title: Conditions for autonomous choice: a qualitative study of older adults' experience of decision-making in TAVR.
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.
authors.affiliation: Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Skaar
authors.affiliation: 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.
authors.forename: Anette Hylen
authors.initials: AH
authors.lastname: Ranhoff
authors.affiliation: Department of Clinical Science, University of Bergen, Bergen, Norway; Kavli Research Centre for Geriatrics and Dementia, Haraldsplass Deaconess Hospital, Bergen, Norway.
authors.forename: Jan Erik
authors.initials: JE
authors.lastname: Nordrehaug
authors.affiliation: Department of Clinical Science, University of Bergen, Bergen, Norway.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Forman
authors.affiliation: Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway.
authors.forename: Margrethe Aase
authors.initials: MA
authors.lastname: Schaufel
keywords: Aortic stenosis; Older adults; Patient-centered care; Shared decision-making; Trans-catheter aortic valve replacement