Semester

Spring

Date of Graduation

2013

Document Type

Dissertation

Degree Type

PhD

College

School of Nursing

Department

Family/Community Health

Committee Chair

Alvita Nathaniel

Committee Co-Chair

Roger D. Carpenter

Committee Member

Daniel D. Matlock

Committee Member

Barbara L. Nunley

Committee Member

Mary Jane Smith

Abstract

BACKGROUND: Heart failure is a severe, chronic condition characterized by high mortality and high morbidity. Sudden cardiac death is the leading cause of death for people with heart failure as well as the primary cause of death in the United States. Implantable cardioverter defibrillators (ICDs) represent the standard of care as the only effective therapy for primary prevention of sudden cardiac death. However, a significant proportion of qualifying heart failure patients declines this life-saving device. Nurses are charged with advocating for well-informed patient decisions. Yet, there is little extant literature that addresses the decision-making process for patients considering an ICD. PURPOSE: The purpose of this study was to explore the decision-making process heart failure patients experience when considering a primary prevention ICD. METHODS: This classic grounded theory study utilized purposive sampling to recruit 12 heart failure patients who had been offered primary prevention ICD implantation. Data from open-ended interviews were collected and analyzed. RESULTS: The grounded theory of embodied revelation: the threat of sudden cardiac death for ICD candidates describes the decision-making process of heart failure patients considering an ICD. The theory consists of four stages and a critical juncture. The first stage of the theory is living in conscious denial in which patients are aware on some level that they have heart failure and that they could die from this condition. Regardless of the degree of understanding, the awareness of true mortality risk is repressed. The stage ends abruptly with the critical juncture of grasping the threat of sudden cardiac death when the patient begins to comprehend the risk of death and the second stage of heightening awareness begins if the condition of valuing longevity is met. This stage is usually precipitated by a significant medical event and newly realized candor displayed by the health care provider concerning the significant death risk and recommendation for an ICD. Patients who declined ICD therapy remain in the first stage. They did not experience the critical juncture and never moved to the second stage of heightening awareness. The third stage of sanctioning ICD therapy begins while the patient is still experiencing some degree of anxiety related to a new understanding of the risk of death and the life-saving capabilities of the ICD. The decision to accept the device occurs rather quickly. At this point, the patient usually takes on a passive role and acquiesces to their provider's recommendation. The final stage of the theory, living in new assurance, describes how the heart failure patient continues to consider and support the decision made often downplaying the rigor of the process. The patient enjoys a more blissful state of assurance fueled by a new sense of security with having an ICD.;CONCLUSIONS: Embodied revelation: the threat of sudden cardiac death for ICD candidates explains the complex decision-making process surrounding an invasive life-sustaining therapy. This new grounded theory has profound implications for research, nursing and medical practice, and bioethical considerations.

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