Patient Prefers to be Called
- Ask them their preferred name
Information Provided By
- Who was involved in the session?
Concerns Identified by Team
- Did any team members give you a heads-up on areas of concern prior to the evaluation?
Primary Medical Issues
- What is their main medical issue(s)?
History of illness/referral for transplant/VAD (ventricular assist device, a pump that assists their heart function)
- When were they diagnosed with the condition for which transplant/VAD is being considered?
- When was the possibility of transplant/VAD first discussed with them?
Type of Surgery
- Heart Transplant? Lung Transplant? VAD?
Description of Family System/Emergency Contacts
- Create a list of family members, including partner, children, parents, siblings, etc.
- List their main support persons with phone #’s
- Is the patient responsible for taking care of anyone else?
Who would you like involved in planning your care?
- Which of their family/friends will be most involved in planning?
Current ADL Equipment/Home Services?
- Social Workers or Case Managers?
Plan for Post-Transplant Assistance
- Patients are required to have at least one person to provide assistance to them 24 hours a day after they are discharged from the hospital. Who will this person be?
- If patient lives more than 30 minutes away, they are expected to stay in Madison for 7-10 days minimum while coming in daily as an outpatient for tests, therapies, etc. Where do they plan on staying? If a hotel, can they afford the cost (If not, we may be able to use the hop-tel)? Does insurance cover? (OPatientum does)
- Patients can not drive for several weeks post transplant (potentially for longer if the have a VAD). Who will drive them to clinic appointments?
- Do they currently live in a house, apartment, or some other type of dwelling?
- Is it accessible?
- Do they live alone, or with others?
- If they are alone during interview, ask if they feel safe in their home/if they have ever felt hurt, threatened, frightened or neglected.
- How many years did they go in school?
- Do they have any problems with reading or learning?
- Do they have a POA-HC? If so, do we have a copy? We strongly recommend they complete one prior to surgery.
- Living Will?
- DNR/DNI (patients need to suspend this if they wish to proceed with transplant/VAD)
- Is religion or spirituality a part of their life? Affiliated with any group?
- How much support do they get from their personal or spiritual beliefs?
- How important are spiritual beliefs and values in coping with illness?
- Any cultural/healing practices that we need to be sensitive to?
- Is their primary language one other than English? Do they need an interpreter?
- Is the patient/partner employed? Occupation? Full time or part time?
- Are either of them collecting SSDI or SSI? Private Disability?
- What is their payer source? Is it through the patient or partner? How long do they anticipate being able to keep this insurance? (notes on COBRA, etc)
- Does it cover medications post transplant (these are VERY expensive and most people can not afford to pay for them out of pocket)? What is the co-pay?
- Did they serve in any of the armed forces? If so, when?
- Do they have VA Health benefits?
Recent Changes in Relationships/Other Current Stressors
- Is there anything else in their life besides their health they are worried about?
Mental Health History
- Any feelings of depression or anxiety?
- If yes to depression: Any suicidal thoughts in the last week? Desire to make a suicide attemPatient? Plan?
- Any other history of mental health issues?
- Do they go to/have they gone to a counselor? If current, would they sign a Release of Information?
- Are they on any psychotropic medications? If so, do they feel dosing is adequate?
- **Review risk of depression, anxiety, PatientSD, guilt**
Adaptation/Reaction to Illness
- How has their illness impacted them emotionally?
- How do they feel they are coping?
Stress Reduction Techniques/Tools
- Complementary therapies?
- What things do they do to reduce stress in their life?
- Is this working for them?
- Are they interested in further exploring deep breathing/guided imagery/mindfulness meditation?
- How many times a day do they currently take their medications? Are they prepared to take up to 15 different pills up to 8 different times per day??
- How often do they forget to take their medications as prescribed?
- Have they ever chosen to not follow a doctor’s recommendations? Circumstances.
- Have they ever missed a clinic appointment? Circumstances.
- How closely have they followed diet/fluid allowances (patients with heart failure must limit sodium to 2g day and liquids from 1.5-2L a day)?
Substance Abuse History
- Any history of nicotine use? If so, type; amount (need to calculate pack/years); quit date; ongoing exposure to second hand smoke.
- Patient will need to be abstinent from nicotine x6 months prior to listing.
- Do they drink alcohol? If so, type, amount; last used. If they drink heavily, will need to abstain 6 months prior to listing. In general, doctors do not want patient to exceed one drink a day.
- Have they ever used any recreational drugs? If so, type; amount; last used
- Will need to be abstinent from illicit drugs x6 months prior to listing .
- Any history of social or legal problems as a result of substance use? (DUI, jail time, etc.)
- Ever sought treatment/rehab for substance use?
- Any legal issues that they are involved in?
Prior Personal Experiences with Transplant/VAD
- Do they know/have they met anyone that has had a transplant and/or VAD?
Expectations for Transplant/VAD
- “What do you think it will be like to have a new heart/lung(s)/heart pump?”
- “How do you think this new heart/lung(s)/pump will affect you?”
Family/Patient Concerns about Transplant/VAD?
- “Does anything worry you or your family about transplant/VAD?”
- Any other pertinent psychosocial issues that you feel may impact a successful transplant/VAD outcome
- Indicate whether you provided them with any hand-outs
- If no “red flags” were raised, the patient does not have any known psychosocial obstacles to transplant/VAD
- If issues did arise, summarize them here. Common issues include lack of support, lack of funding, recent/continuing alcohol/nicotine/drug abuse, adherence issues, psychiatric issues.
Recommendations/Plans/Goals (Choose One)
- More information is required before a decision can be made (comment on what is needed)
- Patient is currently a transplant/VAD candidate from a psychosocial perspective
- Patient is a high risk transplant/VAD candidate from a psychosocial perspective (comment on why)
After the Assessment
After you have completed the assessment, please type into a HealthLink note using the appropriate SmartText.
Heart Transplant: The heart transplant coordinators can be reached at 2-8915.
Lung Transplant: The lung coordinators can be reached at 5-5658.
VAD: The VAD coordinator can be reached at 2-0773.