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Hargraves IG, Boehmer KR, Amer H, Kennedy CC, Griffin JM, Finnie DM, Montori VM, Smither FC, Mardini S, Moran S, Jowsey-Gregoire S. The role of the purposeful shared decision making model in vascularized composite allotransplantation. FRONTIERS IN TRANSPLANTATION 2024; 3:1421154. [PMID: 38993756 PMCID: PMC11235292 DOI: 10.3389/frtra.2024.1421154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 06/17/2024] [Indexed: 07/13/2024]
Abstract
For some patients who have lost the lower part of an arm, hand transplant offers the possibility of receiving a new limb with varying degrees of sensation and function. This procedure, Vascularized Composite Allotransplantation (VCA), is demanding for patients and their care community and comes with significant risks. As a high-stakes decision, patients interested in VCA are subject to extensive clinical evaluation and eligibility decision making. Patients and their care community must also decide if hand transplant (versus other approaches including rehabilitative therapies with or without prosthesis) is right for them. This decision making is often confusing and practically and emotionally fraught. It is complicated in four ways: by the numerous beneficial and harmful potential effects of hand transplant or other options, the number of people affected by VCA and the diverse or conflicting positions that they may hold, the practical demands and limitations of the patient's life situation, and the existential significance of limb loss and transplant for the patient's being. Patients need support in working through these treatment determining issues. Evaluation does not provide this support. Shared decision making (SDM) is a method of care that helps patients think, talk, and feel their way through to the right course of action for them. However, traditional models of SDM that focus on weighing possible beneficial and harmful effects of treatments are ill-equipped to tackle the heterogeneous issues of VCA. A recent model, Purposeful SDM extends the range of troubling issues that SDM can help support beyond opposing effects, to include conflicting positions, life situations, and existential being. In this paper we explore the pertinence of these issues in VCA, methods of SDM that each require of clinicians, the benefits of supporting patients with the breadth of issues in their unique problematic situations, implications for outcomes and practice, and extend the theory of the Purposeful SDM model itself based on the issues present in hand transplant decision making.
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Affiliation(s)
- Ian G. Hargraves
- Knowledge and Encounter Research (KER) Unit, Mayo Clinic, Rochester, MN, United States
| | - Kasey R. Boehmer
- Knowledge and Encounter Research (KER) Unit, Mayo Clinic, Rochester, MN, United States
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, United States
| | - Hatem Amer
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - Cassie C. Kennedy
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
| | - Joan M. Griffin
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, United States
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | - Dawn M. Finnie
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | - Victor M. Montori
- Knowledge and Encounter Research (KER) Unit, Mayo Clinic, Rochester, MN, United States
| | - Fantley Clay Smither
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, United States
| | - Samir Mardini
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, United States
| | - Steven Moran
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, United States
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Gordon EJ, Gacki-Smith J, Kuramitsu BR, Downey M, Vanterpool KB, Nordstrom MJ, Riggleman T, Cooney CM, Jensen S, Dumanian G, Tintle S, Levan M, Brandacher G. Ethical and Psychosocial Factors in the Decision-Making and Informed Consent Process for Upper Extremity Vascularized Composite Allotransplantation: A Mixed-Methods Study. Transplant Direct 2023; 9:e1515. [PMID: 37492079 PMCID: PMC10365204 DOI: 10.1097/txd.0000000000001515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/27/2023] [Indexed: 07/27/2023] Open
Abstract
Although upper extremity (UE) vascularized composite allotransplantation (VCA) aims to improve quality of life, relatively few have been performed worldwide to support evidence-based treatment and informed decision-making. Methods We qualitatively examined factors contributing to anticipated and actual decision-making about UE VCA and perceptions of the elements of informed consent among people with UE amputations, and UE VCA candidates, participants, and recipients through in-depth interviews. Thematic analysis was used to analyze qualitative data. Results Fifty individuals participated; most were male (78%) and had a mean age of 45 y and a unilateral amputation (84%). One-third (35%) were "a lot" or "completely" willing to pursue UE VCA. UE VCA decision-making themes included the utility of UE VCA, psychosocial impact of UE VCA and amputation on individuals' lives, altruism, and anticipated burden of UE VCA on lifestyle. Most respondents who underwent UE VCA evaluation (n = 8/10) perceived having no reasonable treatment alternatives. Generally, respondents (n = 50) recognized the potential for familial, societal, cultural, medical, and self-driven pressures to pursue UE VCA among individuals with amputations. Some (n = 9/50, 18%) reported personally feeling "a little," "somewhat," "a lot," or "completely" pressured to pursue UE VCA. Respondents recommended that individuals be informed about the option of UE VCA near the amputation date. Conclusions Our study identified psychosocial and other factors affecting decision-making about UE VCA, which should be addressed to enhance informed consent. Study participants' perceptions and preferences about UE VCA suggest re-examination of assumptions guiding the UE VCA clinical evaluation process.
