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里，老年人经常接受侵入性治疗，尽管他们倾向于避免 繁重的干预措施，效果有限。减少临终时过度治疗的策略有 侧重于改善沟通和决策，但系统级实践模式具有很强的 对病人护理服务的影响。我的以病人为中心的研究计划专注于提高专业 对患有严重疾病的老年人的治疗决定。作为职业生涯早期调查人员的热门导师， 我现在希望将我的研究计划扩展到包括人的因素和系统层面的力量，这些因素导致 这些决定并建立了一个强大的研究人员渠道，专注于改善老年人的护理。 应用系统工程评价老年糖尿病患者生命支持治疗的启动 限制生命的疾病是为期五年的K24职业生涯中期研究员奖，以患者为导向和老龄化研究 响应PA-20-186。我们的研究团队之前已经认识到系统级的实践模式 导致过度治疗，并开发了一个概念模型来描述这种现象，我们称之为临床 势头。我们的理论是，临床势头是老年人过度治疗的主要原因 这是一种限制生命的疾病，是传播干预成功的重要障碍，旨在 在生命末期改善护理。这项建议的目标是使用系统工程方法来 描述作出有关生命维持治疗的决定的系统的特征，并使用用户- 以设计为中心，生成干预措施，以改善患者、临床医生和组织的结果。在这 观察性研究我们将对生命维持治疗的启动进行比较分析， 特别是透析、放置饲养管和延长机械通气时间，这将提供丰富的 各种指导项目的实验室。对于目标1，我们将使用系统工程方法来 描述导致生命支持治疗开始的护理模式。对于目标2，我们将开发 干扰患有限制生命疾病的老年人的临床势头的干预措施。 这个奖项将使我(1)建立一个研究和调查技能的新方向，(2)扩大我的 作为导师的能力和技能，并增加以发展事业为目标的年轻调查人员的数量 在以病人为中心和老龄化研究方面。这项研究是创新的，因为它使用了一种新的实证策略 找出在为老年人提供过度治疗方面可能起关键作用的做法模式 限制生命的疾病。这项研究具有重要意义，因为它表征了临床动量在 生命支持治疗的启动有可能开启真正由患者驱动的护理途径 偏好，而不是系统层面的激励和力量。有了我强大的指导团队，事业 发展计划，以及现有研究的资源，我很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.