Promoting Behavior Change to Increase Engagement in Advance Care Planning

描述(由申请人提供)：预先护理计划(ACP)的概念正在演变。ACP最初被概念化为患者可以提前指定如果他们变得决定性无能力时他们想要接受的治疗的过程。传统上，它包括完成先行指令(AD)。然而，已经表明，文件的完成虽然很可能是必要的，但其本身并不足以改善报废结果。这导致了对ACP的更新概念，将其视为患者与代理人之间以及患者与医生之间的一种沟通行为，其重点不是特定治疗的偏好，而是更广泛的护理目标。这些较新的概念实现了许多重要成果，包括提高了临终决策的质量，减轻了与代孕决策相关的负担，并有助于确保患者在临终时接受的护理与其核心价值观一致。对让患者参与ACP的干预研究的回顾得出结论，它们只有轻微的效果。大多数旨在提高ACP参与率的干预措施都集中在ADS的完成上，并假设患者已经为这种参与做好了准备。然而，越来越多的证据表明，个人有不同的参与意愿，针对准备参与的人的干预材料对处于准备阶段的人不会有效。在这种情况下，ACP类似于许多其他健康行为，健康行为变化模式被用作成功干预的框架。该项目建立在一系列工作的基础上，证明了跨理论模型(TTM)对非加太的适用性。TTM是健康行为改变的模式，已被用作针对广泛行为的大量且不断增加的有效干预的基础。目前的提议寻求开发一种互动的、个性化的、针对TTM量身定做的干预措施，这种干预措施可以经济高效地提供给大部分人口，同时为个人量身定做。在这份提案中，ACP被定义为由四个部分组成：1)明确护理目标；2)就这些目标与代理医生进行沟通；3)与医生就这些目标进行沟通；以及4)完成书面文件。具体目标是：主要目标1：制定专门针对TTM的干预措施，旨在提高老年人参与非加太项目的比率；主要目标2：通过试行实施干预措施的程序和评估干预材料的可接受性和清晰度，确定TTM干预措施的可行性。主要目的3.根据参与者的反馈对干预材料进行修改。

DESCRIPTION (provided by applicant): The concept of advance care planning (ACP) is evolving. ACP was originally conceptualized as the process by which patients could specify in advance the treatment they would want to receive if they became decisionally incapable. Traditionally, it consisted of the completion of advance directives (AD). However, it has been shown that the completion of documents, while most likely necessary, is not in and of itself sufficient to improve end-of-life outcomes. This has led to newer conceptions of ACP as an act of communication, between patients and surrogates, and between patients and physicians, that focuses not on preferences for specific treatments but rather on broader goals of care. These newer conceptions achieve a number of important outcomes, including improving the quality of end-of-life decision-making, decreasing the burden associated with surrogate decision-making, and helping to ensure that the care patients receive at the end of life is consistent with their core values. Reviews of intervention studies to engage patients in ACP conclude that they have had only modest effects. The majority of interventions designed to increase rates of ACP participation have focused on the completion of ADs and also assume that patients are prepared for this participation. There is growing evidence, however, that individuals have variable readiness to participate, and that intervention materials aimed at persons who are ready to participate will not be effective for those at earlier stages of readiness. In this way, ACP is similar to many other health behaviors, for which models of health behavior change have served as the framework for successful interventions. This project builds upon a body of work demonstrating the applicability of the Transtheoretical Model (TTM) to ACP. The TTM is a model of health behavior change that has been used as the foundation for a large and growing number of effective interventions aimed at a wide range of behaviors. The current proposal seeks to develop an interactive, individualized, TTM-tailored intervention which can be delivered cost-effectively to large segments of a population, and at the same time, be tailored to individuals. In this proposal, ACP is defined as consisting of four components: 1) clarification of goals of care; 2) communication with surrogates physicians regarding these goals; 3) communication with physicians regarding these goals; and 4) completion of written documents. The specific aims are: Primary Aim 1: To develop a TTM-tailored intervention designed to increase the rates of older persons' participation in ACP: Primary Aim 2: To determine the feasibility of the TTM intervention by pilot-testing procedures for delivering the intervention and assessing the acceptability and clarity of intervention materials. Primary Aim 3. To revise the intervention materials based on participants' feedback.