Meeting the Challenges of COVID-19 by Expanding the Reach of Palliative Care: Proactive Advance Care Planning with Videos for the Elderly and all Patients with Dementia

通过扩大姑息治疗的范围来应对 COVID-19 的挑战：为老年人和所有痴呆症患者提供视频的主动预先护理计划

• 批准号: 10784057
• 负责人: Michael Paasche-Orlow
• 金额: $ 148.32万
• 依托单位: TUFTS MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-02-15 至 2025-04-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10784057
• 关键词: Acute; Address; Administrator; Admission activity; Advance Care Planning; Alzheimer' s disease caregiver; Alzheimer' s disease patient; Alzheimer' s disease related dementia; American; Boston; COVID-19; COVID-19 pandemic; COVID-19 patient; Caregivers; Caring; Certification; Cessation of life; Cluster randomized trial; Communication; Communication Barriers; Complex; Consult; Consultations; Country; Critical Illness; Decision Aid; Decision Making; Dementia; Documentation; Effectiveness of Interventions; Elderly; Electronic Health Record; Emotional; Enrollment; Ensure; Equilibrium; Family; Family member; Future; Health system; Hospitalization; Hospitals; Infrastructure; Inpatients; Intervention; Intubation; Knowledge; Language; Learning; Limited English Proficiency; Loneliness; Mechanical ventilation; Medical; Medical center; Modeling; Natural Language Processing; Outcome; Palliative Care; Palliative Care Nursing; Patient-Centered Care; Patient-Focused Outcomes; Patients; Phase; Proxy; Quality of Care; Randomized, Controlled Trials; Recommendation; Resuscitation; Risk; Role; Services; Testing; Triage; University Hospitals; Work; aged; care systems; compare effectiveness; dementia care; end of life; end of life care; evidence base; experience; follow-up; health literacy; hospice environment; human old age (65+); implementation facilitators; implementation intervention; improved; innovation; literacy; meetings; mortality; novel coronavirus; older patient; palliative; pandemic disease; patient-clinician communication; preference; primary outcome; response; satisfaction; visual information; ward

The majority of patients aged 65 or over, and patients with Alzheimer's Disease and Related Dementias (ADRD), have never communicated their preferences to clinicians or completed advance care planning (ACP) documents. Palliative care has the potential to improve ADRD care, improve patient-clinician communication and patient-centered outcomes, while decreasing unwanted burdensome treatments and improving care at the end of life. The novel Coronavirus Disease 2019 (COVID-19) has acutely escalated the importance of integrating ACP and palliative care services into medical care. The default response to critical illness for patients with ADRD (and all others) is intubation, mechanical ventilation, and aggressive care despite having no change in mortality outcome. ADRD patients and their caregivers may prefer to avoid these interventions. To address these gaps, we have developed a COVID-19 ACP Educator-led, video-assisted palliative care intervention to improve patient-clinician communication, increase ACP documentation, and lead to more patient-centered care at the end of life. We will identify all hospitalized patients aged 65 and older, and any patient with ADRD, and then an ACP Educator will proactively proceed with primary palliative care services of ACP, leveraging certified video decision aids that we have developed. The ACP Educator to be tested in this proposal represents a new role and proactive function for the palliative care team. The ACP Educator, who will be a palliative care nurse, will work with older patients or patients with ADRD and proxy decision-makers to learn about and document patients' wishes. The overall objective is to reduce the burden of COVID-19 by expanding the reach of inpatient palliative care, especially for patients with ADRD. We propose to conduct a stepped wedge cluster randomized trial of an ACP Educator intervention among hospitalized patients aged 65 and over, or any patient with ADRD and their proxy decision-makers in the ward and ICU settings of two major hospitals: Boston Medical Center and North Shore University Hospital. Patient outcomes will be abstracted from electronic health records with Natural Language Processing. We will evaluate intervention effectiveness by comparing the following outcomes among 9,000 hospitalized patients: ACP documentation; preferences for resuscitation; palliative care consults; and, hospice use. We will characterize caregiver-centered outcomes of patients with ADRD, including: (1) knowledge, (2) confidence in future care, (3) communication satisfaction, and (4) decisional certainty in 600 caregivers of patients with ADRD admitted to the hospital. COVID-19 poses a unique dilemma for older Americans and patients with ADRD and their caregivers, who must balance their desire to live against the risk of a lonely and potentially traumatic hospital death. Video decision support is a practical, evidence- based, and innovative approach to assist patients facing such choices. If proven effective, this innovative care model can be immediately deployed across the country to improve the quality of care for millions of Americans.

