Promoting Advance Care Planning as a Healthy Behavior

促进预先护理计划作为一种健康行为

• 批准号: 10028218
• 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: 2017
• 资助国家: 美国
• 起止时间: 2017-05-01 至 2021-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10028218
• 关键词: Abbreviations; Address; Advance Care Planning; Advance Directives; Age; Americas; Analysis of Variance; Area; Attitude; Behavior; Behavioral; Belief; Caregivers; Caring; Chronic Disease; Clinical; Clinical Services; Cognitive; Communication; Computer Models; Computers; Connecticut; Counseling; Data; Decision Making; Disease; Elderly; Eligibility Determination; Emotional; Ensure; Equation; Equilibrium; Evaluation; Expert Systems; Face; Feedback; Future; Goals; Health; Health Status; Health behavior; Health behavior change; Healthcare; Healthcare Systems; Individual; Institute of Medicine (U.S.); Intervention; Interview; Judgment; Life; Living Wills; Longevity; Maintenance; Measures; Medical; Modeling; Motivation; Multivariate Analysis; Outcome; Outcome Measure; Pamphlets; Participant; Patients; Physicians; Preparation; Primary Health Care; Principal Investigator; Process; Proxy; Public Health; Randomized Controlled Trials; Readiness; Recording of previous events; Reporting; Research Personnel; Specific qualifier value; Subgroup; Telephone; Testing; Theoretical model; Time; Veterans; Work; base; behavior change; care preference; cohort; design; end of life; end of life care; experience; follow-up; group intervention; health care quality; improved; insight; intervention effect; loved ones; meetings; middle age; motivational enhancement therapy; motivational intervention; patient oriented; preference; premature; sociodemographic variables; success; surrogate decision maker; theories; therapy design; treatment as usual

The recent Institute of Medicine report “Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life” endorses advance care planning (ACP) as a key component of quality healthcare. In contrast to the prevailing model of engaging only individuals with serious illness in ACP, it proposes a continuous process, starting earlier in the lifespan with individuals in good health. Such an approach helps to prepare the individual for more in-depth discussions and treatment decision making as more serious illness develops. This project is responsive to this call. It builds upon earlier work of the Principal Investigator (PI) providing two key insights for improving the process of ACP. The first of these is shifting the purpose of ACP away from the pre-specification of treatment preferences to preparation for making the best possible “in-the-moment” healthcare decisions. This is accomplished by conceptualizing ACP as acts of communication among patients, surrogates, and clinicians. The second is explicitly addressing the many attitudinal, cognitive, and behavioral barriers to engagement in ACP. This is accomplished by treating ACP as a health behavior and intervening using validated models for health behavior change. The PI has developed and pilot-tested an intervention based on the Trans-Theoretical Model. This intervention consists of an expert system that assesses an individual's readiness to engage in ACP along with the attitudes and beliefs influencing the desire, motivation, and ability to engage. It then provides individually tailored feedback materials providing information, motivation, and/or behavior change strategies (computer-tailored information or CTI). This project will also utilize a form of motivational interviewing called motivational enhancement therapy (MET), which, while also including the concept of readiness for behavior change, is distinct from CTI. It consists of brief counseling exploring an individual's readiness to engage in behavior change and helping the individual to identify motivators for change. The objective of the project is to examine the effects of CTI and MET on Veteran engagement in ACP. The specific aim is: To conduct a randomized controlled trial examining the effects of: a) usual care; b) CTI; c) MET; d) CTI + MET on the proportion of middle-age and older Veterans receiving primary care at the VA who complete the process of ACP. Broad eligibility criteria will be used to identify Veterans age 55 years and older who are receiving primary care within VA Connecticut Healthcare System and who have not completed all of the 4 key ACP behaviors: health care proxy assignment, living will completion, communication with the health care proxy about views on quality vs. quantity of life, communication with the clinician about these views. The intervention(s) will be delivered over the phone. For Veterans receiving CTI, an individually tailored feedback report, a stage-matched brochure, and a pamphlet for the surrogate will be mailed. This will be repeated at 2 and 4 months. For Veterans receiving MI, the Veteran and surrogate will participate in a dyadic interview. Follow-up interviews will occur at 2 and 4 months. For Veterans receiving CTI + MI, the printed materials will be mailed, and the interview will be conducted within 2 weeks. Baseline measures, including stage of change for the 4 key ACP behaviors, pros and cons of behavior change, and health status and sociodemographic variables, will be obtained for all participants. The outcome measure, obtained at 6 months, will be the proportion of participants who have completed the 4 ACP behaviors. The proposal will also lay the groundwork for more widespread implementation by collecting implementation data on the time and effort required to deliver the interventions, success of and barriers to delivering the interventions, and spill-over effects on other clinical services. Additional work will be done to strategize about the most efficient ways to embed the interventions into existing clinical services.

