A Pragmatic Randomized Control Trial of Nurse-Delivered Brief Meaning Centered Psychotherapy for Homebound Palliative Care Patients

项目摘要/摘要：重大疾病患者往往面临着生存窘迫

Project Summary/Abstract: Patients with serious illness are often confronted with existential distress that contributes to anxiety and depression and when left unaddressed, leads to increased suffering and despair. Homebound individuals face compounded existential concerns and loss of meaning above and beyond ambulatory patients with advanced illnesses, as they contend with an even greater loss of independence and declining opportunities for activities and social engagement. Nonetheless, this group has been described as “invisible” due to a lack of consensus on quality of care benchmarks. Despite this great need, most of these individuals do not receive mental health services. As the demand for the delivery of comprehensive, high quality palliative care in the community continues to grow, so too does the need to address these vulnerable patients’ existential and emotional needs with targeted interventions that can be feasibly delivered in the home. This study seeks to evaluate the impact of a brief nurse-delivered psychosocial intervention, Meaning Centered Psychotherapy – Palliative Care (MCP-PC), to homebound adults with advanced cancer. This pragmatic trial is conceptualized through the lens of dissemination and implementation (D&I) science using the Iowa Model of Evidence Based Practice indicators (i.e., knowledge, perception/attitude, behavior/practice, outcomes, balancing measures). Using a mixed methods design, including a pilot randomized control trial, this study has three specific aims: (1) To refine the MCP-PC training and study procedures for homecare delivery by nurse interventionists through a single arm open pilot (n=10 nurses; n=10 patients); (2) To evaluate the feasibility and acceptability (Iowa Model knowledge, perception/attitude, behavior/practice, balancing measures) of nurse- delivered MCP-PC in an RCT (n=10 nurses; n=60 patients); and (3) To assess the efficacy of nurse-delivered MCP-PC compared to treatment as usual (TAU) on patients’ spiritual well-being, psychological distress, QOL, and end of life despair (Iowa Model outcomes) in an RCT. After a brief open pilot and refinement of study procedures, we will recruit 60 patients through the Visiting Nurse Service of New York (VNSNY) home-based care program and randomize them to either MCP-PC or TAU. All participants will be asked to complete a short battery of self-report instruments at baseline, after treatment, and one-month post-treatment (TAU assessments will follow a similarly spaced time line). Brief qualitative interviews evaluating the treatment and implementation outcomes will be conducted with patients and nurses upon completion of MCP-PC. The MCP- PC program leverages the existing infrastructure of a high-volume homecare agency to address the insufficient mental health workforce in palliative care. If proven effective, MCP-PC can be successfully embedded in existing systems of care as a potentially widely disseminable approach to reaching historically underserved patient populations (e.g., rural, ethnic minorities) on a national scale.