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

美国三十年的研究表明，垂死的美国老年人经常在痛苦中度过最后的日子，并接受他们不会选择的治疗。四分之一的老年人死亡发生在重症监护室或出院后不久，在那里，临床医生与家人的沟通和临终关怀存在有据可查的问题。这些缺陷与家庭成员中的高比率的不利丧亲结果，信息不足的治疗决定，以及在生命结束时昂贵，负担沉重的治疗的高利用率有关。不幸的是，没有实际的、可推广的干预措施被证明能有效缓解这三个公共卫生问题。在一项由NIA资助的研究中（Beeson K23AG032875），我们开发，完善并成功地进行了试点测试四种支持干预，这是一种多方面的干预措施，其中受过专门训练的护士与临床团队协调，为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名重症老年人中进行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理人，四个支持干预将改善决策的关键要素，减少代理人之间的长期心理困扰，并在生命结束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对决策质量和以患者为中心的护理决策的关键要素的影响。在目标2中，我们将评估干预对代理人焦虑、抑郁、创伤后应激障碍和复杂悲伤症状的影响，随访时间超过6个月。在目标3中，我们将对干预措施进行经济学评估，以确定每位患者的实施成本，以及对指数住院期间和6个月以上随访期间医疗保健成本的影响。如果成功，这项研究将产生很大的影响，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死亡的50多万老年人。该干预措施在决策心理学的理论基础、为代理人提供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方面具有创新性，而不是使用美国医院中可能不广泛使用的专业人员。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，并且因为我们在ICU成功进行代理决策的多中心研究方面有着良好的记录。

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.