How well caregivers understand the patient’s illness affects mortality rates of patients with left ventricular assist devices (LVADs), found a study.1

“There is a tendency on the part of providers to just look at the medical and surgical factors and not give psychosocial factors much weight, or give them weight arbitrarily,” says Courtenay R. Bruce, JD, MA, assistant professor of medicine and medical ethics at the Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston.

Researchers reviewed social workers’ clinical assessments of 96 adult patients implanted with LVADs from 2010-2014. Having a caregiver who understands the severity of the illness and options available to the patient, who has identified a backup plan, and who is able to provide logistical support significantly mitigated risk of death.

“We need to determine which psychosocial factors actually impact outcomes, and how much weight to give them,” says Bruce. “Otherwise, we are making decisions in a very unfair and biased way.”

Fairer Decisions Made

Patients with LVADs require significant support from caregivers. This goes beyond someone who can be reached in the case of an emergency. “You need someone by your side who can be depended on for a while — for a good year — before you can do it on your own,” says Bruce.

This raises the question of how this kind of sustained support can be provided to patients who lack it. Hired caregivers or support groups are possibilities, but the main thing is that it is something providers should carefully consider, says Bruce. “It impacts mortality and morbidity and it should count, and we need to figure out how to strengthen people’s networks to make it happen,” she says. Bruce suggests the following:

• Social workers or psychiatrists who perform assessments for LVAD programs must consider the right psychosocial factors and weigh them appropriately. “We need to know what actually impacts morbidity and mortality, and what we can do to make outcomes as good as they can be,” says Bruce.

• Ethicists should attend patient selection committees to minimize bias or arbitrary decision-making.

“We need to make more consistent, fairer decisions,” Bruce says. Medical patient selection committees aren’t immune to bias, power differentials, and group dynamics, adds Bruce: “It’s a role for an ethicist, to be present and try to mitigate the chances of those things impacting the group’s decisions.”

REFERENCE

1. Bruce CR, Minard CG, Wilhelms LA, et al. Caregivers of patients with left ventricular assist devices: Possible impacts on patients’ mortality and interagency registry for mechanically assisted circulatory support-defined morbidity events. Circ Cardiovasc Qual Outcomes 2017; 10(1). pii: e002879.

SOURCE

• Courtenay R. Bruce, JD, MA, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston. Phone: (713) 798-4929. Email: crbruce@bcm.edu.