Pilot Randomized Clinical Trial of a Goals-of-Care Decision Aid for Surrogates of Patients With Severe Acute Brain Injury
Pilot Randomized Clinical Trial of a Goals-of-Care Decision Aid for Surrogates of Patients With Severe Acute Brain Injury
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DOI：
10.1212/wnl.0000000000200937
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发表时间：
2022-10-04
期刊：
影响因子：
9.9
通讯作者：
Hwang, David Y.
中科院分区：
文献类型：
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作者：
Muehlschlegel, Susanne;Goostrey, Kelsey;Hwang, David Y.
背景和目的在神经重症监护病房（neuroICUs）中，医生与家庭沟通的失败是很常见的，特别是在考虑长期预后的情况下，继续或退出维持生命治疗的护理目标决定。共同决策干预（决策辅助[da]）可能会预防这个问题，并增加以病人为中心的护理，但目前还没有。我们评估了DA在半球急性缺血性卒中、脑出血或外伤性脑损伤后重症严重急性脑损伤（SABI）患者与替代决策者进行护理目标沟通的可行性、可接受性和感知有用性。方法：我们在2个三级护理美国神经icu中进行了一项平行、非盲、患者水平的随机对照试验，并将替代参与者1:1随机分配到在临床-家庭护理目标会议或常规护理（在临床-家庭会议之前不进行干预）之前提供给替代参与者的定制的纸质DA。主要结果是采用DA的可行性（招募、参与和保留）、可接受性和替代受试者对DA的感知有用性。探索性结果包括替代治疗目标决定的结果、入院期间代码状态的变化、患者3个月的功能结果和替代治疗者3个月的有效心理结果。结果我们接触了58名患者中的83名代理人，招募了41名患者中的66名代理人（80%的同意率）。在66名代孕母亲中，45名在3个月时仍留在研究中（保留率68%）。在随机分配到干预组的33名受试者中，27名能够接受DA， 25名随后阅读DA（93%的参与率）。82%的人认为数据处理的可接受性为良好或优秀（可接受性中位数得分为2 [IQR 2-3]）；96%的人认为它对制定护理目标很有用。在DA组中，有更少的舒适护理决定的趋势（27%对56%，p = 0.1）和更少的代码状态变化（没有变化，73%对44%，p = 0.02）。在3个月时，DA组的患者死亡较少（33% vs 69%, p = 0.05；中位格拉斯哥结局量表3 vs1， p = 0.05）。无论干预措施如何，选择继续治疗的代孕母亲3个月的心理结果明显更差。一个支持SABI患者ICU共同决策的护理目标数据是可行的，并且被代理人很好地感知。进行更大规模的试验是可行的，尽管选择继续治疗的代孕母亲应该得到额外的社会心理支持。
Background and Objectives Breakdowns in clinician-family communication in neurologic intensive care units (neuroICUs) are common, particularly for goals-of-care decisions to continue or withdraw life-sustaining treatments while considering long-term prognoses. Shared decision-making interventions (decision aids [DAs]) may prevent this problem and increase patient-centered care, yet none are currently available. We assessed the feasibility, acceptability, and perceived usefulness of a DA for goals-of-care communication with surrogate decision makers for critically ill patients with severe acute brain injury (SABI) after hemispheric acute ischemic stroke, intracerebral hemorrhage, or traumatic brain injury.Methods We conducted a parallel-arm, unblinded, patient-level randomized, controlled pilot trial at 2 tertiary care US neuroICUs and randomized surrogate participants 1:1 to a tailored paper-based DA provided to surrogates before clinician-family goals-of-care meetings or usual care (no intervention before clinician-family meetings). The primary outcomes were feasibility of deploying the DA (recruitment, participation, and retention), acceptability, and perceived usefulness of the DA among surrogates. Exploratory outcomes included outcome of surrogate goals-of-care decision, code status changes during admission, patients' 3-month functional outcome, and surrogates' 3-month validated psychological outcomes.Results We approached 83 surrogates of 58 patients and enrolled 66 surrogates of 41 patients (80% consent rate). Of 66 surrogates, 45 remained in the study at 3 months (68% retention). Of the 33 surrogates randomized to intervention, 27 were able to receive the DA, and 25 subsequently read the DA (93% participation). Eighty-two percent rated the DA's acceptability as good or excellent (median acceptability score 2 [IQR 2-3]); 96% found it useful for goals-of-care decision making. In the DA group, there was a trend toward fewer comfort care decisions (27% vs 56%, p = 0.1) and fewer code status changes (no change, 73% vs 44%, p = 0.02). At 3 months, fewer patients in the DA group had died (33% vs 69%, p = 0.05; median Glasgow Outcome Scale 3 vs1, p = 0.05). Regardless of intervention, 3-month psychological outcomes were significantly worse among surrogates who had chosen continuation of care.Discussion A goals-of-care DA to support ICU shared decision making for patients with SABI is feasible to deploy and well perceived by surrogates. A larger trial is feasible to conduct, although surrogates who select continuation of care deserve additional psychosocial support.