Improving Medical Decision Making for Older Patients with End Stage Renal Disease

改善老年终末期肾病患者的医疗决策

• 批准号: 10390330
• 负责人: Michael Paasche-Orlow
• 金额: $ 218.06万
• 依托单位: BOSTON MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-04-15 至 2022-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10390330
• 关键词: Address; Advance Care Planning; Aging; American; Cardiopulmonary Resuscitation; Caregivers; Caring; Cessation of life; Chronic Kidney Failure; Communication; Complex; Conflict (Psychology); Control Groups; Counseling; Decision Aid; Decision Making; Dialysis procedure; Documentation; Early Intervention; Education; Effectiveness; Elderly; Electronic Health Record; Emotional; End stage renal failure; Family Caregiver; Intervention; Kidney; Kidney Diseases; Knowledge; Language; Lead; Length; Life; Longevity; Medical; Methods; Natural Language Processing; Palliative Care; Patient Care Planning; Patient Focused Care; Patient Self-Report; Patients; Persons; Physicians; Pilot Projects; Population; Process; Prognosis; Quality of Care; Quality of life; Quality-Adjusted Life Years; Randomized; Randomized Controlled Trials; Research; Supportive care; Technology; Testing; Time; Use Effectiveness; Vulnerable Populations; Work; advanced disease; aged; care delivery; care outcomes; clinical practice; cost; design; efficacy study; evidence base; improved; innovation; literacy; older patient; preference; primary outcome; randomized trial; secondary outcome; success; symptom management; tool; treatment as usual; treatment planning; visual information

A growing number of older patients are living with chronic kidney disease (CKD) due to advances in life- prolonging technologies and the aging of the population. As CKD advances towards end-stage renal disease (ESRD), even life-prolonging technologies cannot extend life indefinitely, especially for patients who have a poor prognosis and for whom decisions about medical interventions become particularly important. Consequently, older patients with advanced CKD need to communicate with their physicians about their preferences regarding CPR, dialysis and supportive kidney care (medical management of symptoms of advanced CKD without dialysis) in order to make crucial decisions impacting the length and quality of their lives. Communication surrounding medical decision making is formalized in Advance Care Planning (ACP), a process involving verbal or written information designed to inform patients of possible medical options including CPR, dialysis and supportive kidney care. Traditional ACP for patients with ESRD relies on ad hoc verbal descriptions of treatment options. This approach is limited because these options are difficult to envision. We have developed a video decision aid for reviewing CPR, dialysis and non-dialytic treatment preferences in ESRD. The tool, which is available in both English and Spanish, also allows patients to video record their preferences ("video declaration") and share their preferences with their clinicians and caregivers. The overall objective of this study is to conduct a multi-center randomized trial of the video intervention (vs. usual care) to test the hypothesis that the video better informs older persons with advanced CKD and poor prognosis of their treatment options and leads to more ACP documentation, informed decision making, and improved quality of life. We will compare ACP documentation after one year (or at time of death) among 600 patients aged 75 or older with advanced CKD and poor prognosis randomly assigned to either the video intervention or usual care (Aim 1). We will compare ESRD treatment preferences, decisional conflict, ACP engagement and conversations, and concordance of preferences stated after the video intervention or usual care with ESRD care delivery after one year (or at time of death) (Aim 2). We will explore the quality of life, longevity, and cost per Quality Adjusted Life Year (QALY) associated with patients' ESRD treatment decisions in the video vs. control groups (Aim 3). We will also conduct a qualitative assessment of the video declarations as well as barriers and facilitators for intervention success (Aims 4 and 5). ESRD in older patients involves complex decision making. It is imperative that we develop and evaluate early interventions to deliver more patient- focused care to this rapidly growing segment of the population. Using videos to enhance communication offers an opportunity to improve care of this vulnerable group of patients. Video is a practical, evidence-based, and innovative approach that has the potential to improve the quality of care provided to tens of thousands of older Americans.

由于生活的进步，越来越多的老年患者患有慢性肾脏疾病（CKD） 延长技术和人口的老化。随着CKD前进到末期肾脏疾病 （ESRD），即使是生命的技术也无法无限期地延长寿命，尤其是对于患者 预后不佳，对医疗干预措施的决定变得尤为重要。 因此，患有高级CKD的老年患者需要与医生就他们的医生进行沟通 关于CPR，透析和支持性肾脏护理的偏好（症状的医疗管理 没有透析的高级CKD）为了做出关键决定，影响其长度和质量 生命。围绕医疗决策的沟通在预先护理计划（ACP）中正式化了 涉及口头或书面信息的过程，旨在告知患者可能的医疗选择 心肺复苏术，透析和支持性肾脏护理。 ESRD患者的传统ACP依赖于临时语言 治疗选择的描述。这种方法是有限的，因为这些选项很难设想。我们 已经开发了视频决策辅助 ESRD。该工具具有英语和西班牙语，还允许患者视频记录他们的 偏好（“视频声明”），并与临床医生和护理人员分享他们的偏好。总体 这项研究的目的是进行视频干预的多中心随机试验（与通常的护理） 测试视频更好地告知老年人的高级CKD和预后不佳的假设 治疗选择并导致更多的ACP文档，明智的决策以及提高的质量 生活。我们将在600名75岁或75名患者中比较ACP文档 随机分配给视频干预或通常的护理的高级CKD和不良预后的年龄较大 （目标1）。我们将比较ESRD治疗偏好，决策冲突，ACP参与和 对话，以及视频干预或ESRD通常护理后所陈述的偏好的一致性 一年后（或死亡时）的护理服务（AIM 2）。我们将探索生活质量，寿命和成本 每个质量调整的生活年份（QALY）与视频vs中的患者的ESRD治疗决策相关。 对照组（目标3）。我们还将对视频声明进行定性评估以及 干预成功的障碍和促进者（目标4和5）。老年患者的ESRD涉及复合物 决策。我们必须制定和评估早期干预措施，以提供更多的患者 - 集中注意这一迅速增长的人群。使用视频来增强沟通优惠 有机会改善对这一脆弱患者的护理。视频是一种实用的，循证的，并且 创新的方法有可能提高为成千上万的年龄较大的护理质量 美国人。