Evaluating effectiveness of a communication facilitator to reduce distress and improve goal concordant care for critically ill patients and their families

项目摘要 由于我们的人口老龄化以及有效性和安全性的进步， 关键护理的可用性。重症患者及其家属遭受严重的症状负担， 抑郁、焦虑和创伤后应激障碍，部分原因是零散的医疗护理往往很差， 与他们的目标一致。分散式护理包括患者和家属的众多过渡， 临床医生和跨环境，从ICU开始，扩展到急性护理，熟练的护理设施，或 回家随着病情的发展，患者和家属很难在护理目标的范围内导航， 他们的价值观和目标与治疗，沟通他们的目标，他们的临床医生，并使困难 不受未满足的情感需求的干扰。沟通不畅加剧了这些问题 过渡期使本已紧张的经历更加复杂，给病人及其家属造成痛苦。采取 总之，这些问题导致ICU期间和之后的无效沟通，这通常会导致高 强度“默认”护理可能是不需要的。使用随机试验，本申请建议评估 一种创新的护理模式，其中ICU护士促进者支持，建模和教授沟通 使患者和家属能够在疾病轨迹上根据其目标获得护理的战略， 从重症监护室开始，一直到社区。辅导员将使用沟通技巧， 理论，并调解，以提高：1）病人和家属的自我效能感，与临床医生沟通， 2）患者和家属的结果期望，与临床医生的沟通可以 改善他们的护理; 3）通过技能建设解决障碍，提高患者和家属的行为能力 有效沟通和调解冲突。促进者将与重病患者（n=376）和 他们的家人（n=564）从重症监护病房开始，并在3个月内对其进行随访。 干预措施的有效性将通过以患者和家庭为中心的结果来衡量，包括 抑郁、焦虑和创伤后应激的症状，以及生活质量和目标评估， 随机化后1、3和6个月的一致性治疗。主要结果将是家庭成员的 6个月内抑郁症状的负担。我们还将评估干预是否改善 通过降低医疗保健成本，同时改善患者和家庭的结果来实现医疗保健的价值。最后我们 将使用定性方法探索实施因素（干预、环境、个人、过程） 与改进执行成果（可接受性、忠实性、渗透性）相关，以告知传播情况 这类干预措施来支持患者及其家属。此应用程序将解决关键知识 在评估方法上严格的干预措施以改善严重 在整个护理轨迹和护理目标的范围内，

PROJECT SUMMARY The impact of critical illness is increasing due to our aging population as well as advances in effectiveness and availability of critical care. Critically ill patients and their families suffer a high burden of symptoms of depression, anxiety, and post-traumatic stress due, in part, to fragmented medical care that is often poorly aligned with their goals. Fragmented care includes numerous transitions for patients and families across clinicians and across settings, starting in the ICU and extending to acute care, skilled nursing facilities, or home. As illness progresses, patients and families struggle to navigate the spectrum of goals of care, to match their values and goals with treatments, to communicate their goals to their clinicians, and to make difficult medical decisions without letting unmet emotional needs interfere. Poor communication exacerbated by these transitions compounds an already stressful experience, causing distress to patients and their families. Taken together, these issues lead to ineffective communication during and after the ICU which can often result in high intensity “default” care that may be unwanted. Using a randomized trial, this application proposes to evaluate an innovative model of care in which ICU nurse facilitators support, model, and teach communication strategies that enable patients and families to secure care in line with their goals over an illness trajectory, beginning in the ICU and continuing into the community. Facilitators will use communication skills, attachment theory, and mediation to improve: 1) patients' and families' self-efficacy to communicate with clinicians within and across settings; 2) patients' and families' outcome expectation that communication with clinicians can improve their care; and 3) patients' and families' behavioral capability through skill building to resolve barriers to effective communication and mediate conflict. Facilitators will work with seriously ill patients (n=376) and their families (n=564) beginning with a critical care unit stay and following them over the course of 3 months. The intervention's effectiveness will be measured with patient- and family-centered outcomes including symptoms of depression, anxiety, and post-traumatic stress, as well as quality of life and assessments of goal- concordant care, at 1, 3, and 6 months post-randomization. The primary outcome will be family members' burden of symptoms of depression over the 6 months. We will also evaluate whether the intervention improves the value of healthcare by reducing healthcare costs while improving patient and family outcomes. Finally, we will use qualitative methods to explore implementation factors (intervention, settings, individuals, processes) associated with improved implementation outcomes (acceptability, fidelity, penetration) to inform dissemination of this type of intervention to support patients and their families. This application will address key knowledge gaps while evaluating a methodologically rigorous intervention to improve outcomes for patients with serious illness and their families across the trajectory of care and the spectrum of goals of care.