Patient-centered and efficacious advance care planning in cancer: the PEACe comparative effectiveness trial

摘要摘要： 未能在生命即将结束时提供反映患者需求、价值观和偏好的护理 晚期癌症仍然是我们癌症护理提供系统的一个关键缺陷。全国性组织 包括美国国家医学科学院和美国临床肿瘤学会在内的 增加对提前护理计划(ACP)的关注，以改善接近生命末期的以患者为中心的护理。一位批评者 在这一领域取得进展的障碍是缺乏证据表明最有效和最高效的非加太战略 改善临终前的治疗决策，确保患者的意愿得到尊重。 两种不同的面向患者的ACP干预措施被广泛使用，并已知有效，但需要相当大的费用 部署成本和复杂性的差异：(1)与训练有素的辅导员进行面对面讨论；(2)网络- 使用交互式视频进行提前护理计划。这些方法从未被直接比较过；它 因此，尚不清楚一种形式的非加太是否更有效--如果是，对谁和在什么情况下 情况。了解面对面、促进的ACP与基于Web的ACP的相对有效性是 重要，因为面对面的ACP需要更多的资源。 这项建议是一项单盲、患者水平的随机试验，以解决这一证据差距，使用混合 方法对400例急性呼吸窘迫综合征患者进行面对面、便利化ACP与基于网络的ACP的疗效比较。 晚期癌症和他们的家庭照顾者。目的1比较这些方法对患者和患者的影响 家庭照顾者结果(参与非加太项目--主要结果；与家庭护理者的非正式项目讨论和 医生；提前指令(AD)完成；照顾者抑郁和焦虑症状)。为 在研究期间死亡的患者，我们将使用经过验证的照顾者报告的测量方法来比较 EOL护理的感知质量，患者EOL目标的实现，以及失去照顾者的抑郁症状， 焦虑和创伤后应激障碍。目标2评估每项干预措施的实施成本和影响 生命周期结束时的医疗保健利用率。目标3确定了影响以下目标有效性的背景和机制 每种方法。 这项试验将产生很大的影响，因为它将提供关于两个 成功克服传统书面先行指令限制的面向患者的ACP方法 但需要投入非常不同的时间和资源。它在使用混合方法方面具有创新性 不仅要评估这些方法的相对有效性，而且要评估这些方法对谁、如何以及在什么方面的有效性 在某些情况下，它们是有效的。它是可行的，因为它建立在由 经验丰富的研究团队，具有进行行为干预试验和定性研究的经验 ACP和肿瘤学。

Abstract Summary: Failure to deliver care near the end of life that reflects the needs, values and preferences of patients with advanced cancer remains a key shortcoming of our cancer care delivery system. National organizations including the National Academy of Medicine and American Society of Clinical Oncology have called for increased attention to advance care planning (ACP) to improve patient-centered care near end of life. A critical barrier to progress in the field is a lack of evidence about the most effective and efficient ACP strategy to improve treatment decisions near end of life and ensure patients' wishes are honored. Two different patient-facing ACP interventions are widely used and known to be effective but entail sizeable differences in costs and complexity to deploy: (1) in-person discussions with trained facilitators and (2) web- based advance care planning using interactive videos. These approaches have never been compared directly; it is therefore unclear whether one form of ACP is more potent—and if so, for whom and under what circumstances. Understanding the relative effectiveness of in-person, facilitated versus web-based ACP is important because in-person ACP requires far more resources. This proposal is a single-blind, patient-level randomized trial to address this evidence gap, using mixed methods to compare the effectiveness of in-person, facilitated ACP vs web-based ACP among 400 patients with advanced cancer and their family caregivers. Aim 1 compares the effect of these approaches on patient and family caregiver outcomes (engagement in ACP—primary outcome; ACP discussions with family caregivers and physicians; advance directive (AD) completion; and caregiver symptoms of depression and anxiety). For patients who die during the study period, we will use validated, caregiver-reported measures to compare perceived quality of EOL care, patients' EOL goal attainment, and bereaved caregiver symptoms of depression, anxiety and post-traumatic stress. Aim 2 assesses implementation costs of each intervention and effects on healthcare utilization at end of life. Aim 3 identifies contexts and mechanisms influencing the effectiveness of each approach. This trial will have a high impact because it will provide new and much-needed empirical evidence about two patient-facing ACP approaches that successfully overcome limitations of traditional written advance directives but entail very different investments of time and resources. It is innovative in using mixed methods to evaluate not only the comparative effectiveness of these approaches, but also for whom, how and in what circumstances they are effective. It is feasible because it builds on extensive infrastructure developed by an accomplished research team with experience conducting behavioral intervention trials and qualitative research in ACP and oncology.