Perceived Stress and Depressive Symptoms as Predictors of Decisional Conflict in Dyads Considering a Left Ventricular Assist Device.

BACKGROUND: The decision to pursue a left ventricular assist device (LVAD) commits loved ones to major caregiving responsibilities and, often, medical decision-making. How emotional domains overlap within patients and their caregivers and contribute to conflict around the decision to pursue LVAD remains largely unexplored. METHODS AND RESULTS: The associations within and between individuals in patient-caregiver dyads considering LVAD were estimated in a specific type of structural equation model known as the Actor-Partner Interdependence Model. This model tested whether each person's depression and stress predicted their own decisional conflict (actor effects), as well as their partner's decisional conflict (partner effects). At the time of study enrollment when a formal LVAD evaluation was initiated, 162 patient-caregiver dyads completed assessments of decisional conflict using the Decisional Conflict Scale, depressive symptoms using the Patient Health Questionnaire-2, and stress using the Perceived Stress Scale. Across both models, decisional conflict was significantly correlated within patient-caregiver dyads (ß=0.47 and 0.44, for depression and perceived stress models, respectively, P<0.001). Greater perceived stress in both the patient (ß=0.18; P<0.05) and caregiver (ß=0.28; P<0.001) was significantly related to greater decisional conflict (both actor effects). Greater patient depressive symptoms were related to greater patient decisional conflict (ß=0.16; P<0.05), whereas caregiver depression symptoms was not related to their own decisional conflict (ß=0.07; P=0.37). There were no partner effects identified between decisional conflict and perceived stress or depressive symptoms. CONCLUSIONS: Patient and caregiver conflict over the decision to pursue an LVAD was highly correlated in this sample, with greater perceived stress significantly predicting greater decisional conflict in both patients and caregivers. Depressive symptoms in patients also predicted greater patient decisional conflict. No partner effects were identified in predicting decisional conflict. These results contribute to a larger body of work acknowledging the importance of patient-caregiver well-being in serious illness. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02344576.

Physician Bias in Prophylactic Cranial Irradiation Decision Making-An Opportunity for a Patient Decision Aid.

INTRODUCTION: Guidelines have recommended prophylactic cranial irradiation (PCI) for patients with limited-stage small-cell lung cancer with at least a partial response after thoracic chemoradiation. However, the survival advantage has been small and was observed in an era before magnetic resonance imaging and surveillance. Neurotoxicity also remains a concern, especially in older adults. Thus, patients have a complex value-laden decision to make. We sought to better understand the role physicians play in patient decision making and introduce a patient decision aid (PDA) to potentially facilitate these discussions. MATERIALS AND METHODS: An e-mail survey was sent to International Association for the Study of Lung Cancer members querying their personal perspectives and professional recommendations regarding PCI for limited-stage small-cell lung cancer. RESULTS: We received 295 responses. Most were from the United States (35%) and Europe (35%) and were radiation (45%) or medical (43%) oncologists. Of those responding, 88% and 50% reported they would recommend PCI to a 50- and 70-year-old patient, respectively. Also, 79% reported that they would wish to receive PCI if faced with this decision. The physicians who would have chosen PCI if faced with the decision were 27.6 and 12.9 times more likely to recommend PCI to a 50- and 70-year-old patient, respectively, than were physicians who would not undergo PCI themselves. Most of the respondents had positive responses to the proposed PDA. CONCLUSION: Physician bias appears to play a role in PCI counseling, and most physicians reported that the provided PDA was better than their present method for discussing PCI and would help patients make such value-laden choices.