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Affiliation(s)
- Elisa J. Gordon
- Department of Surgery, and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN
| | - Jessica Gacki-Smith
- Center for Health Services and Outcomes Research, Northwestern University, Chicago, IL
| | - Brianna R. Kuramitsu
- Center for Health Services and Outcomes Research, Northwestern University, Chicago, IL
| | - Max Downey
- Department of Surgery, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Karen B. Vanterpool
- Department of Surgery, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Michelle J. Nordstrom
- Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Tiffany Riggleman
- Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Carisa M. Cooney
- Department of Plastic and Reconstructive Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Sally Jensen
- Department of Medical Social Sciences and Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Gregory Dumanian
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Scott Tintle
- Department of Orthopaedic Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Macey Levan
- Department of Surgery, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD
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Downey MC, Gacki-Smith J, Kuramitsu B, Vanterpool KB, Nordstrom M, Luken M, Langlee W, Riggleman T, Fichter S, Altema W, Jensen SE, Dumanian GA, Cooney CM, Levan ML, Tintle S, Brandacher G, Gordon EJ. Patient definitions of transplant success in upper extremity vascularized composite allotransplantation: A mixed-methods study. SAGE Open Med 2023; 11:20503121231184677. [PMID: 37465724 PMCID: PMC10350745 DOI: 10.1177/20503121231184677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/12/2023] [Indexed: 07/20/2023] Open
Abstract
Objective Upper extremity vascularized composite allotransplantation is an innovative treatment option for people with upper extremity amputations. Limited patient-relevant long-term outcomes data about transplant success may impede patients' informed treatment decision-making. We assessed perceptions of what constitutes upper extremity vascularized composite allotransplantation success among individuals with upper extremity amputations. Methods This multisite study entailed interviews and focus groups with individuals with upper extremity amputations and upper extremity vascularized composite allotransplantation candidates, participants, and recipients. We examined perceptions of transplant success and preferences for five upper extremity vascularized composite allotransplantation outcomes. Qualitative data were analyzed using thematic analysis; and quantitative data were analyzed using descriptive statistics. Results In all, 50 individuals participated in interviews (61.7% participation rate), and 37 participated in nine focus groups (75.5% participation rate). Most were White (72%, 73%), had a mean age of 45 and 48 years, and had a unilateral amputation (84%, 59%), respectively. Participants conceptualized upper extremity vascularized composite allotransplantation success as transplant outcomes: (1) restoring function and sensation to enable new activities; (2) accepting the transplanted limb into one's identity and appearance; (3) not having transplant rejection; (4) attaining greater quality of life compared to prosthetics; and (5) ensuring benefits outweigh risks. Participants rated their most important upper extremity vascularized composite allotransplantation outcomes as follows: not having transplant rejection, not developing health complications, grasping objects, feeling touch and temperature, and accepting the upper extremity vascularized composite allotransplantation into your identity. Conclusion Individuals with upper extremity amputations maintain several conceptions of vascularized composite allotransplantation success, spanning functional, psychosocial, clinical, and quality of life outcomes. Providers should address patients' conceptions of success to improve informed consent discussions and outcomes reporting for upper extremity vascularized composite allotransplantation.