大多数患者年龄在 65 岁或以上，以及患有阿尔茨海默病和相关痴呆症的患者 (ADRD)，从未向临床医生传达过他们的偏好或完成预先护理计划 (ACP) 文件。姑息治疗有潜力改善 ADRD 护理、改善患者与临床医生的沟通 和以患者为中心的结果，同时减少不必要的繁重治疗并改善护理 生命的终结。 2019 年新型冠状病毒病 (COVID-19) 急剧提升了以下问题的重要性： 将 ACP 和姑息治疗服务纳入医疗保健。对重大疾病的默认反应 ADRD 患者（以及所有其他患者）需要插管、机械通气和积极护理，尽管 死亡率结果没有变化。 ADRD 患者及其护理人员可能更愿意避免这些干预措施。 为了弥补这些差距，我们开发了一种由 COVID-19 ACP 教育者主导的视频辅助姑息疗法 护理干预，以改善患者与临床医生的沟通、增加 ACP 文档并引导 在生命的尽头提供更多以患者为中心的护理。我们将识别所有年龄在 65 岁及以上的住院患者， 以及任何患有 ADRD 的患者，然后 ACP 教育者将主动进行初级姑息治疗 ACP 服务，利用我们开发的经过认证的视频决策辅助工具。 ACP 教育者 该提案中所测试的内容代表了姑息治疗团队的新角色和主动职能。非加太集团 教育工作者将担任姑息治疗护士，将与老年患者或患有 ADRD 和代理的患者一起工作 决策者了解并记录患者的意愿。 总体目标是通过扩大住院姑息治疗的范围来减轻 COVID-19 的负担 护理，尤其是 ADRD 患者。我们建议进行阶梯式楔形聚类随机试验 ACP 教育者对 65 岁及以上住院患者或任何 ADRD 患者进行干预 他们在两家主要医院的病房和 ICU 环境中的代理决策者：波士顿医疗中心和 北岸大学医院。患者结果将从电子健康记录中提取 自然语言处理。我们将通过比较以下各项来评估干预效果 9,000 名住院患者的结果：ACP 文档；对复苏的偏好；姑息治疗 咨询；以及临终关怀用途。我们将描述 ADRD 患者以护理人员为中心的结果， 包括：(1) 知识，(2) 对未来护理的信心，(3) 沟通满意度，以及 (4) 决策 600 名 ADRD 入院患者的护理人员的确定性。 COVID-19 带来了独特的困境 对于美国老年人和 ADRD 患者及其护理人员来说，他们必须在生活欲望与生活欲望之间取得平衡 孤独且可能造成创伤的医院死亡的风险。视频决策支持是一种实用的、有证据的 基于创新的方法来帮助面临此类选择的患者。如果证明有效，这种创新护理 该模型可以立即在全国范围内部署，以提高数百万美国人的护理质量。

项目成果

Study protocol for Video Images about Decisions to Improve Ethical Outcomes with Palliative Care Educators (VIDEO-PCE): a pragmatic stepped wedge cluster randomised trial of older patients admitted to the hospital.

关于与姑息治疗教育者改善道德结果的决定的视频图像研究方案 (VIDEO-PCE)：一项针对入院老年患者的实用阶梯楔形聚类随机试验。

• 发表时间: 2022-07-25
• 影响因子: 2.9
• 作者: Lakin, Joshua R;Zupanc, Sophia N;Lindvall, Charlotta;Moseley, Edward T;Das, Sophiya;Sciacca, Kate;Cabral, Howard J;Burns, Edith A;Carney, Maria T;Itty, Jennifer;Lopez, Santiago;Emmert, Kaitlin;Martin, Narda J;Lambert, Sherene;Polo, Jennifer
• 通讯作者: Polo, Jennifer