Intensive Palliative Care: Improving the Process of Palliative Ventilator Withdrawal Among Critically Ill Older Adults

重症姑息治疗：改善危重老年人姑息性呼吸机撤除过程

• 批准号: 10597599
• 负责人: Corey R Fehnel
• 金额: $ 19.44万
• 依托单位: HEBREW REHABILITATION CENTER FOR AGED
• 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 2025-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10597599
• 关键词: Absence of pain sensation; Adherence; Adopted; Age; Agitation; American; Area; Beds; Boston; Caring; Cessation of life; Consultations; Critical Care; Critical Illness; Data; Data Collection; Delirium; Development; Discipline of Nursing; Distress; Dose; Dyspnea; Elderly; Excision; Expert Opinion; Family; Frequencies; Future; Geriatrics; Guidelines; Hospitals; Intensive Care Units; Intervention; Intervention Studies; Interview; Investigation; Israel; Literature; Measures; Mechanical ventilation; Medical; Multivariate Analysis; Nurses; Observational Study; Operative Surgical Procedures; Palliative Care; Patient Care; Patient Self-Report; Patients; Persons; Pharmaceutical Preparations; Physicians; Pilot Projects; Principal Investigator; Process; Prospective Studies; Protocol Compliance; Protocols documentation; Provider; Proxy; Public Health; Publishing; Reaction; Research; Research Personnel; Resources; Retrospective cohort study; Risk; Sample Size; Sedation procedure; Standardization; Structure; Symptoms; Team Nursing; Testing; Time; Training; Ventilator; Vulnerable Populations; Withdrawal; Woman; Work; advanced disease; airway obstruction; comorbidity; design; evidence base; experience; field study; improved; novel; older patient; pain scale; palliative; pilot test; primary outcome; process improvement; prospective; quality of death; recruit; respiratory; skills; surgery outcome; symptomatic improvement; trend

Nearly 25% of Americans die in intensive care units (ICUs), the largest proportion of whom are older persons with advanced illness. Most deaths in ICUs are expected and involve the removal of ventilator support, or palliative ventilator withdrawal (PVW). Prior work by the Principal Investigator (PI) found more than two-thirds of ICU patients undergoing PVW were over age 60. Moreover, there are unique management considerations when transitioning an older ICU patient to comfort care, including for the PVW process (e.g. choice and dose of drugs to alleviate distressing symptoms and approach to agitated delirium). While research conducted over the past 15 years has informed several aspects of palliative care in the ICU, relatively little of that work has focused on PVW. As such, PVW practices vary widely, and patient suffering is common; 30-59% of terminally extubated patients experience dyspnea. Thus, experts and national organizations have called for evidence to inform guidelines for PVW, an area of particular relevance to older patients. The over-riding objective of the proposed research is to generate the evidence-base to improve PVW in older ICU patients. The Specific Aims are: 1. To better understand the patient experience and providers’ perspectives, 150 mechanically ventilated ICU patients over 60 years old will be recruited and prospectively followed in two Boston hospitals (180 beds) undergoing PVW. 2. To develop and refine a Comfort Measures Only Time out (CMOT) intervention consisting of a structured time out with check-list protocol for the ICU team (nurse, physician, respiratory therapist) to improve the process of PVW. 3. To pilot test the CMOT intervention in 4 ICUs (2 medical/2 surgical) among 40 PVW patients. Impact: By rigorously characterizing the experience of older ICU patients undergoing PVW, and developing and pilot testing a novel CMOT intervention, the proposed work will generate the much need evidence base to improve the care provided to this vulnerable population. Findings will directly inform the design of a larger RCT (R01) to fully evaluate the intervention. This work will establish the PI as an independent investigator with unique skills conducting palliative care intervention research among older adults in the ICU setting.

近25％的美国人死于重症监护病房（ICU），其中最大的是老年人 患有晚期疾病。预期ICU中的大多数死亡都会涉及去除通风支持，或 姑息呼吸机提取（PVW）。首席研究员（PI）的事先工作发现了三分之二以上 在ICU患者中，正在进行PVW年龄超过60岁。此外，还有独特的管理注意事项 当过渡年龄较大的ICU患者舒适护理时，包括PVW过程（例如，选择和剂量 减轻令人痛苦的症状和躁动del妄的药物）。而研究进行了 过去的15年已经告知ICU中姑息治疗的几个方面，这项工作相对较少 专注于PVW。因此，PVW的实践差异很大，患者痛苦很常见。终端的30-59％ 拔管患者患有呼吸困难。那，专家和国家组织呼吁提供证据 告知PVW指南，这是与老年患者特别相关的领域。过度骑行的目标 拟议的研究是为了产生证据库以改善老年ICU患者的PVW。具体目标 为：1。为了更好地了解患者体验和提供者的观点，150个机械通风 60岁以上的ICU患者将在两家波士顿医院（180张床）中招募并前景。 经历PVW。 2。开发和完善舒适度的措施仅超时（CMOT）干预措施 由ICU团队（护士，身体，呼吸治疗师）进行检查列表协议的结构化时间 3。试点测试40个ICU（2个医疗/2手术）的CMOT干预措施40 PVW患者。影响：严格地描述了接受PVW的老年ICU患者的经验，并 开发和试点测试新颖的CMOT干预措施，拟议的工作将产生急需的需求 改善提供给这个脆弱人群的护理的证据基础。调查结果将直接告知 设计较大的RCT（R01）以充分评估干预措施。这项工作将把PI确定为 独立的研究者，具有独特的技能进行姑息治疗干预研究的独特技能 在ICU设置中。