Guidelines as rationing tools: a qualitative analysis of psychosocial patient selection criteria for cardiac procedures

Background: Cardiac procedure guidelines often include psychosocial criteri a for selecting patients that potentially introduce social value judgements into clinical decisions and decisions about the rationing of care. The aim of this study was to investigate the terms and justifications for and the meanings of psychosocial patient characteristics used in cardiac procedure guidelines. Methods: We selected English-language guidelines published since 1990 and c hapters in textbooks published since 1989. These guidelines amalgamated mul tiple sources of evidence and expertise and made recommendations regarding patient selection for specific procedures. A multidisciplinary team of phys icians and social scientists extracted passages regarding psychosocial crit eria and developed categories and conceptual relationships to describe and interpret their content. Results: Sixty-five papers met the criteria for inclusion in the study. For ty-five (69%) mentioned psychosocial criteria as procedure indications or c ontraindications. The latter fell into several categories, including behavi oural and psychological issues, relationships with significant others, fina ncial resources, social roles and environmental circumstances. Interpretation: Psychosocial characteristics are portrayed as having 2 role s in patient selection: as risk factors intrinsic to the candidate or as in dicators of need for special intervention. Guidelines typically simply list psychosocial contraindications without clarifying their specific nature or providing any justification for their use. Psychosocial considerations can help in the evaluation of patients for cardiac procedures, but they become ethically controversial when used to restrict access. The use of psychosoc ial indications and contraindications could be improved by more precise des criptions of the psychosocial problem at issue, explanations regarding why the criterion matters and justification of the characteristic using a biolo gical rationale or research evidence.