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Purpose Left ventricular assist devices (LVAD) are approved for acute and long-term support, however morbidity during device support complicates the post-operative course and may lead to earlier death in some patients. The aim of this study is to understand difficulties and opportunities for improvement in advance directive (AD) use and informed consent (IC) in the care of the LVAD population. Methods Semi-structured interviews with heart failure physicians (HFP), cardiac surgeons, and LVAD support staff were conducted at an academic institution. A single investigator experienced in semi-structured interviewing administered each interview. Recorded interviews were transcribed and coded by independent investigators; disagreements were resolved by discussion and consensus. Software for mixed methods analysis (NVIVO v12.1) was used to analyze the interviews. Results A total of 20 respondents completed interviews. Respondents disagreed on who should lead the AD discussion as HFPs (40%), LVAD coordinators (50%), and the LVAD “team” (30%) were all identified. Importantly, 50% of respondents thought that primary care doctors had inadequate expertise to lead the AD discussion. 50% of respondents cited difficulty in initiating an AD dialogue due to patients’ emotional states. Most respondents recommended expanding the AD's scope to include preferences in the event of an LVAD-specific complication. Respondents primarily described offering two choices during the IC session: palliative inotropes (90%) and VAD implantation (100%), while a minority mentioned hospice or transplant. 50% identified patient education level, and 30% identified emotional-state issues as barriers to the IC process. Respondents suggested creating a more consistent message (30%), with repeat exposures (40%), and moving toward more concrete examples as educational tools (20%) to improve the IC process. Conclusions A qualitative analysis of interviews with a range of staff identified a number of commonly held beliefs, difficulties, and possible improvements in the AD and IC process for patients considering LVAD implantation. While concern over more fundamental difficulties were expressed, multiple opportunities for improvement were identified. |
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