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Human Factors Issues in Ventricular Assist Device Recipients and Their Family Caregivers

AORN Journal, Nov, 2002 by Cecil A. King

MA Dew et al ASAIO Journal Vol 46 (May/June 2000) 367-373

Although ventricular assist devices (VADs) were developed as a bridge to transplantation, they now are being considered and studied as a permanent alternative to heart transplantation. This study examined patients' and patients' family members' satisfaction with and concerns regarding VADs. The researchers focused on

* patients' and their family members' perceptions and concerns about living with a VAD;

* the concerns of inpatients versus outpatients living with VADs; and

* demographic, functional, and psychological factors associated with living with a VAD.

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Patients' social functioning and overall quality of life (QOL) also were assessed, the hypothesis being that their QOL was at least "similar to and often considerably better than that of other transplant candidates."

Methodology. Of 62 patients who underwent VAD implantation for cardiac failure refractory to inotropic and intra-aortic balloon pump support at the University of Pittsburgh Medical Center, 38 were enrolled in the study. Participants had their VADs for an average of 28 days (M = 27.7) at the time of initial interview. Eleven were discharged home with the VAD in place and reinterviewed approximately one month after discharge. This follow-up interview was conducted 68 days (M = 67.7) postimplantation. Both participants and caregivers were revaluated using individual, semi-structured interviews employing four instruments.

Perceptions of living with a VAD were assessed using the opinions about VAD treatment questionnaire, which is designed to elicit both positive and negative perceptions of living with a VAD. Three physical activity subscales of the sickness impact profile were used to assess physical status. Psychological well-being was measured using the depression, anxiety, and anger-hostility subscales of the self-report symptom checklist-90. In addition, the sense of mastery scale was used to measure feelings of personal competence and control while living with a VAD. Patients' social functioning and overall QOL were evaluated using a nine-item scale to assess global well-being and satisfaction (one = low QOL, seven = high QOL, [alpha] = 0.89).

Results. After initial baseline data were analyzed, general perceptions and prevalence were compared between outpatients and inpatients using Chi-square analysis. In addition, point biserial correlations between items reflecting patient concerns and demographic measures were analyzed.

Three percent to 8% of participants would not recommend the VAD or believed their overall physical functioning was not improved by the device. Eighteen percent said "they did not have a brighter outlook since receiving the VAD." The most prevalent concerns were infection (52%), difficulty sleeping (52%), driveline pain (46%), device malfunction (40%), and the noise of the device (32%). Caregiver and patient concerns did not differ significantly.

Qualitative findings regarding participants and caregivers were very similar. When asked what they liked best about the VAD, participants responded "it keeps me alive," and "I can enjoy life more." Caregivers responded "it allows [my spouse] to live until a transplant is available." When asked what they liked least about the VAD, participants indicated that it was the noise. Caregivers were more concerned about infection. Participants expressed concerns regarding risk of stroke, device malfunction, noise during sleep, and infection the longer they were on VAD support. The effect ([chi square] = 12.94, df = 8, P = .11) was only statistically significant for infection. In general, extended life and QOL improvements were the most positive factors for those living with a VAD.

Limitations. Given the small sample size, it is difficult to generalize these findings beyond the study population. In addition, this study lacks an adequate description of procedures to ensure participants gave informed consent. This study was supported in part by funding from two companies that manufacture VADs. Of the four instruments used, reliability and validity were reported for only two. Although very interesting, given these findings, I would be reluctant to conclude that VAD support is an acceptable permanent alternative to heart transplantation.

After patients habituated to the most positive effect of VAD support (ie, being keep alive), they began to find the secondary effects on their life bothersome, if not intolerable. This begs the question of whether being kept alive is justifiable in and of itself, whatever the cost.

Perioperative implications. This study clearly indicates the need for further research concerning the effect of perioperative technology on patients' QOL. We live and practice in an era of extremely advanced technology that has far exceeded our ethical ability to know the effect on patients' QOL and, as suggested in this study, the overall effect on their caregivers and family members. Not only must we determine the efficacy of technology, but also its overall effect on patients' and patients' family members' QOL. Although no definition of QOL was given for this study, the findings suggest that "extended life and QOL related improvements were found to be the most positive human factors of living with a VAD."

Health Care Industry

Human Factors Issues in Ventricular Assist Device Recipients and Their Family Caregivers

AORN Journal, Nov, 2002 by Cecil A. King

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