Use of systems engineering to evaluate the initiation of life-supporting treatments in older adults with life-limiting illness

摘要 在生命的最后六个月，老年人经常接受侵入性治疗，尽管他们倾向于避免 繁琐的干预措施，效果有限。减少生命末期过度治疗的策略有 专注于改善沟通和决策制定，但系统级实践模式有很强的 对患者护理的影响。我的以病人为导向的研究项目侧重于提高专业 为患有严重疾病的老年人做出治疗决定。作为一个受欢迎的导师，为早期的职业调查， 我现在希望扩展我的研究计划，包括导致 这些决定，并建立了一个强大的研究人员管道，专注于改善老年人的护理。 系统工程在老年人生命支持治疗中的应用 生命限制性疾病是一个为期五年的K24中期职业生涯研究者奖，以患者为导向，老龄化研究 请拨打PA-20-186我们的研究团队之前已经认识到系统级实践模式 并发展了一个概念模型来描述这种现象，我们称之为临床 势头.我们认为，临床动力是老年人过度治疗的主要原因， 是限制生命的疾病，也是沟通干预成功的重要障碍， 改善临终关怀。本提案的目的是采用系统工程方法， 描述生命支持治疗决策发生的系统，并使用用户- 集中设计，以生成干预措施，从而改善患者、临床医生和组织结果。在这 观察性研究我们将对生命支持治疗的启动进行比较分析， 特别是透析、饲管放置和长时间的机械通气，这将提供丰富的 实验室为各种辅导项目。对于目标1，我们将采用系统工程方法， 描述导致启动生命支持治疗的护理模式。为了实现目标2， 干预措施，以破坏老年人与生命限制性疾病的临床势头。 这个奖项将使我（1）建立一个新的研究方向和调查技能，（2）扩大我的 作为导师的能力和技能，并增加旨在发展职业生涯的年轻调查员的人数 以病人为导向的老龄化研究这项研究是创新的，因为它使用了一种新颖的实证策略 确定可能在为老年人提供过度治疗方面发挥关键作用的实践模式， 限制生命的疾病这项研究是重要的，因为表征临床势头的作用， 生命支持治疗的启动有可能开启真正由患者驱动的护理之路 偏好，而不是系统层面的激励和力量。凭借我强大的导师团队， 发展计划，以及现有研究的资源，我完全有能力实现这些目标。

ABSTRACT In the final six months of life older adults often receive invasive treatments despite their preferences to avoid burdensome interventions with limited efficacy. Strategies to reduce overtreatment at the end of life have focused on improving communication and decision making, yet systems-level practice patterns have a strong influence on the delivery of patient care. My patient-oriented research program focuses on improving major treatment decisions for older adults with serious illness. As a sought after mentor for early-career investigators, I now wish to expand my research program to include the human factors and systems-level forces that lead to these decisions and build a robust pipeline of researchers focused on improving care for older adults. Use of systems engineering to evaluate the initiation of life-supporting treatments in older adults with life-limiting illness is a five-year K24 Midcareer Investigator's Award in patient-oriented and aging research responding to PA-20-186. Our research team has previously recognized systems-level practice patterns leading to overtreatment and developed a conceptual model to describe this phenomenon that we call clinical momentum. We theorize that clinical momentum is a major contributor to overtreatment for older adults with life-limiting illness and is an important barrier to the success of communication interventions designed to improve care at the end of life. The objective of this proposal is to use a systems engineering approach to characterize the systems in which decisions about life-supporting treatments occur and to employ user- centered design to generate interventions to improve patient, clinician and organizational outcomes. In this observational study we will perform a comparative analysis of the initiation of life-supporting treatments, specifically dialysis, feeding tube placement, and prolonged mechanical ventilation, which will provide a rich laboratory for a variety of mentored projects. For aim 1, we will use a systems engineering approach to characterize patterns of care leading to initiation of life-supporting treatments. For aim 2, we will develop interventions to disrupt clinical momentum for older adults with life-limiting illness. This award will allow me to (1) build a new direction of research and investigative skills and (2) expand my capacity and skill as a mentor and to increase the number of young investigators who aim to develop a career in patient-oriented and aging research. This research is innovative because it uses a novel empirical strategy to identify practice patterns that may play a critical role in the provision of overtreatment for older adults with life-limiting illness. This research is significant because characterizing the role of clinical momentum in the initiation of life-supporting treatments has the potential to unlock the pathway to care truly driven by patient preferences instead of systems-level incentives and forces. With my strong mentorship team, career development plan, and the resources of existing studies I am well-positioned to achieve these objectives.