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，临终的美国老年人常常在痛苦中度过最后的日子，并接受他们不愿选择的治疗。四分之一的老年人死亡发生在重症监护室或出院后不久，其中临床医生与家人的沟通和临终关怀方面存在有据可查的问题。这些缺陷与家庭成员中不良丧亲结果的高发生率、治疗决策的知情不力以及临终时昂贵、繁重的治疗的高利用率有关。不幸的是，没有任何实际的、普遍的干预措施被证明可以有效缓解这三个公共卫生问题。在 NIA (Beeson K23AG032875) 资助的一项研究中，我们开发、完善并成功试点了“四支持干预”，这是一种多方面的干预措施，其中经过专门培训的护士与临床团队协调，集中向代理人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。本提案的目的是在 400 名危重老年人中开展四支持干预的多中心疗效试验。中心假设是，通过在这种高度紧张的情况下大力支持代孕妈妈，“四项支持干预”将改善决策的关键要素，减少代孕妈妈的长期心理困扰，并在临终时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措施对决策质量关键要素和护理决策以患者为中心的影响。在目标 2 中，我们将在 6 个月的随访中评估干预措施对代理人焦虑、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，以确定每位患者的实施成本，以及指标住院期间和超过 6 个月的随访期间对医疗保健费用的影响。如果成功，这项研究将产生巨大影响，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 中死亡的超过 500,000 名老年人。该干预措施的创新之处在于其决策心理学的理论基础、为代理人提供的支持的广度和强度，以及培训从医院现有员工中选出的护士来部署干预措施的策略，而不是使用美国医院可能不广泛提供的专业人士。这项工作在我们手中是可行的，因为我们的资深研究人员团队开发并成功地对干预措施进行了试点测试，并且因为我们拥有在 ICU 中成功进行替代决策的多中心研究的良好记录。

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.