First of all, it is essential to define which concept of quality of life we want to refer: the health-related QoL is a meaning strictly related to a biomedical model of QoL. The physical well-being is obviously important, but QoL is a broad construct: the absence of physical symptoms does not always correspond with a complete well-being. The WHA, in 2008, coins the slogan “no health without mental health” [28]. In the same way, it is not possible to have a good QoL only considering physical aspects.

So QoL, also in patients with VADs, must be evaluated considering together the physical symptoms (related both to disease and treatments), the individual functional status (total or partial preservation of job, hobbies, daily living), the social relationships (such as interpersonal relations and social role), the well-being (e.g., compromised by anxiety, chronic stress, mood depression, and low self-esteem), and several other components (such as sexual functioning, body image, and the global patient’s satisfaction). The latter is a balance between the advantages coming from the device use and the tolerability (somatic and psychological) of the same device. Such tolerability is reduced by biological complications (insertion problems, infections, thrombosis, obstructions, sleeve formation, extravasation) or by social problems (body image alterations, illness reminder linked to the device) or from psychological (discomfort, emotional symptoms, restrictions) and cognitive aspects (poor information). Anxiety and fear are common reactions in VAD patients and have been associated with realistic physical threats, such as catheter infection, thrombosis, obstruction, sleeve formation, and extravasation, but also with negative self-image and illness reminder. The most commonly reported VAD-related psychosocial problems, also in patients with home parenteral nutrition (HPN), are fatigue, depression, and social impairment, which have a major impact on patient QoL. Fatigue can be the most frequent general complaint in HPN patients and consistently interfere with daily activities such as work and leisure [15]. The National Comprehensive Cancer Network (NCCN) defines cancer-related fatigue as “a distressing persistent, subjective sense of physical, emotional and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning” [22] and that is not relieved by rest [20]. This definition is according to that described by patients themselves with the addition of cognitive aspects, such as diminished concentration or attention, and emotional ones, such as distress or frustration and irritability, sleep disturbances (insomnia or hypersomnia), and decreased motivation and interest [2, 7]. Mood depression can also have a marked impact on many aspects of QoL. Huisman-de Waal et al. [15] showed that depression was observed in 10–80 % of the HPN patients, ranging from mild to severe [16]. In our experience, about 53 consecutive patients affected by colorectal (62.5 %), lung (12.5 %), or breast (12.5 %) cancer who had their therapy performed through a port, several years ago, we found that 24.1 % of port patients showed pathological levels of mood depression (with a HADS cutoff > 8) and 20 % of subjects obtained HADS values between 6 and 7, typical of a subthreshold depression [25]. Moreover, mood depression impairs one’s functional capacity to work in a social function and increases the painful physical perception [24]. Social impairment has a major impact on the daily lives, particularly in HPN patients. Huisman-de Waal et al. [15] reported that between 35 and 43 % of patients experienced social impairment due to HPN, mainly because HPN administration takes a lot of time. Moreover, VADs can interfere with social contact because of the catheter, the schedule of HPN, mobility problems, and physical complaints [15]. Both mood depression and fatigue [24] can obviously contribute to the social impairment.

The World Health Organization [28] proposed five groups of factors reducing the adherence to any kind of therapy: patient-related, condition-related, therapy-related, social-/economic-related, and healthcare team-/system-related factors. When concerning VAD implants, we will reconsider these factors under the different biopsychosocial model point of view: to evaluate the patient’s adherence to a device, clinicians have to obviously consider biological aspects (such as gender, pathology, wanted side effects) but also social factors that can hardly influence patients (as the level of information and education received about the implant and the social support, from both family and medical staff, in its management). Finally, psychological factors have to be taken into account, mainly the emotional status (anxiety and particularly mood depression can increase the devices discomfort consequences and reduce the patient’s motivation toward the cures), and both the temperament and the coping style can be a mainstay on the device acceptance. In this way, the temperament of an individual can strongly influence the treatment adherence: a patient that is categorized as novelty seeker at the TCI (Temperament and Character Inventory) [9] is easily inclined to accept new and also more aggressive treatments, while a harm avoider is surely more worried about possible discomforts or complications. Coping can be defined as cognitive and behavioral efforts to master, reduce, or tolerate the internal and/or external demands that are created by the stressful transaction. Coping styles are very interactive on adherence to treatments: people with a fighting spirit are more inclined to accept the negative consequences of an implant, if they can maintain an internal locus of control about the medical strategy. Patients with hopelessness are devoid of confidence in the treatment efficacy and so are more sensitive to discomfort and complications. Patients characterized by a denial coping style have great difficulty with VAD acceptance.

