Objective To understand mechanical circulatory support (MCS) coordinators’ perspectives related to destination therapy left ventricular assist devices (DT LVAD) decision making Background MCS coordinators are central to the team that interacts with patients considering DT LVAD, and are well positioned to comment upon the pre-implantation process. Methods From August 2012–January 2013, MCS coordinators were recruited to participate in semi-structured, in-depth interviews. Established qualitative approaches were used to analyze and interpret data. Results Eighteen MCS coordinators from 18 programs were interviewed. We found diversity in coordinators’ roles and high programmatic variability in how DT LVAD decisions are approached. Despite these differences, three themes were consistently recommended: 1) DT LVAD is a major patient-centered decision: “you’re your best advocate…this may not be the best choice for you”; 2) this decision benefits from an iterative, multidisciplinary process: “It is not a one-time conversation”; and 3) this process involves a tension between conveying enough detail about the process yet not overwhelming patients: “It’s sometimes hard to walk that line to not scare them but not paint a rainbow and butterflies picture.” Conclusions MCS coordinators endorsed a shared decision-making process that starts early, uses non-biased educational materials, and involves a multidisciplinary team sensitive to the tension between conveying enough detail about the therapy yet not overwhelming patients.
Background: Patients offered left ventricular assist device as destination therapy (DT LVAD) are typically faced with the decision to undergo major surgery and live their remaining life dependent on mechanical circulatory support (MCS) or transition to end-of-life care. MCS coordinators are often the first point of contact and provide education and support to patients making this difficult decision. Methods: We conducted semi-structured, in-depth interviews with MCS coordinators in order to characterize the range of decision support and preparation offered to patients considering DT LVAD and to solicit input on how to optimize that process. Interviews took place from August 2012 to January 2013. All interviews were digitally recorded and data were analyzed using a directed content analysis approach. Results: Our sample included 20 MCS coordinators from different programs around the United States. The following primary themes emerged: 1) cardiothoracic surgeons or heart failure cardiologists were primarily responsible for presenting risks and benefits of DT LVAD whereas coordinators provided the majority of patient education regarding practical concerns and patient/caregiver responsibilities; 2) existing consents and industry material are too complicated or overly optimistic; 3) tension exists between creating accurate expectations of DT LVADs and providing clinical reassurance - “I don’t want to scare them away from a life-saving therapy either, so I try to paint a realistic picture but not so realistic that it scares them;” and 4) when asked to theoretically consider if they were offered DT LVAD, the majority of coordinators stated that it would be a difficult decision influenced by their own age, co-morbidities, and family dynamics - “I think it would really depend on where I was in my life at that point in time.” Conclusions: MCS coordinators are in a unique position to assist in decision making and preparation for patients eligible for DT LVADs. In order to improve this process, a multidisciplinary and iterative approach appears helpful in conveying the risks and benefits of DT LVAD. Consents and educational materials must be simplified, patient-centered, and free of bias. Patient needs and values should be defined up front to help tailor the process. The uncertainty of many MCS coordinators, who arguably best understand the totality of therapy, to theoretically pursue DT LVAD themselves highlights the difficult trade-offs and personalized nature of this decision.
Limitations include only short-term outcomes measured, and significant biases in more than one domain of included trials.A 2015 meta-analysis of 11 RCTs (N5424) evaluated whether EMDR or CBT was superior for the treatment of adult PTSD. 2 The trials included adults 18 years old and older with PTSD defined per DSM-III or -IV criteria. PTSD severity was measured using various standardized clinician and self-rated assessment tools pretreatment and posttreatment with EMDR and CBT (follow-up periods undefined). Although this meta-analysis included some of the 2018 meta-analysis trials, specific PTSD symptoms were investigated. Overall, EMDR minimally improved symptom scores compared with CBT (SMD -0.43; 95% CI, -0.86 to -0.01). Specifically, a meta-analysis for subscaled scores of PTSD symptoms indicated that EMDR was superior for decreasing intrusion (six trials, n5170; SMD -0.37; 95% CI, -0.68 to -0.06) and arousal severity (five trials, n5146; SMD -0.34; 95% CI, -0.68 to -0.01) compared with CBT. Avoidance severity was not significantly different between groups (n5170; SMD -0.42; 95% CI, -0.92 to 0.08). Limitations include difficulty with double blinding due to nature of psychotherapy, loss to follow-up .20% in five trials, potential biases, and lack of fidelity checks for treatment sessions.A 2007 RCT (N576) compared the efficacy of fluoxetine to EMDR in the treatment of PTSD. 3 The trial included adults 18 to 65 years old with PTSD per DSM-IV criteria with trauma exposure one year or more before intake. Patients were randomly assigned to receive eight weekly treatment sessions with EMDR (n524), fluoxetine (n526), or pill placebo (n526). The primary outcome (PTSD symptom severity) was measured using the Clinician-Administered PTSD Scale (CAPS, total severity score .50, asymptomatic end-state function ,20). CAPS scores were assessed at pretreatment, posttreatment, and six months posttreatment. The Structured Clinical Interview for DMS-IV was used for determination of PTSD and comorbid diagnoses. Posttreatment, 88% of EMDR, 81% of fluoxetine, and 65% of placebo completers no longer met PTSD diagnosis criteria. Of those, 29%, 15%, and 12% of EMDR, fluoxetine, and placebo completers became asymptomatic, respectively. Between-group comparisons immediately after treatment were not statistically significant. After an intent-to-treat analysis, EMDR produced moderate improvement in symptom severity posttreatment and at six-month follow-up for adults (effect size, 0.56, 0.65 respectively) compared with fluoxetine. EMDR achieved small improvements in symptoms only at six months in children compared with fluoxetine (effect size, 0.47). Comparison statistics were not available for this reported finding.
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