Krystina B. Lewis

Making Decisions About Implantable Cardioverter-Defibrillators from Implantation to End of Life: An Integrative Review of Patients’ Perspectives

Implantable cardioverter-defibrillators (ICDs) are used for patients at risk of sudden cardiac death. Patients considering ICD therapy are faced with several preference-sensitive decisions. Our aim was to explore patients’ ICD decision-making experiences from the decision to implant to the consideration of deactivation at end of life. We conducted an integrative review using Whittemore and Knafl’s five steps. MEDLINE, CINAHL, PubMed, PsycINFO, and the Cochrane library were searched from 2000 to 2013. Eligible studies focused on the patient response regarding ICD decision-making. Key themes were identified and used as a framework to discuss findings through the chronological course of decisions faced by these patients. Of 354 potential citations, 25 articles were included. The trajectory of key decision points was whether or not to initiate ICD therapy, replace the battery, and deactivate at end of life. Three common themes from patients’ perspectives were the influence of the patient–practitioner consultation on knowledge uptake, patients’ decision-making preference, and their desire to live. Patients faced with ICD-related decisions often misunderstood the functionality of their ICD, or overestimated its benefit. They also expressed mixed preferences for the desire to be involved in decisions. The decisions around ICDs are particularly difficult for patients given the life and death trade off. Clinicians involved in the care of these patients could better support them by verifying their understanding and eliciting their preferences. Using a shared decision-making approach has the potential to achieve improved patient outcomes.

Decision making at the time of ICD generator change: patients' perspectives.

These findings suggest that many patients are misclassified as having poor exercise capacity and therefore subjected to unnecessary further testing. Our study has several limitations. First, it lacked statistical power to compare subjective assessment vs DASI scores for predicting postoperative outcomes. Second, participants did not undergo formal exercise testing; hence, we cannot quantify the degree to which overestimation of exercise capacity by the DASI contributed to our results. Nonetheless, previous research has demonstrated substantial correlation between DASI scores and objective exercise testing in surgical patients.6 Our study raises concerns about using subjective assessment to evaluate preoperative exercise capacity and points to the need for improved methods of assessing preoperative exercise capacity to predict patient outcomes. Further research is needed to select the correct assessment tool, with the DASI questionnaire being one potential approach that merits evaluation in adequately powered studies.

Estimating the Risks and Benefits of Implantable Cardioverter Defibrillator Generator Replacement: A Systematic Review.

Every 4–7 years an implantable cardioverter defibrillator (ICD) pulse generator must be replaced surgically. This procedure is not without risk. In some cases, the risk versus benefit ratio may be against replacement. We aimed to synthesize the evidence on risks, benefits, and costs related to ICD replacement.

Patient Decision Aids to Engage Adults in Treatment or Screening Decisions.

Clinical Question Are patient decision aids (PtDAs) associated with (1) improved decision quality defined as a decision informed by the evidence and a value-based decision; (2) improved decision-making processes defined as feeling informed, defining clear values related to the decision, and active participation in making the decision; and (3) better patient and health system outcomes compared with either usual care or a non-PtDA intervention? Bottom Line Patient decision aids are associated with improved decision quality and decision-making processes without worse patient or health system outcomes.

Do choosing wisely tools meet criteria for patient decision aids? A descriptive analysis of patient materials

Objectives Choosing Wisely is a remarkable physician-led campaign to reduce unnecessary or harmful health services. Some of the literature identifies Choosing Wisely as a shared decision-making approach. We evaluated the patient materials developed by Choosing Wisely Canada to determine whether they meet the criteria for shared decision-making tools known as patient decision aids. Design Descriptive analysis of all Choosing Wisely Canada patient materials. Data source In May 2015, we selected all Choosing Wisely Canada patient materials from its official website. Main outcomes and measures Four team members independently extracted characteristics of the English materials using the International Patient Decision Aid Standards (IPDAS) modified 16-item minimum criteria for qualifying and certifying patient decision aids. The research team discussed discrepancies between data extractors and reached a consensus. Descriptive analysis was conducted. Results Of the 24 patient materials assessed, 12 were about treatments, 11 were about screening and 1 was about prevention. The median score for patient materials using IPDAS criteria was 10/16 (range: 8–11) for screening topics and 6/12 (range: 6–9) for prevention and treatment topics. Commonly missed criteria were stating the decision (21/24 did not), providing balanced information on option benefits/harms (24/24 did not), citing evidence (24/24 did not) and updating policy (24/24 did not). Out of 24 patient materials, only 2 met the 6 IPDAS criteria to qualify as patient decision aids, and neither of these 2 met the 6 certifying criteria. Conclusions Patient materials developed by Choosing Wisely Canada do not meet the IPDAS minimal qualifying or certifying criteria for patient decision aids. Modifications to the Choosing Wisely Canada patient materials would help to ensure that they qualify as patient decision aids and thus as more effective shared decision-making tools.