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Affiliation(s)
- Max C Downey
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Jessica Gacki-Smith
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brianna Kuramitsu
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karen B Vanterpool
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Michelle Luken
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - Whitney Langlee
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tiffany Riggleman
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - Shannon Fichter
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - Withney Altema
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - Sally E Jensen
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Macey L Levan
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Scott Tintle
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elisa J Gordon
- Department of Surgery, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
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Finnie D, Griffin JM, Kennedy CC, Schaepe K, Boehmer K, Hargraves I, Amer H, Jowsey-Gregoire S. Education for patients with limb loss or absence: Aging, overuse concerns, and patient treatment knowledge gaps. Front Psychol 2022; 13:953113. [PMID: 36237690 PMCID: PMC9552948 DOI: 10.3389/fpsyg.2022.953113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/16/2022] [Indexed: 11/29/2022] Open
Abstract
The goals of vascular composite allotransplantation (VCA) for hand are to maximize functional status and psychosocial wellbeing and to improve quality of life. Candidates are carefully vetted by transplant programs through an extensive evaluation process to exclude those patients with contraindications and to select those that are most likely to attain functional or quality of life benefit from transplant. Patient choice for any treatment, however, requires that candidates be able to understand the risks, benefits, and alternatives before choosing to proceed. This study aimed to understand patients’ knowledge and perceptions about treatment options for hand loss, including hand transplant. This study will be used to inform a standardized education approach and develop conversation aids for use by clinicians and patients throughout the treatment decision process. Ten individuals who had experienced hand amputation or had congenital limb loss were interviewed to better understand previous and current decisions about treatment, experiences in adjusting to their treatment, and perceptions about hand VCA. From this qualitative interview data, four findings emerged: (1) knowledge and education around VCA as a treatment option; (2) adaptation of individuals with limb loss; (3) fear of risk associated with transplantation; (4) issues of aging and overuse injuries to existing limbs. Results suggests that there is opportunity for expanding education about all treatment options for patients with new loss, long-term loss, and congenital limb loss. Establishing a baseline of knowledge about all options–prosthetics, rehabilitative strategies, and VCA—can help patients evaluate their values and goals of treatment. Issues associated with aging, including overuse and injury, and adaptability over the life course should be included in considerations about treatment choices. Data indicate the need for routinely assessing patient preferences about treatment choice so patients can plan for their future as they adapt and age and as technology for treatments change. To assure that thorough information is provided for current and future decision-making, education about treatment choices and selection procedures for VCA should be standardized.
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Affiliation(s)
- Dawn Finnie
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Dawn Finnie,
| | - Joan M. Griffin
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | | | - Karen Schaepe
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | - Kasey Boehmer
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, United States
| | - Ian Hargraves
- Knowledge Encounter Research Unit, Mayo Clinic, Rochester, MN, United States
| | - Hatem Amer
- Transplant Center, Mayo Clinic, Rochester, MN, United States
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Resnik L, Ni P, Borgia M, Clark M. A Psychosocial Adjustment Measure for Persons With Upper Limb Amputation. CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 2022; 5:37873. [PMID: 37614482 PMCID: PMC10443488 DOI: 10.33137/cpoj.v5i1.37873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/10/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Measurement of psychosocial adjustment after upper limb amputation (ULA) could be helpful in identifying persons who may benefit from interventions, such as psychotherapy and/or support groups. However, available measures of psychosocial adjustment after limb loss are currently designed for prosthetic users only. OBJECTIVE To create a measure of psychosocial adjustment for persons with ULA that could be completed by individuals regardless of whether a prosthesis is use. METHODOLOGY We modified items from an existing Trinity Amputation and Prosthesis Experience Survey (TAPES) measure and generated new items pertinent to persons who did not use a prosthesis. Item content was refined through cognitive interviewing and pilot testing. A telephone survey of 727 persons with major ULA (63.6% male, mean age of 54.4) was conducted after pilot-testing. After exploratory and confirmatory factor analyses (EFA and CFA), Rasch analyses were used to evaluate response categories, item fit and differential item functioning (DIF). Item-person maps, score distributions, and person and item reliability were examined. Test-retest reliability was evaluated in a 50-person subsample. FINDINGS EFA and CFA indicated a two-factor solution. Rasch analyses resulted in a 7-item Adjustment to Limitation subscale (CFI=0.96, TLI=0.95, RMSEA=0.128) and a 9-item Work and Independence subscale (CFI=0.935, TLI=0.913, RMSEA=0.193). Cronbach alpha and ICC were 0.82 and 0.63 for the Adjustment to Limitation subscale and 0.90 and 0.80 for the Work and Independence subscale, respectively. CONCLUSIONS This study developed the Psychosocial Adjustment to Amputation measure, which contains two subscales: 1) Adjustment to Limitation and 2) Work and Independence. The measure has sound structural validity, good person and item reliability, and moderate to good test-retest reliability.
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Affiliation(s)
- L.J. Resnik
- Research Department, Providence VA Medical Center, Providence, USA
- Department of Health Services, Policy and Practice, Brown University, Providence, USA
| | - P. Ni
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, USA
| | - M.L. Borgia
- Research Department, Providence VA Medical Center, Providence, USA
| | - M.A. Clark
- Department of Health Services, Policy and Practice, Brown University, Providence, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Massachusetts, USA
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