A Trial of Expanded Choice Sets in Advance Directives for Hemodialysis Patients

血液透析患者预先医疗指示中扩大选择集的试验

• 批准号: 8982352
• 负责人: Katherine Rinaldi Courtright
• 金额: $ 6.87万
• 依托单位: UNIVERSITY OF PENNSYLVANIA
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-01-01 至 2016-12-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8982352
• 关键词: Address; Advance Care Planning; Advance Directives; Award; Biometry; Businesses; Caring; Cessation of life; Chronic Disease; Clinical; Conduct Clinical Trials; Conflict (Psychology); Critical Illness; Data; Decision Making; Dialysis procedure; End stage renal failure; Enrollment; Family member; Foundations; Frequencies; Future; Goals; Health; Hemodialysis; Home environment; Hospitalization; Hospitals; Intensive Care Units; Intervention; Investments; K-Series Research Career Programs; Length; Life; Light; Living Wills; Maintenance; Malignant Neoplasms; Measures; Medical; Mentored Patient-Oriented Research Career Development Award; Mentors; Methods; Motivation; Outcome; Outpatients; Pain; Patient Care; Patients; Pattern; Population; Probability; Process; Quality of Care; Quality of life; Randomized; Reporting; Research; Research Personnel; Research Project Grants; Risk; Risk Factors; Specific qualifier value; Staging; Supportive care; Task Performances; Testing; Time; To specify; Training; Uncertainty; United States National Institutes of Health; Work; Writing; base; behavioral economics; care preference; clinically actionable; cohort; end of life; experience; functional decline; functional status; health care service utilization; high risk; improved; insight; meetings; novel strategies; patient population; preference; prospective; public health relevance; randomized trial; satisfaction; success; surrogate decision maker; theories; therapy development

 DESCRIPTION (provided by applicant): There is a large gap between the care patients with end-stage renal disease on maintenance hemodialysis (ESRD-HD) want and the care they receive near the end-of-life. Unfortunately, hemodialysis patients experience frequent hospitalizations and aggressive medical care near the end of life despite a preference for comfort-focused care if they are seriously ill. This, in part, is explained by historically unsatisfactory advance care planning including low rates of advance directive completion in this population. Timely engagement in advance care planning is particularly important for ESRD-HD patients who have a median five-year survival shorter than many patients with cancer and have a distinctly rapid functional decline in the final month of life. Advance directives offer an opportunity for patients to express specific end-of-life preferences to avoid unwanted care. As promising as advance directives may be for improving the quality of care near the end of life, rates of completion remain low and previous efforts to encourage their completion have had limited success. Moreover, among patients who do complete an advance directive, one in four do not provide sufficient guidance in it for surrogate decision makers to provide care consistent with their goals and values. Principles of behavioral economics, such as decision framing effects, may offer a novel approach to address previous shortcomings in advance directive implementation and bridge the gap in end-of-life care. For example, targeting patients with identifiable risk factors for critical illness or death in the foreseeable future increases the probability that patients' stated preferences will still apply when the advance directive is needed The goal of this study is to test whether changing the context of decisions regarding advance directive completion can increase the probability that hemodialysis patients will complete, and specify actionable choices within, advance directives. First, we aim to determine if expanding the choices for completing an advance directive by offering different versions of them will increase the proportion of patients who complete one. Second, we aim to determine if expanding the range of choices for receipt or not of life-supportive therapies within an advance directive will decrease the proportion of patients who do not specify any preference. This project will provide essential preliminary data for a planned NIH K23 Career Development Award that would (1) examine more definitively how this and other decision nudges influence ESRD-HD patients' decisions, (2) compare longitudinal patient-reported quality of life, functional status, and healthcare utilization patterns near the end of life among ESRD-HD patients who do or do not complete advance directives, and (3) compare other behavioral economic interventions for improving advance directive completion among a larger population of patients receiving maintenance hemodialysis therapy.

 描述（由适用提供）：在维持血液透析（ESRD-HD）中，患有终末期肾脏疾病的护理患者的差距很大，他们在终止生命后获得的护理。不幸的是，血液透析患者在生命终结结束附近经常住院和积极的医疗服务，如果他们病重，则偏爱以舒适为中心的护理。这部分是由历史上不令人满意的预先护理计划所解释的，包括该人群的预先指令完成率低。及时参与预先的护理计划对ESRD-HD患者的中位数五年生存期短于许多癌症患者并且在生命的最后一个月的功能下降明显快速下降，这一点尤其重要。 Advance指令为患者提供了一个表达特定生命终止偏好的机会，以避免不必要的护理。正如提前指令所承诺的那样，可能是为了提高生命终结的护理质量，完成率仍然很低，并且以前的鼓励完成的努力取得了有限的成功。此外，在完成提前指令的患者中，四分之一的人没有为代理决策者提供足够的指导，以提供符合其目标和价值观的护理。行为经济学的原则，例如决策框架效应，可能会提供一种新颖的方法来解决以前的事先指令实施的缺点，并弥合临终护理中的差距。例如，针对可识别危险因素或可预见的未来死亡的可识别危险因素的患者增加了患者所陈述的偏好仍然适用的概率，而这项研究的目标是测试如何改变有关预先指示完成的决策背景是否会增加血液透析患者的概率，并指定血液lysis contection of Actionable Choce of Active of Activeable of Advactive insped Directives。首先，我们旨在确定通过提供不同版本的不同版本来扩大完成预先指令的选择是否会增加完成患者的比例。其次，我们的目的是确定在提前指令中扩大范围内的选择疗法的选择范围是否会减少未指定任何偏爱的患者的比例。该项目将为计划的NIH K23职业发展奖提供必不可少的初步数据，该奖项将（1）更明确地研究该项目和其他决策如何影响ESRD-HD患者的决定，（（2）比较患者报告的生活质量，功能状况和医疗保健利用模式在ESRD-HD终结中的纵向进行纵向报告的纵向质量，并不适用于ESRD-HD的其他行为，并且（33改善接受血液透析疗法的较大患者人群的提前指令完成。

项目成果

A Randomized Trial of Expanding Choice Sets to Motivate Advance Directive Completion.

• DOI: 10.1177/0272989x16663709
• 发表时间: 2017-07
• 期刊: Medical decision making : an international journal of the Society for Medical Decision Making
• 作者: Courtright KR;Madden V;Gabler NB;Cooney E;Kim J;Herbst N;Burgoon L;Whealdon J;Dember LM;Halpern SD
• 通讯作者: Halpern SD