Milestones, barriers and beacons: Shared decision making in Canada inches ahead

Canadas approach to shared decision making (SDM) remains as disparate as its healthcare system; a conglomerate of 14 public plans - ten provincial, three territorial and one federal. The healthcare research funding environment has been largely positive for SDM because there was funding for knowledge translation research which also encompassed SDM. The funding climate currently places new emphasis on patient involvement in research and on patient empowerment in healthcare. SDM fields have expanded from primary care to elder care, paediatrics, emergency and critical care medicine, cardiology, nutrition, occupational therapy and workplace rehabilitation. Also, SDM has reached out to embrace other health-related decisions including about home care and social care and has been adapted to Aboriginal decision making needs. Canadian researchers have developed new interprofessional SDM models that are being used worldwide. Professional interest in SDM in Canada is not yet widespread, but there are provincial initiatives in Alberta, British Columbia, Ontario, Quebec and Saskatchewan. Decision aids are routinely used in some areas, for example for prostate cancer in Saskatchewan, and many others are available for online consultation. The Patient Decision Aids Research Group in Ottawa, Ontario maintains an international inventory of decision aids appraised with the International Patient Decision Aid Standards. The Canada Research Chair in SDM and Knowledge Translation in Quebec City maintains a website of SDM training programs available worldwide. These initiatives are positive, but the future of SDM in Canada depends on whether health policies, health professionals and the public culture fully embrace it.

Shared Decision-Making Models Acknowledging an Interprofessional Approach: A Theory Analysis to Inform Nursing Practice.

Patient engagement in collaboration with health professionals is essential to deliver quality health care. A shared decision-making (SDM) approach requires that patients are involved in decisions regarding their health. SDM is expanding from the patient–physician dyad to incorporate an interprofessional perspective. Conceptual models can be used to better understand theoretical underpinnings for application in clinical practice. The aim of this article was to conduct a theory analysis of conceptual models using an interprofessional approach to SDM and discuss each model’s relevance to nursing practice. Walker and Avant’s theory analysis approach was used. Three conceptual models were eligible. For all models, the decision-making process was considered iterative. The development process was described for 1 model. All models were logical, parsimonious, and generalizable. One was supported by empirical testing. No model described how partnerships are enacted to achieve interprofessional SDM. Also, there was limited articulation as to how nurses’ roles and contributions differ from other team members. This theory analysis highlights the need for a model that explains how partnerships among interprofessional team members are enacted to better understand the operationalization of interprofessional SDM. Implications for nursing practice at all system levels are offered and supported by the 3 models.

Choosing treatment and screening options congruent with values: Do decision aids help? Sub-analysis of a systematic review

OBJECTIVE To understand how well patients make value congruent decisions with and without patient decision aids (PtDAs) for screening and treatment options, and identify issues with its measurement and evaluation. METHODS A sub-analysis of trials included in the 2014 Cochrane Review of Decision Aids. Eligible trials measured value congruence with chosen option. Two reviewers independently screened 115 trials. RESULTS Among 18 included trials, 8 (44%) measured value congruence using the Multidimensional Measure of Informed Choice (MMIC), 7 (39%) used heterogeneous methods, and 3 (17%) used unclear methods. Pooled results of trials that used heterogeneous measures were statistically non-significant (n=3). Results from trials that used the MMIC suggest patients are 48% more likely to make value congruent decisions when exposed to a PtDA for a screening decision (RR 1.48, 95% CI 1.01 to 2.16, n=8). CONCLUSION Patients struggle to make value congruent decisions, but PtDAs may help. While the absolute improvement is relatively small it may be underestimated due to sample size issues, definitions, and heterogeneity of measures. PRACTICE IMPLICATIONS Current approaches are inadequate to support patients making decisions that are consistent with their values. There is some evidence that PtDAs support patients with achieving values congruent decisions for screening choices.

Quality of reporting of patient decision aids in recent randomized controlled trials: A descriptive synthesis and comparative analysis

OBJECTIVE Variable reporting of patient decision aids (PDAs) in published articles raises uncertainty about whether the intervention meets the definition of a PDA. We appraised the quality of reporting of PDA characteristics in randomized controlled trials (RCTs). METHODS RCTs eligible for the Cochrane review of PDAs and published June 2012 to April 2015 were included. Quality of PDA reporting was appraised using the International Patient Decision Aid Standards Instrument (v4.0). We descriptively synthesized and comparatively analysed qualifying and certification criteria reported in each publication against their presence in actual PDAs. RESULTS Seventeen RCTs evaluating sixteen PDAs were included. Ten PDAs (58.8%) were reported using all qualifying criteria. Two (11.8%) were reported using all certification criteria. The median score for reporting qualifying criteria was 6 of 6 (range 4-6). The median score for reporting certification criteria was 2 of 10 (range 2-3) for screening and 1 of 6 (range 0-6) for treatment decisions. CONCLUSION Reporting of PDAs in RCTs is suboptimal. Incomplete reporting poses challenges for clinicians and researchers needing to identify PDA content for clinical practice and/or future research. PRACTICE IMPLICATIONS Authors should report IPDASi (v4.0) criteria in published articles. Reporting guidelines for PDA evaluation studies are in development to improve reporting within the scientific literature.

Letter by Nery et al Regarding Article, “Implantable Cardioverter-Defibrillator for Nonischemic Cardiomyopathy: An Updated Meta-Analysis”

The debate about the benefit of implantable cardioverter-defibrillator (ICD) for patients with heart failure in the setting of nonischemic cardiomyopathy (NICMP) has been reignited after the 2016 publication of the DANISH trial (Danish Study to Assess the Efficacy of ICDs in Patients With Non-Ischemic Systolic Heart Failure on Mortality).1 Golwala et al2 sought to update the meta-analysis of randomized controlled trials evaluating the utility of ICDs in patients with NICMP. We congratulate the authors for their …