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Complex Decision-Making in Heart Failure: A Systematic Review and Thematic Analysis

Hamel, Aimee, V., MN, RN; Gaugler, Joseph, E., PhD; Porta, Carolyn, M., PhD, MPH, RN, SANE-A; Hadidi, Niloufar, Niakosari, PhD, APRN, CNS-BC, FAHA

The Journal of Cardiovascular Nursing: May/June 2018 - Volume 33 - Issue 3 - p 225–231
doi: 10.1097/JCN.0000000000000453
ARTICLES: Heart Failure

Background: Heart failure follows a highly variable and difficult course. Patients face complex decisions, including treatment with implantable cardiac defibrillators, mechanical circulatory support, and heart transplantation. The course of decision-making across multiple treatments is unclear yet integral to providing informed and shared decision-making. Recognizing commonalities across treatment decisions could help nurses and physicians to identify opportunities to introduce discussions and support shared decision-making.

Objective: The specific aims of this review are to examine complex treatment decision-making, specifically implantable cardiac defibrillators, ventricular assist device, and cardiac transplantation, and to recognize commonalities and key points in the decisional process.

Methods: MEDLINE, CINAHL, PsycINFO, and Web of Science were searched for English-language studies that included qualitative findings reflecting the complexity of heart failure decision-making. Using a 3-step process, findings were synthesized into themes and subthemes.

Results: Twelve articles met criteria for inclusion. Participants included patients, caregivers, and clinicians and included decisions to undergo and decline treatment. Emergent themes were “processing the decision,” “timing and prognostication,” and “considering the future.” Subthemes described how participants received and understood information about the therapy, making and changing a treatment decision, timing their decision and gauging health status outcomes in the context of their decision, the influence of a life or death decision, and the future as a factor in their decisional process.

Conclusions: Commonalities were present across therapies, which involved the timing of discussions, the delivery of information, and considerations of the future. Exploring this further could help support patient-centered care and optimize shared decision-making interventions.

Aimee V. Hamel, MN, RN Nursing Student, School of Nursing, University of Minnesota, Twin Cities, Minneapolis.

Joseph E. Gaugler, PhD Professor, School of Nursing, University of Minnesota, Twin Cities, Minneapolis.

Carolyn M. Porta, PhD, MPH, RN, SANE-A Associate Professor, School of Nursing, University of Minnesota Y Twin Cities.

Niloufar Niakosari Hadidi, PhD, APRN, CNS-BC, FAHA Associate Professor, School of Nursing, University of Minnesota, Twin Cities, Minneapolis.

The authors have no funding or conflicts of interest to disclose.

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Correspondence Aimee V. Hamel, PhD, MN, RN, School of Nursing, University of Minnesota, Twin Cities, 308 Harvard St SE, Minneapolis, MN 55455 (

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