Pilot Testing of a Communication Intervention to Promote Shared Dialysis Decision Making in Older Patients with Chronic Kidney Disease (DIAL-SDM Trial)

简要总结 ≥65岁的老年慢性肾病（CKD）患者在透析决策方面面临挑战 入会仪式这些患者报告说，医生几乎没有努力引起治疗偏好，讨论病情， 解释透析选择的负担/益处，包括保守治疗。老年CKD患者 比起延长生命，他们更喜欢维持生活质量，许多人后悔开始透析的决定： 每年有近四分之一的人退出透析。共享透析决策需要主动 肾病学家和患者之间的互动，以协调患者、护理人员和医生之间的沟通， 共同的目标。拟议的研究是一项共享透析决策的试点随机分组务实试验- 对肾病科医生（n=20）及其年龄≥65岁的患者（n=60）进行（DIAL-SDM）干预， 估计肾小球滤过率（eGFR）≤ 20 ml/min/ /1.73 m2。干预组的肾病学家将 接受3次远程在线沟通培训课程，由标准化患者指导员（SPI）提供 通过Zoom技术，他们将制定临床场景并提供反馈。同时，患者（和护理人员，如果 可用）将接受由健康教练提供的2次辅导课程，健康教练将探索每位患者的相关 情境信息（价值观、偏好和目标），并帮助他们识别和练习重要问题 给他们的肾病医生对照组中的肾病学家将为患者提供常规护理。研究 将在两次肾病门诊访视期间和6个月时评估结局。 具体而言，我们的目标是： 目标1（主要）：评估DIAL-SDM干预的可行性、可接受性和保真度。 目标2（次要）：测试干预措施在以下方面的初步有效性：（a）患者积极参与 透析决策，通过录音中的患者主动参与编码评分进行测量 门诊访视;（B）共享透析决策，通过录音中的OPTION量表评分进行测量 的门诊访视，和患者报告的共同决策问卷;（c）患者的最初选择 透析选择（家庭vs.中心透析vs.保守治疗）。

Brief Summary Older patients ≥65 years with chronic kidney disease (CKD) face challenges in decision making around dialysis initiation. These patients report little effort by physicians to elicit treatment preferences, discuss prognoses or explain the burdens/benefits of dialysis options including conservative management. Older patients with CKD often prefer maintaining the quality of life over prolonging life, and many regret their decision to start dialysis: nearly one quarter withdraw from dialysis each year. Shared dialysis decision-making requires active engagement between nephrologists and patients to align patient, caregiver and physician communication around common goals. The proposed study is a pilot randomized cluster pragmatic trial of a shared dialysis decision- making (DIAL-SDM) intervention for nephrologists (n=20) and their patients ≥65 years old (n=60) with an estimated glomerular filtration rate (eGFR) of ≤ 20 ml/min/ /1.73 m2. Nephrologists in the Intervention Group will receive 3 remote online communication training sessions, delivered by a standardized patient instructor (SPI) via Zoom technology who will enact clinical scenarios and offer feedback. In parallel, patients (and caregivers, if available) will receive 2 coaching sessions provided by a health coach, who will explore each patient's relevant contextual information (values, preferences, and goals), and help them identify and practice important questions for their nephrologist. Nephrologists in the Control Group will provide their patients with usual care. The study outcomes will be assessed during two nephrology office visits and at 6 months. Specifically, we aim to: Aim 1 (primary): Assess the feasibility, acceptability, and fidelity of the DIAL-SDM intervention. Aim 2 (secondary): Test the preliminary effectiveness of the intervention on (a) active patient participation in dialysis decision-making, as measured by the Active Patient Participation Coding scores from audio-recordings of office visits; (b) shared dialysis decision-making, as measured by OPTION scale scores from audio-recordings of the office visits, and patient-reported Shared Decision-Making Questionnaire; (c) patients' initial choice of dialysis options (home vs. in-center dialysis vs. conservative management).