Psychosocial Evaluation of Candidates for Heart Transplant and Ventricular Assist Devices: Beyond the Current Consensus

Abstract

Advanced heart failure therapies, including heart transplantation and durable mechanical circulatory support, are available to a limited number of patients because of the scarcity of donors, expense, and large burden of care. The importance of psychological and social determinants of health, including cognitive status, health literacy, psychopathology, social support, medical adherence, and substance abuse, are emphasized in advanced heart failure and further amplified in the context of mechanical circulatory support and heart transplantation. The psychosocial assessment of advanced heart failure therapy candidates remains largely subjective, requiring a multidisciplinary evaluation, which may include psychiatrists, social workers, case managers, financial coordinators, pharmacists, and clinicians. Objective tools—including the Stanford Integrated Psychosocial Assessment for Transplantation, Psychosocial Assessment of Candidates for Transplantation, and Transplant Evaluation Rating Scale—were developed and validated in limited populations to help standardize the evaluation process. Small, retrospective studies have inconsistently shown that these tools may predict clinical outcomes in the transplant population, with higher-risk scores associated with readmissions, rejection episodes, and infections. However, it has been more difficult to show that these tools can predict mortality, and their applicability to the mechanical circulatory support population is less studied. The International Society for Heart and Lung Transplantation released a consensus statement in 2018 to promote consistency of psychosocial evaluation across advanced heart failure programs, but it lacks specific recommendations given the current state of evidence. This state-of-the-art review expands on the current consensus by critically reviewing current studies supporting available objective assessment tools, proposing a psychosocial evaluation framework that uses a multidisciplinary approach and offering future directions for research.

Association of Gender and Race With Allocation of Advanced Heart Failure Therapies

“…12,13,31 Subjective rather than objective assessments may be used partially because of limited data regarding these contraindications. 32 A number of different objective measures for social support and adherence exist, but most evidence comes from singlecenter studies and other organ replacements. 32 Thus, the governing bodies for heart and lung transplantation and social work recommend that standardized psychosocial evaluations be routinely performed among patients being considered for advanced heart therapies, but do not elaborate which measures of social support should be used or the data supporting their use.…”

“…32 A number of different objective measures for social support and adherence exist, but most evidence comes from singlecenter studies and other organ replacements. 32 Thus, the governing bodies for heart and lung transplantation and social work recommend that standardized psychosocial evaluations be routinely performed among patients being considered for advanced heart therapies, but do not elaborate which measures of social support should be used or the data supporting their use. 33 Important areas for future investigation include generating multicenter data on the use of objective social assessments for advanced heart therapy allocation.…”

Psychosocial considerations in the assessment of hand transplant candidates: A single‐center experience and brief literature review

“…Social support is the most widely assessed and prognostic element of transplant candidacy evaluation. 18,28,29 Within the Duke VCA program, caregivers are assessed both by a clinical social worker and a medical psychologist. HT candidates and their caregivers are assessed using the Psychosocial Assessment of Candidates for Transplant (PACT), which is widely used across transplant populations and provides an overall psychosocial candidacy score for the transplant candidate and their caregiving system.…”

“…Social support is the most widely assessed and prognostic element of transplant candidacy evaluation 18,28,29 . Within the Duke VCA program, caregivers are assessed both by a clinical social worker and a medical psychologist.…”

“…Within the Duke VCA program, caregivers are assessed both by a clinical social worker and a medical psychologist. HT candidates and their caregivers are assessed using the Psychosocial Assessment of Candidates for Transplant (PACT), which is widely used across transplant populations and provides an overall psychosocial candidacy score for the transplant candidate and their caregiving system 13,29 . The PACT assesses transplant candidacy within four domains: social support, psychological health, lifestyle factors (including behavioral compliance and substance use), and knowledge pertaining to the transplant surgery and follow‐up.…”