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）的概念正在发生演变。 ACP 最初的概念是这样一个过程，通过该过程，患者可以提前指定如果他们变得完全丧失能力，他们希望接受的治疗。 按照传统的格式，它包括完成预先指示。 然而，事实证明，完成文件本身并不足以改善临终结果。 这导致了 ACP 作为一种沟通行为的新概念，因此 ACP 曾经被认为是由个人完成的过程，现在被视为一个二元过程。 患者和代理人之间关于患者价值观和偏好的沟通尤为重要，因为代理人经常参与急症患者的治疗决策。 代理人对患者偏好的了解有助于确保患者接受符合这些偏好的护理。 尽管患者与代理人沟通很重要，但人们对 ACP 的这一二元方面知之甚少。 现有的少数检验沟通的观察性研究仅依赖于患者或代理人的报告，而没有同时检验两者的观点。 首席研究员之前的工作基于跨理论模型 (TTM)，将 ACP 描述为健康行为改变的过程。 这项工作表明，老年人和代理人在关于临终问题的沟通方面经常处于行为改变的不同阶段。 因此，相当大比例的配对者对于他们是否处于行动/维护阶段存在分歧，这意味着他们对于是否参与 ACP 存在分歧。 此外，也有相当一部分人认为 ACP 的参与尚未发生。 作为沟通有效性的最基本衡量标准，对 ACP 参与缺乏共识表明沟通存在障碍。 了解参与 ACP 的共同理解的障碍和促进因素对于设计改变行为的干预措施至关重要。 关于参与 ACP 的一致意见是否会导致对患者的治疗目标（ACP 参与的关键结果之一）达成共识，目前还不得而知。 这项工作的长期目标是制定量身定制的干预措施来改善 ACP。 该提案的直接目标是更好地理解 ACP 作为一个二元过程。 由于对这一过程知之甚少，因此将利用混合的定量和定性方法来确保从参与者中引出先前文献中未记录的相关领域。 具体目标是： 主要目标 1：定量研究老年人-代理人关于 ACP 行为变化组成部分的协议与关于老年人治疗目标的协议之间的关联。 主要目标 2：定性地阐明老年人-代理人二人组达成一致意见的障碍和促进因素，即他们已达到（已参与）ACP 的行动/维持阶段。 参与者将是 55 岁及以上的退伍军人以及他们认为的代理决策者。 两人将接受定量电话访谈，旨在确定他们的四种关键 ACP 行为的变化阶段以及有关 ACP 的决策冲突和价值观/信仰，并描述老年人与代理人之间关于老年人治疗目标的协议，以便他们之间的关系这些变量可以被建模。 一部分两人将接受后续的联合电话开放式访谈。 将对成绩单进行内容分析，以制定障碍和促进因素的分类法 两人达成一致同意参与 ACP。