.

Setting

Barnes-Jewish Hospital in St Louis, Missouri.

Patients

50 adult lung transplant patients: 23 pretransplant and 27 posttransplant.

Main Outcome Measures

Patients' interest in receiving specific transplant information, the stage in the transplant process during which they wanted to receive the education, and the preferred format for presenting the information.

Results

Patients most wanted information about how to sustain their transplant (72%), when to contact their coordinator immediately (56%), transplant benefits (56%), immunosuppressants (54%), and possible out-of-pocket expenses (52%). Patients also wanted comprehensive information early in the transplant process and a review of a subset of topics immediately before transplant (time between getting the call that a potential donor has been found and getting the transplant). Patients reported that they would use Internet resources (74%) and converse with transplant professionals (68%) and recipients (62%) most often.

Discussion

Lung transplant patients are focused on learning how to get a transplant and ensuring its success afterwards. A comprehensive overview of the evaluation, surgery, and recovery process at evaluation onset with a review of content about medications, pain management, and transplant recovery repeated immediately before surgery is ideal.

[Information needs of liver transplant candidates: the first step of the teaching-learning process]

'Information need' is defined as a deficiency of information or skill related to a domain of life that is relevant to the patient. This study's objective was to identify the information needs of candidates on the waiting list for a liver transplant. This is a descriptive study and was conducted at a transplant center in the State of São Paulo-Brazil. The sample consisted of 55 patients and data were collected from March to June 2009. The results showed higher average scores for information needs concerning the preoperativeperiod. Identifying the information needs of liver transplant candidates is important to planning the teaching-learning process.

Physician practices for communicating with patients with cystic fibrosis about the use of noninvasive and invasive mechanical ventilation

BACKGROUND

Many patients with advanced cystic fibrosis (CF) lung disease receive intensive treatments such as noninvasive and invasive mechanical ventilation for respiratory failure after little or no communication with physicians.

METHODS

Using surveys and follow-up interviews, physicians at two major CF care centers reported their practices for discussing intensive treatment preferences with patients with CF and about barriers and facilitators to communication.

RESULTS

Surveys were completed by 30 (88%) and 26 (76%) of 34 eligible CF physicians who provide care for children (60%), adults (23%), or both (17%). Respondents described variable timing and content of discussions. They identified patient/family factors such as denial of disease severity, optimistic expectations of treatment outcomes, inability of ill patients to participate in discussions, and family disagreements about treatments as primary barriers to discussions. They also acknowledged physician factors, including concern for taking away hope and uncertainty about when to address treatment preferences. Patient/family factors were also the most common facilitators identified, particularly disease severity and inquiry about intensive treatments. They recommended: (1) developing standards for communication, (2) offering training in communication for physicians, (3) creating decision support tools for patients and families, and (4) using the multidisciplinary CF care team to facilitate communication.

CONCLUSIONS

CF physicians describe numerous patient/family factors barriers to communicating about intensive treatments for respiratory failure. They recommend changing physician and organizational factors to improve practice and promote effective communication. Innovation in clinical training, team roles, and decision support may prompt changes in practice standards.

Development of a decision aid for adult cystic fibrosis patients considering referral for lung transplantation

CONTEXT

Most adults with cystic fibrosis are eventually required to make a decision about referral for lung transplantation.

OBJECTIVE

To identify the decisional needs of these patients and to develop a decision aid to address these needs.

METHODS

A comprehensive review of the literature, a review of Canadian transplant statistics from 2002 to 2006, and a self-assessment survey of patients who had already made a decision about referral were performed to identify the decisional needs of patients. A decision aid was then developed and evaluated by an expert panel of health care professionals and patients.

RESULTS

Transplant referral patterns vary widely among Canadian cystic fibrosis clinics. Canadian patients with cystic fibrosis who were not residing in transplant centers between 2002 and 2006 were significantly less likely to undergo lung transplants (P < .001). Decisional needs identified by patients included wanting more information on (1) relocation to the transplant center, (2) the benefits and risks of surgery, and (3) how to cope with anxiety and depression when making the decision. In response to these identified needs, a decision aid for lung transplantation was developed. A panel of health care professionals and patients reviewed the decision aid and agreed that the content was appropriate, easy to understand, and unbiased.

CONCLUSION

The decisional needs of patients with cystic fibrosis who are considering lung transplantation are not being addressed in Canadian cystic fibrosis clinics, especially in clinics outside of transplant centers. An evidence-based decision aid could serve as a useful tool to help address these needs.

Development of a Decision Aid for Adult Cystic Fibrosis Patients considering Referral for Lung Transplantation

Context

Most adults with cystic fibrosis are eventually required to make a decision about referral for lung transplantation.

Objective

To identify the decisional needs of these patients and to develop a decision aid to address these needs.

Methods

A comprehensive review of the literature, a review of Canadian transplant statistics from 2002 to 2006, and a self-assessment survey of patients who had already made a decision about referral were performed to identify the decisional needs of patients. A decision aid was then developed and evaluated by an expert panel of health care professionals and patients.

Results

Transplant referral patterns vary widely among Canadian cystic fibrosis clinics. Canadian patients with cystic fibrosis who were not residing in transplant centers between 2002 and 2006 were significantly less likely to undergo lung transplants ( P < .001). Decisional needs identified by patients included wanting more information on (1) relocation to the transplant center, (2) the benefits and risks of surgery, and (3) how to cope with anxiety and depression when making the decision. In response to these identified needs, a decision aid for lung transplantation was developed. A panel of health care professionals and patients reviewed the decision aid and agreed that the content was appropriate, easy to understand, and unbiased.

Conclusion

The decisional needs of patients with cystic fibrosis who are considering lung transplantation are not being addressed in Canadian cystic fibrosis clinics, especially in clinics outside of transplant centers. An evidence-based decision aid could serve as a useful tool to help address these needs.

Developing New Ways to Address Learning Needs of Adult Abdominal Organ Transplant Recipients

Context

The degree to which patients are knowledgeable about posttransplant care can affect outcomes and patients' satisfaction. Transplant team members must identify knowledge gaps, contributory factors, and innovative methods to address learning needs.

Objective

To identify patients' perceptions of their knowledge gaps and identify ways to improve current approaches to patient education.

Design

Nonexperimental.

Setting

Midwestern teaching hospital.

Patients

726 adult abdominal organ transplant recipients.

Intervention(s)

A patient education survey was mailed out to solid-organ transplant recipients who met study criteria. A modified version of the Patient Learning Needs Scale (PLNS) was used to identify the recipients' learning needs. Additional questions on the survey addressed factors that we hypothesized would influence responses to the PLNS and asked patients which methods would help them learn during various phases of the transplant process.

Main Outcome Measure(s)

Statistical analysis was conducted on survey responses.

Results

Overall, PLNS scores were satisfactory in all 4 categories. Analysis of PLNS subscales revealed significantly lower scores in the quality of life/psychosocial subscale compared with the other 3 subscales. Significantly lower scores in the medications and follow-up categories of the PLNS items were found among the group whose length of stay was between 15 to 30 days compared with patients with shorter and longer stays. A variety of different methods are desired by patients in order to get information, especially before transplant.