Advance care planning in Veterans with kidney disease

患有肾脏疾病的退伍军人的预先护理计划

• 批准号: 8486692
• 负责人: ANN M. O'HARE
• 金额: --
• 依托单位: VA PUGET SOUND HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2014
• 资助国家: 美国
• 起止时间: 2014-04-01 至 2018-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8486692
• 关键词: Advance Care Planning; Advance Directives; Cardiopulmonary Resuscitation; Caring; Chronic; Chronic Disease; Clinical; Comorbidity; Data; Databases; Dialysis patients; Dialysis procedure; Disease; Disease Management; Effectiveness of Interventions; Elderly; Event; Family; Family member; Foundations; Frequencies; Goals; Health Care Costs; Healthcare Systems; Home environment; Hospitals; Intensive Care Units; Intervention; Interview; Intubation; Kidney Diseases; Life; Life Expectancy; Medical center; Modeling; Nature; Outcome; Patient Care; Patient Preferences; Patients; Pattern; Physicians; Population; Procedures; Process; Provider; Readiness; Staging; System; Testing; Time; Veterans; Work; abstracting; aged; base; cost; end of life; experience; health care service utilization; hospice environment; meetings; older patient; patient oriented; pilot trial; preference; randomized trial; sound; tube feeding

DESCRIPTION (provided by applicant): A growing number of older Veterans are initiating chronic dialysis. These patients have a high burden of co-morbidity and very limited life expectancy after dialysis initiation. As they approac the end of their lives, many will follow a pattern of escalating healthcare utilization and costs. During the final month of life, elderly US dialysis patients spend an average of almost 10 days in the hospital, almost half are admitted to the intensive care unit and almost one third undergo an intensive procedure intended to prolong life such as intubation, feeding tube placement or cardiopulmonary resuscitation. These highly intensive patterns of end-of-life care seem to be driven much more by physician practices than by patient preferences: available data suggest that most patients with advanced kidney disease do not wish to receive interventions that prolong the dying process and would prefer to die at home or in a hospice rather than in the hospital. Thus contemporary patterns of end-of-life care among older dialysis patients may be out of step with patient preferences and values. Advance care planning (ACP) is the process whereby patients engage in discussions with their families and providers about their treatment preferences in the event of a serious life-threatening illness. Most prior studies of ACP in patients with kidney disease have focused on advance directives (which are only one aspect the ACP process), have been conducted at the level of the dialysis facility (and thus have included only dialysis patients), and have been cross-sectional in nature (and thus have not provided information on outcomes). A facilitated disease-specific approach to ACP has been proposed for patients with chronic illness, and has been shown to promote end-of-life care that is more congruent with patient preferences in select populations, including patients receiving chronic dialysis. To our knowledge facilitated patient-centered advance care planning has not been applied to patients with earlier stages of kidney disease who are approaching the need for chronic dialysis. In these patients, there might be an important opportunity for synergy between advance care planning and chronic disease management: framing decisions related to dialysis initiation within a broader context of ACP while grounding abstract discussions about ACP in real-world treatment decisions that arise in the course of advanced kidney disease. A facilitated disease-specific approach to ACP among elderly Veterans with advanced kidney disease could be effective in aligning end-of-life care practices with patient goals and preferences. The goal o this proposal will be to collect quantitative and qualitative data that will be used to tailor a facilitated patient-centered model of ACP to older Veterans with advanced kidney disease. We propose three study aims: 1) to develop a comprehensive national database of Veterans aged 70 years and older with advanced kidney disease that will provide information on clinical outcomes and contemporary ACP practices in this population. This quantitative aim will provide information on contemporary ACP practices among older Veterans with advanced kidney disease within the VA system and their relationship with downstream patterns of end-of-life care; 2) to conduct a qualitative study among Veterans aged 70 years and older with advanced kidney disease, their family members and providers at 4 different VA medical centers to elicit their perspectives about the optimal approach toward ACP in this population; 3) based on the results of these formative study aims, we will adapt a patient-centered model of facilitated ACP to older veterans with advanced kidney disease. We will conduct a pilot trial at the VA Puget Sound Healthcare System to evaluate the impact of the intervention on readiness to engage in ACP. Pilot data will be used to support the feasibility of a larger randomized trial in Veterans with advanced kidney disease to determine whether the intervention leads to greater alignment between patient preferences and care received at the end of life.

描述（由申请人提供）： 越来越多的老年退伍军人开始进行慢性透析。 这些患者的合并症负担很高，透析开始后的预期寿命非常有限。 当他们接近生命的尽头时，许多人将遵循医疗保健利用率和成本不断上升的模式。 在生命的最后一个月，美国老年透析患者平均在医院度过近10天，近一半的人被送进重症监护室，近三分之一的人接受旨在延长生命的强化手术，如插管，喂食管放置或心肺复苏术。 这些高度密集的临终关怀模式似乎更多地受到医生实践的推动，而不是患者的偏好：现有数据表明，大多数晚期肾病患者不希望接受延长死亡过程的干预措施，宁愿在家中或临终关怀院而不是在医院死亡。 因此，当代老年透析患者的临终关怀模式可能与患者的偏好和价值观不一致。 预先护理计划（ACP）是一个过程，患者在发生严重危及生命的疾病时，与家人和医疗服务提供者讨论他们的治疗偏好。 大多数既往在肾脏疾病患者中进行的ACP研究都集中在预先指导（这只是ACP过程的一个方面），在透析机构水平进行（因此仅包括透析患者），并且本质上是横断面的（因此未提供结局信息）。 针对慢性病患者提出了一种针对特定疾病的ACP方法，并已证明该方法可促进与选定人群（包括接受慢性透析的患者）中患者偏好更一致的临终护理。 据我们所知，以患者为中心的提前护理计划尚未应用于接近慢性透析需求的早期肾病患者。 在这些患者中，可能有一个重要的机会，提前护理计划和慢性疾病管理之间的协同作用：框架内的ACP更广泛的背景下透析启动相关的决定，同时接地抽象的讨论在现实世界中出现的治疗决定，在晚期肾脏疾病的过程中。 在患有晚期肾病的老年退伍军人中，促进针对特定疾病的ACP方法可以有效地将临终关怀实践与患者的目标和偏好相结合。 本提案的目标是收集定量和定性数据，用于为患有晚期肾脏疾病的老年退伍军人量身定制以患者为中心的ACP模型。 我们提出三个研究目标：1）建立一个全面的70岁及以上晚期肾病退伍军人国家数据库，提供该人群的临床结局和当代ACP实践信息。 这一定量目标将提供关于VA系统内患有晚期肾病的老年退伍军人的当代ACP实践及其与下游临终护理模式的关系的信息; 2）在70岁及以上患有晚期肾病的退伍军人中进行定性研究，他们的家庭成员和提供者在4个不同的VA医疗中心，以了解他们对ACP在这一人群中的最佳方法的看法; 3）基于这些形成性研究目标的结果，我们将采用以患者为中心的促进ACP模型，以适应患有晚期肾脏疾病的老年退伍军人。 我们将在VA普吉特湾医疗保健系统进行试点试验，以评估干预对参与ACP的准备程度的影响。 试点数据将用于支持在患有晚期肾病的退伍军人中进行更大规模随机试验的可行性，以确定干预是否会导致患者偏好与生命结束时接受的护理之间的更大一致性。