Understanding Advance Care Planning as a Dyadic Process

将预先护理计划理解为二元过程

• 批准号: 8480116
• 负责人: Terri R. Fried
• 金额: --
• 依托单位: VA CONNECTICUT HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2013
• 资助国家: 美国
• 起止时间: 2013-07-01 至 2016-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8480116
• 关键词: Accounting; Advance Care Planning; Advance Directives; Age; Aging; Agreement; Behavior; Belief; Caregivers; Caring; Categories; Cognition; Communication; Complex; Conceptions; Conflict (Psychology); Data; Decision Making; Development; Elderly; Emotions; Ensure; Equilibrium; Evaluation; Evolution; Face; Foundations; Goals; Health; Health behavior change; Healthcare; Individual; Intervention; Interview; Joints; Knowledge; Life; Literature; Living Wills; Maintenance; Measures; Modeling; Observational Study; Outcome; Participant; Patient Preferences; Patients; Persons; Population; Principal Investigator; Process; Proxy; Qualitative Methods; Readiness; Reporting; Research; Specific qualifier value; Staging; Taxonomy; Telephone; Telephone Interviews; Transcript; Veterans; Work; base; behavior change; design; effective intervention; effectiveness measure; end of life; falls; follow-up; improved; member; preference; response; surrogate decision maker; therapy design

DESCRIPTION (provided by applicant): The concept of advance care planning (ACP) is undergoing an evolution. 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. In its traditional format, it consist of the completion of advance directives. However, it has been shown that the completion of documents 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, so that ACP, once considered a process completed by an individual, is now viewed as a dyadic process. Communication between patients and surrogates regarding patients' values and preferences is particularly important because surrogates are frequently involved in treatment decision making for acutely ill patients. Surrogates' knowledge of patients' preferences can help to ensure that patients receive care consistent with these preferences. Despite the importance of patient-surrogate communication, little is known about this dyadic aspect of ACP. The few existing observational studies examining communication rely on either patient or surrogate report alone, without concomitantly examining the perspectives of both. Prior work of the Principal Investigator has characterized ACP as a process of health behavior change, based on the Transtheoretical Model (TTM). This work has demonstrated that older persons and surrogates are frequently in different stages of behavior change regarding communication about end-of-life issues. As a consequence, sizeable proportions of pairs disagree about whether they are in the Action/Maintenance stage, meaning they disagree about whether engagement in ACP has occurred. In addition, there are also substantial proportions who agree that engagement in ACP has not occurred. As the most fundamental measure of the effectiveness of communication, lack of a shared understanding about engagement in ACP indicates the presence of barriers to communication. Understanding the barriers to and facilitators of a shared understanding about engagement in ACP is critical to the design of interventions to change behavior. Whether agreement about engagement in ACP leads to a shared understanding of the patient's treatment goals, one of the key outcomes of ACP engagement, is also unknown. The long-term objective of this body of work is the development of tailored interventions to improve ACP. The immediate objective of this proposal is to understand ACP better as a dyadic process. Because so little is known about this process, mixed quantitative and qualitative methods will be utilized to ensure that relevant domains not previously documented in the literature are elicited from participants. The specific aims are: Primary Aim 1: To examine quantitatively the association between older person-surrogate agreement regarding the components of ACP behavior change and agreement regarding older persons' treatment goals. Primary Aim 2: To elucidate qualitatively the barriers to and facilitators of older person-surrogate dyads reaching agreement that they have achieved the Action/Maintenance stage of (have engaged in) ACP. Participants will be veterans age 55 and older and the person they identify as their surrogate decision maker. Dyads will undergo a quantitative telephone interview designed to identify their Stage of Change for four key ACP behaviors as well as Decisional Conflict and Values/Beliefs regarding ACP and to characterize older person-surrogate agreement regarding the older person's treatment goals, so that the relationships among these variables can be modeled. A subset of dyads will undergo a follow-up joint telephone open-ended interview. Content analysis of the transcripts will be conducted to develop a taxonomy of barriers to and facilitators of dyads' reaching agreement that they have engaged in ACP.

描述（由申请人提供）： 先进的护理计划（ACP）的概念正在经历一个演变。 ACP最初被概念化为一个过程，通过该过程，患者可以提前指定他们在无法做出决定时想要接受的治疗。 在其传统格式中，它包括完成预先指示。 然而，事实表明，完成文件本身并不足以改善寿命终了的结果。 这导致了ACP作为一种沟通行为的新概念，因此ACP曾经被认为是一个由个人完成的过程，现在被视为一个二元过程。 患者和代理人之间关于患者价值观和偏好的沟通尤为重要，因为代理人经常参与急性病患者的治疗决策。 代理人了解患者的偏好有助于确保患者获得与这些偏好一致的护理。 尽管患者-代理人沟通的重要性，但对ACP的这种二元方面知之甚少。 少数现有的观察性研究检查通信依赖于单独的患者或代理报告，没有同时检查双方的观点。 主要研究者之前的工作将ACP描述为基于跨理论模型（TTM）的健康行为变化过程。 这项工作表明，老年人和代理人经常处于不同的行为变化阶段，关于临终问题的沟通。 因此，相当大比例的配对不同意他们是否处于行动/维持阶段，这意味着他们不同意是否参与ACP。 此外，也有相当比例的人同意，没有参与非加太国家方案。 作为衡量沟通有效性的最基本标准，对参与非加太国家方案缺乏共同理解表明存在沟通障碍。 了解参与ACP的共同理解的障碍和促进因素对于设计干预措施以改变行为至关重要。 关于参与ACP的协议是否会导致对患者治疗目标的共同理解，这是ACP参与的关键结局之一，也是未知的。 这一系列工作的长期目标是制定有针对性的干预措施，以改进非加太国家方案。 这项建议的直接目标是更好地了解非加太作为一个二元进程。 由于对这一过程知之甚少，将采用定量和定性相结合的方法，以确保从参与者中引出以前文献中未记录的相关领域。 具体目标是：主要目标1：定量研究老年人-代理人关于ACP行为改变的组成部分的一致性与老年人治疗目标的一致性之间的关联。 主要目标2：定性地阐明老年人-代理人二人组达成协议的障碍和促进因素，即他们已经达到（已经参与）ACP的行动/维持阶段。 参与者将是55岁及以上的退伍军人，以及他们确定为代理决策者的人。 二人组将接受定量电话访谈，旨在确定他们的四个关键ACP行为的变化阶段，以及关于ACP的决策冲突和价值观/信念，并描述老年人的治疗目标，使这些变量之间的关系可以建模。 一组二人组将接受后续联合电话开放式访谈。 将对成绩单进行内容分析，以制定障碍和促进因素的分类 双方达成协议，他们参与了非加太。