In order to evaluate the emotional status of patients that are implanted with devices, it is useful to screen the presence of anxiety, mood depression, and pathological levels of stress than can interfere with the patient’s perception of the satisfaction about the devise. Other relevant aspects that have to be evaluated are the patient coping style, his or her QoL, and fatigue. It is mostly suggested to use self-evaluative instruments that allow a subjective evaluation from the patient’s point of view and that are also less expensive because drawn up by patients during their permanence in the waiting rooms. If the screening cutoff is over the threshold, a standardized clinical interview takes place in order to confirm or disconfirm the screening data. An important underlying question actually was whether the occurrence of psychosocial problems associated with VAD-related complications could be somehow prevented. Fatigue severity can be measured using a subscale of the Checklist Individual Strength (CIS), composed by 8 items, with a score ranging between 8 and 56. A clinically severe fatigue can be considered present when the score is >35. This subscale demonstrated a good internal consistency and a convergent validity, with Cronbach α for fatigue severity of 0.88 [16]. Another valuation instrument for fatigue is the Edmonton Symptom Assessment System (ESAS) (Bruera et al. [5]) (0 = no fatigue, 10 = worse fatigue). An ESAS score ≥ 4 should be followed by an in-depth clinical evaluation, including fatigue history, physical exam, and medications, mainly in order to exclude an anemic status, vitamin deficiencies [5], and/or the usual association of CRF with a larger cluster of symptoms including sleep disturbance, emotional distress, and pain [29]. Mood depression and its severity can be evaluated with the Hospital Anxiety Depression Scale (HADS) that screens both depression and anxiety. The HADS is a 14-item (rated 0–3) self-report scale widely used in clinical practice [20]. The total HADS depression score ranges from 0 (absence of depression) to 21 (severe depression), and the proposed screening cutoff of HADS for depression is 8. Another self-evaluating instrument is the Beck Depression Inventory for Primary Care (BDI-PC) that is a 7-item self-questionnaire (each item rated 0–3) in which patients were asked to describe their past 2 weeks of symptoms. Symptoms taken into consideration are sadness, pessimism, past failure, loss of pleasure, self-dislike, self-criticalness, and suicidal thoughts and wishes. A cutoff score of >4 is given a diagnosis of major depressive disorder. The internal consistency is high (α = 0.86), and BDI-PC was positively associated with the diagnosis of major depressive disorders (r = 0.66, P < .001) [16]. The social impairment can be carried out with the social behavior subscale of the Sickness Impact Profile 68 (SIP68) that is composed by 12 dichotomous items, with a high internal consistency (Cronbach α = 0.92) [16]. The stress levels can be easily measured by the Distress Thermometer (DT) [12] that is a visual analog tool that asks the respondent to rate his or her level of distress in the past week on a scale from 0 (no distress) to 10 (extreme distress). The problem list (PL) consists of a list of 34 problems grouped into 5 categories (practical problems, family problems, emotional problems, spiritual/religious concerns, and physical problems) and is rated in a yes/no format. The QoL can be evaluated with EORTC or with SF 36. The EORTC QLQ-C30 [1] is composed of 30 items, concerning functional status, symptoms, and financial problems. Specific items evaluate the QoL, and the global health and single items measure specific symptoms, such as hyporexia and insomnia. Items were rated on a four-point Likert scale: “not at all, a little, quite a bit, very much.” In the functional scales and in the Global Health Status, a higher score is indicative of better functioning and better QoL. To the contrary, in the symptom scales, a higher score reflects a higher level of symptoms. The Short Form (36) Health Survey [27] is a patient-reported survey of patient health that consists of eight scaled scores (vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning, and mental health). Each scale is directly transformed into a 0–100 scale on the assumption that each question carries equal weight. The lower the score, the more the disability, and the higher the score, the lesser the disability. The coping style can be evaluated with the mini-Mac that is a 29-item instrument that examines the cognitive and behavioral responses to cancer using a 4-point Likert scale. Five subscales identified fighting spirit (4 items), hopelessness (8 items), anxious preoccupation (8 items), fatalism (5 items), and cognitive avoidance (4 items) [13]. Another widespread instrument is the Brief COPE that is the abridged version of the COPE inventory and presents 14 scales all assessing different coping dimensions: active coping, planning, using instrumental support, using emotional support, venting, behavioral disengagement, self-distraction, self-blame, positive reframing, humor, denial, acceptance, religion, and substance use. Each scale contains two items (28 altogether). It can be used to assess trait coping (the usual way people cope with stress in everyday life) and state coping (the particular way people cope with a specific stressful situation) [6]. So a fast screening of emotional and distress levels can help to identify patients at risk of psychological detrimental consequences after implantation in order to support them avoiding an emotional worsening of QoL in spite of medical advantages.