最近的医学研究所报告“在美国死亡：提高质量并尊重个人” “临近生命终结时的偏好”认可预先护理计划 (ACP) 作为质量的关键组成部分 与仅让患有严重疾病的个人参与 ACP 的流行模式相反，它 提出了一个持续的过程，从生命周期的早期开始，从健康状况良好的个体开始。 方法有助于个人为更深入的讨论和治疗决策做好准备，因为更多 该项目是响应这一号召而建立的，它建立在校长早期工作的基础上。 研究者 (PI) 提供了改进 ACP 流程的两个关键见解，其中第一个是转变流程。 ACP 的目的不再是预先指定治疗偏好，而是为做出最佳治疗做好准备 这是通过将 ACP 概念化为行为来实现的。 第二个是明确解决许多问题。 参与 ACP 的态度、认知和行为障碍可以通过将 ACP 视为来实现。 PI 开发了健康行为并使用经过验证的模型进行干预。 并对基于跨理论模型的干预进行了试点测试 该干预由一位专家组成。 评估个人参与 ACP 的准备情况以及态度和信念的系统 然后它会影响参与的愿望、动机和能力。 提供信息、动机和/或行为改变策略的材料（计算机定制的信息 该项目还将采用一种称为动机增强的动机访谈形式。 治疗（MET）虽然也包括行为改变准备的概念，但与 CTI 不同。 包括简短地咨询个人是否已准备好进行行为改变并帮助 个人识别变革的动机。 该项目的目标是研究 CTI 和 MET 对退伍军人参与 ACP 的影响。 具体目标是： 进行一项随机对照试验，检查以下各项的效果： a) 常规护理； b) CTI； MET；d) CTI + MET 关于在 VA 接受初级护理的中年和老年退伍军人的比例 完成 ACP 流程将使用广泛的资格标准来识别 55 岁及以上的退伍军人。 正在 VA 康涅狄格州医疗系统内接受初级护理且尚未完成所有任务的人 ACP 的 4 项关键行为：医疗保健代理人分配、生前遗嘱的填写、与健康人员的沟通 关心代表对生活质量与数量的看法，与临床医生就这些观点进行沟通。 对于接受 CTI 的退伍军人，将通过电话提供针对个人的反馈。 报告、舞台匹配的小册子和代孕妈妈的小册子将在 2 点重复邮寄。 对于接受 MI 的退伍军人，退伍军人和代理人将参加二元面试。 对于接受 CTI + MI 的退伍军人，后续访谈将在 2 个月和 4 个月进行。 邮寄，访谈将在 2 周内进行 基线措施，包括变更阶段。 4 种关键 ACP 行为、行为改变的利弊以及健康状况和社会人口统计 变量，将获得所有参与者 6 个月时获得的结果测量值。 完成 4 种 ACP 行为的参与者比例 该提案还将奠定基础。 通过收集实施所需时间和精力的数据来更广泛地实施 实施干预措施、实施干预措施的成功和障碍以及对其他方面的溢出效应 将开展额外的工作来制定最有效的嵌入方法的策略。 对现有临床服务的干预。