Developing a Web and Tablet based Tool to Improve Communication and Shared Decision Making between Clinicians and Surrogates in ICUs

开发基于网络和平板电脑的工具，以改善 ICU 中临床医生和代理人之间的沟通和共享决策

• 批准号: 8881427
• 负责人: Douglas B White
• 金额: $ 19.24万
• 依托单位: UNIVERSITY OF PITTSBURGH AT PITTSBURGH
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-07-01 至 2017-02-28
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8881427
• 关键词: Address; Adult; Advance Care Planning; Affect; American; Anxiety; Caring; Cessation of life; Communication; Computer software; Consultations; Critical Care; Critical Illness; Data; Decision Making; Distress; Elderly; Elements; Emotions; Evaluation; Eye; Face; Family; Family health status; Family member; Galvanic Skin Response; Goals; Health system; Healthcare; Intensive Care Units; Internet; Intervention; Interview; Letters; Life; Measurement; Measures; Medical; Methods; Multicenter Trials; Nurses; Outcome; Outcome Measure; Pain; Palliative Care; Patients; Perception; Physicians; Physiological; Preparation; Procedures; Process; Professional counselor; Public Health; Questionnaires; Research; Research Personnel; Role; Suggestion; Tablets; Techniques; Testing; Time; United States; Vulnerable Populations; Work; base; clinical research site; cognitive load; cost; depressive symptoms; design; end of life; evidence base; expectation; group intervention; health care service utilization; high risk; improved; innovation; instrument; novel; outcome forecast; preference; prevent; prototype; psychological distress; psychological outcomes; public health relevance; randomized trial; shared decision making; success; successful intervention; tool; treatment as usual; usability; user centered design

 DESCRIPTION (provided by applicant): Three decades of research in the United States indicates that Americans who are dying often spend their final days in pain and receiving treatments they would not choose. One in five deaths among adults occurs in or shortly after discharge from an intensive care unit (ICU), where there are well-documented problems with clinician-family communication and end-of-life care. These deficiencies are associated with poorly informed treatment decisions, lasting psychological distress among patients' surrogates, and high utilization of expensive, burdensome treatments at the end of life. Unfortunately, there are no practical, generalizable interventions proven effective in mitigating these three public health problems. In this application, we propose to address this gap by developing a web and tablet-based tool to enhance communication and shared decision making in ICUs, then conducting a pilot RCT among 100 patients assessing the interventions' impact on key elements of decision making quality. In preparation for this application, we conducted in-depth interviews with surrogates and clinicians to assess the acceptability of a web and tablet-based tool, which revealed broad support for the intervention, as well as valuable design suggestions: the tool should be accessible on-line at multiple time-points, and it should be designed to enhance rather than replace clinician-family communication. In Aim 1, We will engage surrogates, clinicians, and experts in a highly iterative process of user- centered design to develop a tool that is usable, accessible, and poses low cognitive load for surrogates. In Aim 2, we will conduct detailed usability and acceptability evaluations of the prototype tool among surrogates of patients with advanced critical illness and critical care physicians and nurses. In Aim 3, we conduct a pilot RCT, using validated instruments to assess the intervention's impact on key elements of decision quality and the patient-centeredness of care decisions. We will also finalize procedures to collect long-term outcome data on patient, family, and health care utilization outcomes, which will be the main outcome measures of the anticipated multi-center trial that will follow. This project will have high impact if successful because it will yield a rigorously developed intervention and crucial preliminary data needed to conduct a multi-center trial to assess the interventions impact on patient and family outcomes. The tool has the potential to overcome major public health problems that affect the more than 600,000 Americans annually who die in ICUs and their family members. This proposal is innovative because it will produce a novel tool that challenges the existing paradigm of how decision support is provided in ICUs. The work is feasible in our hands because our team of established investigators has a proven record of success conducting trials in ICUs, have successfully used all methods proposed in this application, and have obtained buy-in for participation from the clinical sites.

 描述（由适用提供）：在美国进行了三十年的研究表明，死亡的美国人经常花时间痛苦和接受他们不会选择的治疗。成年人中有五分之一的死亡发生在重症监护室（ICU）后不久或不久，那里存在临床家庭沟通和生活终止护理的有据可查的问题。这些缺陷与知情的治疗决策不佳，患者的替代者之间的心理困扰以及生命末期昂贵，耐磨治疗的高利用有关。不幸的是，没有实用的，可推广的干预措施可有效缓解这三个公共卫生问题。在此应用程序中，我们建议通过开发基于网络和平板电脑的工具来解决此差距，以增强ICU中的沟通和共享决策，然后在100名患者中进行试点RCT，以评估干预措施对决策质量的关键要素的影响。为了准备此应用程序，我们对替代物和临床医生进行了深入的访谈，以评估基于网络和平板电脑的工具的可接受性，该工具揭示了对干预措施的广泛支持，以及有价值的设计建议：该工具应在多个时间点上在线访问，并且应设计以增强临床范围的交流。在AIM 1中，我们将与代理人，临床医生和专家一起参与以用户为中心的设计的高度迭代过程，以开发一种可用，可访问并为代理人带来低认知负荷的工具。在AIM 2中，我们将对患有晚期严重疾病和重症监护医师和护士的替代物的原型工具进行详细的可用性和可接受性评估。在AIM 3中，我们使用经过验证的工具来评估干预措施对决策质量关键要素和以患者为中心的护理决策的影响。我们还将敲定程序，以收集有关患者，家庭和医疗保健利用结果的长期结果数据，这将是预期的多中心试验的主要结果指标。如果成功，该项目将产生很大的影响，因为它将产生严格开发的干预措施和至关重要的初步数据，以进行多中心试验以评估干预措施对患者和家庭成果的影响。该工具有可能克服重大的公共卫生问题，这些问题每年在ICU及其家人中影响60万以上的美国人。该提案具有创新性，因为它将产生一种新颖的工具，挑战现有的ICU中决策支持的范式。这项工作在我们手中是可行的，因为我们成熟的研究人员团队拥有在ICU中进行成功进行试验的可靠记录，成功地使用了本应用程序中提出的所有方法，并获得了从临床站点参与的买入。