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Research Article
Conditions for autonomous choice: a qualitative study of older adults' experience of decision-making in TAVR
Elisabeth Skaar,Anette Hylen Ranhoff,Jan Erik Nordrehaug,Daniel E Forman,Margrethe Aase Schaufel.Conditions for Autonomous Choice - a Qualitative Study of Older Adults’ Experience of Decision-making in Trans-catheter Aortic Valve Replacement (TAVR)J Geriatr Cardiol 2017,14(1):42~48
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Authors:Elisabeth Skaar1;Anette Hylen Ranhoff2;Jan Erik Nordrehaug3;Daniel E Forman4;Margrethe Aase Schaufel5

Author Affiliation:1.Department of Heart Disease, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway; Kavli Research Centre for Geriatrics and Dementia, Haraldsplass Deaconess Hospital, Bergen, Norway;2.Department of Clinical Science, University of Bergen, Bergen, Norway; Kavli Research Centre for Geriatrics and Dementia, Haraldsplass Deaconess Hospital, Bergen, Norway;3.Department of Clinical Science, University of Bergen, Bergen, Norway;4.University of Pittsburgh Medical Center, VA Pittsburgh Healthcare System, Pittsburgh, USA;5.Research Unit for General Practice, Uni Research Health, Bergen, Norway; Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway


Abstract: Background Patient autonomy is a leading principle in bioethics and a basis for shared decision making. This study explores conditions for an autonomous choice experienced by older adults who recently underwent trans-catheter aortic valve replacement (TAVR). Methods Qualitative study entailing semi-structured interviews of a purposive sample of ten older (range 73–89, median 83.5 years) adults after TAVR (median 23 days). The study setting was a cardiac department at a university hospital performing TAVR since 2010. Analysis was by systematic text condensation. Results Even when choice seemed hard or absent, TAVR-patients deliberately took the chance offered them by processing risk assessment, ambivalence and fate. They regarded declining the treatment to be worse than accepting the risk related to the procedure. The experience of being thoroughly advised by their physician formed the basis of an autonomous trust. The trust they felt for the physicians’ recommendations mitigated ambivalence about the procedure and risks. TAVR patients expressed feelings consistent with self-empowerment and claimed that it had to be their decision. Even so, choosing the intervention as an obligation to their family or passively accepting it was also reported. Conclusions Older TAVR patients’ experience of an autonomous decision may encompass frank tradeoff; deliberate physician dependency as well as a resilient self-view. Physicians should be especially aware of how older adults’ subtle cognitive declines and inclinations to preserve their identities which can influence their medical decision making when obtaining informed consent. Cardiologists and other providers may also use these insights to develop new strategies that better respond to such inherent complexities.


Aortic stenosis; Older adults; Patient-centered care; Shared decision-making; Trans-catheter aortic valve replacement
Received:October 09, 2016        Accepted:January 19, 2017   Published Online:January 28, 2017
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