Improving Palliative Care for Older Seriously Hospitalized Patients and Their Families: A Randomized Trial of an Informed Assent Communication Intervention about CPR

改善老年严重住院患者及其家人的姑息治疗：关于心肺复苏知情同意沟通干预的随机试验

• 批准号: 9266706
• 负责人: Renee D Stapleton
• 金额: $ 50.24万
• 依托单位: UNIVERSITY OF VERMONT & ST AGRIC COLLEGE
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-05-01 至 2021-02-28
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9266706
• 关键词: Admission activity; Adult; Anxiety; Cardiopulmonary Resuscitation; Caring; Cessation of life; Chronic Disease; Chronically Ill; Collaborations; Communication; Communication Methods; Data; Do Not Resuscitate Order; Elderly; Enrollment; Family; Family member; Feeling; Goals; Home environment; Hospitalization; Hospitals; Impaired cognition; Intervention; Journals; Knowledge; Life; Measures; Medicine; Methodology; Multicenter Studies; New England; Outcome; Palliative Care; Patient Recruitments; Patients; Perception; Phase; Physicians; Pilot Projects; Positioning Attribute; Procedures; Provider; Publishing; Quality of Care; Randomized Controlled Trials; Regrets; Research; Research Personnel; Research Proposals; Stress; Survival Rate; Survivors; Symptoms; Time; Training; Work; anxiety symptoms; attentional control; cost; depressive symptoms; end-of-life communication; experience; functional disability; health care service utilization; hospital readmission; improved; innovation; novel; older patient; patient oriented; preference; public health relevance; randomized trial; reduce symptoms; satisfaction; stress symptom; treatment as usual

 DESCRIPTION (provided by applicant): High quality palliative care and communication in older patients improves quality of care, patient and family satisfaction, and costs of care. One important component of communication is discussing cardiopulmonary resuscitation (CPR), as this is required for every hospital admission and most older patients have not discussed CPR prior to hospitalization. Unfortunately, these conversations are often inadequate and leave patients and families feeling burdened, stressed, and concerned. Outcomes after in-hospital CPR in chronically ill older patients continue to be very poor, despite decades of efforts toward improvement. Our prior work has shown that an increasing proportion of hospitalized older adults receive CPR before death with continued poor survival rates and that the longer-term benefits of CPR are decreasing with fewer patients discharged home after CPR. Additionally, when compared to those without chronic illness, older patients with advanced chronic illness have significantly worse hospital discharge and long-term survival after CPR, and among survivors, experience more hospital readmissions until death and are less likely to be discharged home. We have recently successfully completed two pilot studies of a novel "informed assent" approach to discussing CPR, a specific communication framework whereby older patients who meet specific criteria and do not wish to remain alive at all costs are informed that they should not receive CPR. Our preliminary data demonstrate that this intervention is feasible and well-received by patients, family members, and physicians. Additionally, among patients who wanted CPR at enrollment in our pilot RCT, significantly more patients receiving the intervention changed their preferences to "no CPR" than did control patients. We therefore propose a phase II proof-of-concept RCT comparing our innovative informed assent intervention versus usual care with attention control for older hospitalized adults with severe life-limiting illness or functional or cognitive impairment, enrolling patients and family members. We hypothesize that informed assent will improved quality of and satisfaction with communication about CPR; reduce the burden of potentially harmful CPR discussions, including reduced patient and family symptoms of depression, anxiety and decisional regret; and reduce intensity of care and health care utilization. The research team proposing this project, led by an Early Stage Investigator, has extensive experience with RCTs and patient recruitment, as well as years of successful collaboration, including recent completion of two pilot studies of informed assent. They are well positioned to conduct this study that aims to change the paradigm of CPR discussions with older adults unlikely to benefit from CPR. If effective, this informed assent intervention has the potential to revolutionize discussions about CPR with chronically ill older patients.

 描述（通过应用程序提供）：老年患者的高质量姑息治疗和沟通可改善护理质量，患者和家庭满意度以及护理成本。沟通的一个重要组成部分是讨论心肺复苏（CPR），因为这是每个住院所必需的，并且大多数老年患者在住院之前尚未讨论CPR。不幸的是，这些对话通常不足，使患者和家人感到被烧毁，压力和关心。长期病人的老年患者的院内心肺复苏术后的结局仍然非常贫穷，几十年来为改善而付出了数十年的努力。我们先前的工作表明，越来越多的住院老年人在死亡之前接受心肺复苏率，生存率持续较差，而心肺复苏术的长期益处正在减少，而在CPR之后，患者较少出院。此外，与没有慢性病的患者相比，患有晚期慢性疾病的老年患者的住院和长期生存率明显较差，在生存后，经历了更多的医院再入院，直到死亡，并且不太可能被释放回家。我们最近成功地完成了两项针对讨论CPR的小说“知情同意”方法的试点研究，这是一个特定的沟通框架，符合特定标准并且不希望不惜一切代价保持活力的老年患者。 他们不应该收到CPR。我们的初步数据表明，这种干预措施是可行的，并且受到患者，家庭成员和医生的良好观念。此外，在希望在我们的PILOT RCT入学的患者中，接受干预措施的患者将其偏好更大的偏好更改为“无CPR”，而不是对照患者。因此，我们提出了II阶段概念验证RCT，将我们创新的知情同意干预与通常的护理与通常的护理以及对患有严重生命疾病或功能性或认知障碍的老年人的注意力控制，患者和家庭成员的注意力控制。我们假设知情同意将提高对CPR的沟通的质量和满意。减少可能有害的心肺复苏术讨论的燃烧，包括抑郁症，焦虑和决策的患者症状减少；并降低护理和医疗保健利用的强度。由早期调查员领导的该项目的研究团队在RCT和患者招聘方面拥有丰富的经验，以及多年的成功合作，包括最近完成了两项对知情同意的试点研究。他们在进行这项研究的良好位置，旨在改变与老年人不太可能受益于CPR的CPR讨论的范式。如果有效，这种知情的同意干预有可能彻底改变与年龄较大的老年患者有关CPR的讨论。