Racial disparities in shared decision making for patients with acute respiratory failure

项目总结/摘要 急性呼吸衰竭（ARF）危重患者的护理涉及生死决策。 理想情况下，重症监护室（ICU）的临床医生应该让患者或其家属参与共同决策， 促进目标一致的护理，减少家庭和临床医生的心理困扰， 缩短ICU住院时间。然而，种族差异已被记录在所有组成部分的共享 决策及其相关结果。在门诊环境中，临床医生以不同的方式对待黑人患者 来自白色患者，提供较少的治疗选择，较少的预后信息和较少的情感支持， 做出假设而不是引出病人的偏好。共同决策中的种族差异 在ICU中可能会被放大，因为临床医生通常没有长期的关系， 家庭和决定都是时间紧迫和高度情绪化的。为了促进公平的ICU护理，我们必须填补 两个关键的知识差距：（1）我们不完全理解ICU临床医生如何或为什么不同地使用黑色 和白色家庭在ARF的共同决策，因此（2）我们不知道如何发展一个共同的 决策干预，以减少ARF患者SDM的种族差异。 为了解决这些证据差距，我提出了三个具体目标：（1）比较ICU医生如何参与 ARF患者的黑人和白色家庭在决策中使用混合方法分析现有的 ICU医生家属会议记录;（2）引出家属和ICU医生的决策经验 通过焦点小组和访谈了解ARF，以确定ICU医生层面的共同决策障碍 与黑人家庭一起制作;（3）使用以人为本的设计方法，以来自 家庭和ICU医生适应和可行性测试现有的共享决策干预 （“快速启动”），以减轻ARF患者及其家属的种族差异。这项工作涉及 NHLBI的一个关键优先事项是“更好地整合姑息治疗概念，如尊重治疗偏好， 急性呼吸衰竭患者的管理。 我将得到杜克大学强大的研究环境和跨学科团队的支持 克里斯托弗考克斯，金伯利约翰逊，莎伦多切蒂，和 米塔·科林在拟议的项目完成后，我将在临床试验中发展关键的科学技能， 健康差异研究、混合方法研究和干预发展。我还将收集初步的 后续R 01奖励所需的数据，以进行适应性干预的临床试验。总而言之，K23 奖项对我的职业发展至关重要，其结果将对公共卫生产生重大影响， 促进急性呼吸衰竭患者及其家属公平共同决策。

PROJECT SUMMARY/ABSTRACT The care of critically ill patients with acute respiratory failure (ARF) involves life-or-death decisions. Ideally, intensive care unit (ICU) clinicians should include patients or their families in shared decision making, which promotes goal-concordant care, reduces psychological distress for both families and clinicians, and shortens ICU length of stay. However, racial disparities have been documented in all components of shared decision making and its associated outcomes. In outpatient settings, clinicians treat Black patients differently from White patients, providing fewer treatment options, less prognostic information, and less emotional support, and making assumptions about rather than eliciting patient preferences. Racial disparities in shared decision making are likely to be amplified in the ICU because clinicians often do not have long-standing relationships with families, and decisions are time-pressured and highly emotional. To promote equitable ICU care, we must fill two critical knowledge gaps: (1) we do not fully understand how or why ICU clinicians differently engage Black and White families in shared decision making about ARF, therefore (2) we do not know how to develop a shared decision making intervention to reduce racial disparities in SDM for patients with ARF. To address these evidence gaps, I propose three specific aims: (1) Compare how ICU physicians engage Black and White families of patients with ARF in decision making using mixed methods to analyze existing transcripts of ICU physician-family meetings; (2) Elicit family and ICU physician experiences with decision making about ARF through focus groups and interviews to identify ICU physician-level barriers to shared decision making with Black families; and (3) Use a human-centered design approach that is guided by feedback from families and ICU physicians to adapt and feasibility test an existing shared decision making intervention (“Jumpstart”) in order to mitigate racial disparities for patients with ARF and their families. This work addresses a key NHLBI priority to “better integrate palliative care concepts, such as respect for treatment preferences, in the management of patients” with acute respiratory failure. I will be supported by the robust research environment at Duke University and an interdisciplinary team of dedicated, nationally respected mentors: Drs. Christopher Cox, Kimberly Johnson, Sharron Docherty, and Meeta Kerlin. At the completion of the proposed project, I will have developed key scientific skills in clinical trials, health disparities research, mixed methods research, and intervention development. I will also collect preliminary data necessary for a follow-up R01 Award to conduct a clinical trial of the adapted intervention. In sum, this K23 Award is critical to my career development, and the results will have a substantial public health impact by promoting equitable shared decision making for patients with acute respiratory failure and their families.