Understanding Advance Care Planning as a Dyadic Process

将预先护理计划理解为二元过程

• 批准号: 8480116
• 负责人: Terri R. Fried
• 金额: --
• 依托单位: VA CONNECTICUT HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2013
• 资助国家: 美国
• 起止时间: 2013-07-01 至 2016-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8480116
• 关键词: Accounting; Advance Care Planning; Advance Directives; Age; Aging; Agreement; Behavior; Belief; Caregivers; Caring; Categories; Cognition; Communication; Complex; Conceptions; Conflict (Psychology); Data; Decision Making; Development; Elderly; Emotions; Ensure; Equilibrium; Evaluation; Evolution; Face; Foundations; Goals; Health; Health behavior change; Healthcare; Individual; Intervention; Interview; Joints; Knowledge; Life; Literature; Living Wills; Maintenance; Measures; Modeling; Observational Study; Outcome; Participant; Patient Preferences; Patients; Persons; Population; Principal Investigator; Process; Proxy; Qualitative Methods; Readiness; Reporting; Research; Specific qualifier value; Staging; Taxonomy; Telephone; Telephone Interviews; Transcript; Veterans; Work; base; behavior change; design; effective intervention; effectiveness measure; end of life; falls; follow-up; improved; member; preference; response; surrogate decision maker; therapy design

DESCRIPTION (provided by applicant): The concept of advance care planning (ACP) is undergoing an evolution. ACP was originally conceptualized as the process by which patients could specify in advance the treatment they would want to receive if they became decisionally incapable. In its traditional format, it consist of the completion of advance directives. However, it has been shown that the completion of documents is not in and of itself sufficient to improve end-of-life outcomes. This has led to newer conceptions of ACP as an act of communication, so that ACP, once considered a process completed by an individual, is now viewed as a dyadic process. Communication between patients and surrogates regarding patients' values and preferences is particularly important because surrogates are frequently involved in treatment decision making for acutely ill patients. Surrogates' knowledge of patients' preferences can help to ensure that patients receive care consistent with these preferences. Despite the importance of patient-surrogate communication, little is known about this dyadic aspect of ACP. The few existing observational studies examining communication rely on either patient or surrogate report alone, without concomitantly examining the perspectives of both. Prior work of the Principal Investigator has characterized ACP as a process of health behavior change, based on the Transtheoretical Model (TTM). This work has demonstrated that older persons and surrogates are frequently in different stages of behavior change regarding communication about end-of-life issues. As a consequence, sizeable proportions of pairs disagree about whether they are in the Action/Maintenance stage, meaning they disagree about whether engagement in ACP has occurred. In addition, there are also substantial proportions who agree that engagement in ACP has not occurred. As the most fundamental measure of the effectiveness of communication, lack of a shared understanding about engagement in ACP indicates the presence of barriers to communication. Understanding the barriers to and facilitators of a shared understanding about engagement in ACP is critical to the design of interventions to change behavior. Whether agreement about engagement in ACP leads to a shared understanding of the patient's treatment goals, one of the key outcomes of ACP engagement, is also unknown. The long-term objective of this body of work is the development of tailored interventions to improve ACP. The immediate objective of this proposal is to understand ACP better as a dyadic process. Because so little is known about this process, mixed quantitative and qualitative methods will be utilized to ensure that relevant domains not previously documented in the literature are elicited from participants. The specific aims are: Primary Aim 1: To examine quantitatively the association between older person-surrogate agreement regarding the components of ACP behavior change and agreement regarding older persons' treatment goals. Primary Aim 2: To elucidate qualitatively the barriers to and facilitators of older person-surrogate dyads reaching agreement that they have achieved the Action/Maintenance stage of (have engaged in) ACP. Participants will be veterans age 55 and older and the person they identify as their surrogate decision maker. Dyads will undergo a quantitative telephone interview designed to identify their Stage of Change for four key ACP behaviors as well as Decisional Conflict and Values/Beliefs regarding ACP and to characterize older person-surrogate agreement regarding the older person's treatment goals, so that the relationships among these variables can be modeled. A subset of dyads will undergo a follow-up joint telephone open-ended interview. Content analysis of the transcripts will be conducted to develop a taxonomy of barriers to and facilitators of dyads' reaching agreement that they have engaged in ACP.

描述（由申请人提供）： 预先护理计划（ACP）的概念正在进行进化。 ACP最初被概念化为患者可以在决策上无法做出的治疗方法提前指定的治疗过程。 以传统格式，它由预先指令的完成。 但是，已经表明，文档的完成本身并不足以改善寿命终结结果。 这导致了对ACP作为一种交流的较新概念，因此ACP曾经被认为是一个人完成的过程，现在被视为二元过程。 患者与替代物在患者的价值观和偏好方面之间的沟通特别重要，因为替代物经常参与针对急性疾病的患者的治疗决策。 代理人的“对患者的知识”的偏好可以帮助确保患者获得与这些偏好一致的护理。 尽管患者 - 流媒体的沟通很重要，但对ACP的这一二元方面知之甚少。 少数现有的研究沟通的观察性研究仅依赖于患者或替代报告，而没有同时研究两者的观点。 基于跨理论模型（TTM），首席研究者的先前工作将ACP描述为健康行为变化的过程。 这项工作表明，关于有关终止问题的沟通，老年人和代理人经常处于行为改变的不同阶段。 结果，对它们是否处于行动/维护阶段的大量比例不同意，这意味着他们不同意是否发生过ACP的参与。 此外，还有大量的比例同意，没有发生ACP的参与。 作为对沟通有效性的最基本衡量，对ACP参与的共识缺乏共同的了解，这表明存在沟通的障碍。 了解对ACP参与的共同理解的障碍和促进者对于改变行为的干预措施至关重要。 关于参与ACP的一致性是否导致对患者治疗目标的共识，这是ACP参与的主要结果之一，也是未知的。 这项工作的长期目标是开发量身定制的干预措施以改善ACP。 该提案的直接目的是更好地理解ACP为二元过程。 由于对此过程知之甚少，因此将利用混合定量和定性方法来确保参与者以前未记录的文献中未记录的相关领域。 具体目的是：主要目的1：定量检查老年人 - 流媒体一致性关于ACP行为变化的组成部分与关于老年人治疗目标的一致性的关联。 主要目的2：为了定性地阐明老年人 - 流媒体二元组的障碍和促进者，他们达成了达成共识，他们已经达到了（参与）ACP的行动/维护阶段。 参与者将是55岁及以上的退伍军人，是他们认定为替代决策者的人。 Dyads将进行定量的电话访谈，旨在确定其四个关键ACP行为的变化阶段，以及关于ACP的决策冲突以及价值/信念，并表征有关老年人的老年人治疗目标的老年人酸盐协议，以便可以对这些变量之间的关系进行建模。 一部分二元组将接受后续电话打开式采访。 将对成绩单进行内容分析，以开发出障碍和促进者的分类法 Dyads达成了他们从事ACP的达成协议。