A Trial to Improve Surrogate Decision-Making for Critically Ill Older Adults

描述（由申请人提供）：美国三十年的研究表明，濒死的美国老年人往往在痛苦中度过最后的日子，并接受他们不愿选择的治疗。老年人中有四分之一的死亡发生在重症监护病房或出院后不久，在重症监护病房中，医生与家庭的沟通和临终关怀存在着充分记录的问题。这些缺陷与家庭成员中不良丧亲结局的高发率、不知情的治疗决定以及在生命末期大量使用昂贵且负担沉重的治疗有关。不幸的是，没有任何实际的、可推广的干预措施被证明能有效减轻这三个公共卫生问题。在一项由NIA （Beeson K23AG032875）资助的研究中，我们开发、完善并成功试点了四种支持干预，这是一种多方面的干预，由一名受过专门训练的护士与临床团队协调，集中提供四种类型的支持：情感支持、沟通支持、决策支持和预期悲伤支持。本研究的目的是在400名危重老年人中进行四种支持干预的多中心疗效试验。核心假设是，通过在这种高度紧张的环境中大力支持代理人，四种支持干预将改善决策的关键要素，减少代理人的长期心理困扰，并在生命末期实现更多以患者为中心的护理。在目标1中，我们将使用经过验证的工具来评估干预对决策质量和护理决策以患者为中心的关键要素的影响。在目标2中，我们将在6个月的随访中评估干预对代孕母亲焦虑、抑郁、创伤后应激障碍和复杂悲伤症状的影响。在目标3中，我们将对干预措施进行经济评估，以确定实施的每位患者成本，以及在指数住院期间和超过6个月的随访期间对医疗保健成本的影响。这项研究如果成功，将产生巨大的影响，因为它将为重要的公共卫生问题提供务实的解决方案，这些问题可能影响每年在icu中死亡的50多万老年人。该干预措施的创新之处在于其决策心理学的理论基础，为代孕母亲提供的支持的广度和强度，以及从医院现有员工中挑选一名护士进行培训以部署干预措施的策略，而不是使用在美国医院可能无法广泛获得的专业人员。这项工作在我们手中是可行的，因为我们的研究团队开发并成功地对干预措施进行了试点测试，因为我们在icu中成功开展代理决策的多中心研究方面有良好的记录。

DESCRIPTION (provided by applicant): Three decades of research in the United States indicates that elderly Americans who are dying often spend their final days in pain and receiving treatments they would not choose. One in four deaths among older adults occur in or shortly after discharge from an intensive care unit, where there are well-documented problems with clinician-family communication and end-of-life care. These deficiencies are associated with high rates of adverse bereavement outcomes among family members, poorly informed treatment decisions, and high utilization of expensive, burdensome treatments at the end of life. Unfortunately, there are no practical, generalizable interventions proven effective in mitigating these three public health problems. In a study funded by the NIA (Beeson K23AG032875), we developed, refined, and successfully pilot tested the Four Supports Intervention, a multifaceted intervention in which a specially trained nurse intensively provides four types of support to surrogates in coordination with the clinical team: emotional support, communication support, decision support, and anticipatory grief support. The objective of this proposal is to conduct a multi- center efficacy trial of the Four Supports Intervention among 400 critically ill older adult. The central hypothesis is that by intensively supporting surrogates in this highly stressful circumstance, the Four Supports Intervention will improve key elements of decision making, decrease long-term psychological distress among surrogates, and achieve more patient-centered care near the end of life. In Aim 1, we will use validated instruments to assess the intervention's impact on key elements of decision quality and the patient- centeredness of care decisions. In Aim 2, we will assess the intervention's impact on surrogates' symptoms of anxiety, depression, PTSD, and complicated grief over 6 months of follow-up. In Aim 3, we will conduct an economic evaluation of the intervention to determine the costs per patient of implementation, as well as the impact on health care costs during the index hospitalization and over 6 months of follow up. The research will have high impact if successful because it will yield a pragmatic solution to important public health problems that potentially affect more than 500,000 older adults who die annually in ICUs. The intervention is innovative in its theoretical grounding in decision psychology, the breadth and intensity of support provided to surrogates, and the strategy of training a nurse selected from the hospital's existing staff to deploy the intervention, rather than using specialized professionals who may not be widely available in U.S. hospitals. The work is feasible in our hands because our team of established investigators developed and successfully pilot-tested the intervention, and because we have a proven record of successfully conducting multi-center studies of surrogate decision making in ICUs.