Mapping Complex Influences on Aggressiveness of End of Life Cancer Care

晚期癌症患者继续接受积极的治疗（新的化疗，静脉注射）。 化疗，重症监护病房停留），尽管没有证据表明这种护理在生命结束（EOL） 与更好的结果相关。最近的研究表明，化疗的使用增加， 生命的最后30天与不良结局相关，例如临终关怀天数少和EOL护理质量较低。 这些不良结局，加上与此类治疗相关的症状负担增加， 导致患者在EOL时的财务和个人成本。太多晚期癌症患者死于- 医院远离家庭和有意义的支持是质量终末期护理的关键。 对这些患者的决策是困难的-特别是决定是否以及何时过渡 to a goal目标of comfort舒适-orient导向care护理.这个决定需要了解复杂的医疗信息， 与医疗团队沟通的细微差别。为了了解影响 积极的治疗决定在EOL，研究只集中在一个方面的复杂现象， 决策--MD输入或患者决定。然而，这并不能反映“真实的生活”中的决策。 临床设置。如果我们要了解EOL时积极治疗决策的细微差别， 需要一个重大的重新概念化，在如何有效地纳入复杂的过程中， 这些艰难的治疗和护理决定。如果我们要促进提供 为这些脆弱的患者提供必要的姑息治疗和终末期护理。 这项拟议中的研究将是第一次应用复杂性科学的原则来检查这些过程 导致EOL治疗决策（从最大化生存到最大化生活质量）的 患者接受高级护理。研究问题为：（1）临终关怀的积极性如何影响临终关怀的积极性 随着时间的推移，护理重点（肿瘤学家、患者和二人组）？(2)护理重点（肿瘤学家，患者， 受临床触发因素、EOL偏好和治疗有效性评价的影响， 时间？(3)治疗有效性评价如何受到EOL偏好、临床触发因素和 随着时间的推移，护理重点（肿瘤学家，患者）？; (4)治疗评价是否影响EOL偏好 随着时间的推移，？(5)EOL偏好是否受特征（肿瘤学家、患者）影响？ 这种新方法的结果，检查复杂的过程中，EOL决策可以提供 这些信息将允许为晚期乳腺癌患者设计和测试定制的支持策略， 癌除了临床应用，如果能够开发出新的策略， 为这些患者及其护理人员提供支持，然后有可能促进有关EOL的有意义的决策 护理，并可能减少使用无效的积极治疗对个人和经济的影响 不仅对患者有益，对社会也有益。

Patients with advanced cancer continue to receive aggressive care (new chemotherapy, intravenous chemotherapy, intensive care unit stays) despite the absence of evidence that such care at end of life (EOL) is associated with better outcomes. Recent research has shown that the rise in use of chemotherapy within the last 30 days of life is associated with poor outcomes such as few hospice days and lower quality EOL care. These poor outcomes, coupled with the increased symptom burden associated with such treatments often leads to financial and personal costs for patients at the EOL. Too many patients with advanced cancer die in- hospital away from family and meaningful supports that are essential for quality EOL care. Decision making for these patients is difficult-especially the decision whether or not and when to transition to a goal of comfort-orient care. This decision requires understanding of complex medical information and nuances in communication with the healthcare team. In an effort to understand factors that influence aggressive treatment decisions at EOL, research has focused on only one side of the complex phenomena of decision making--either MD input or patient decision. Yet this is not reflective of "real life" decision making in the clinical setting. If we are to understand the nuances involved in aggressive treatment decisions at EOL, we need a major re-conceptualization in how to effectively incorporate the complex processes involved in making these difficult treatment and care decisions. This must be accomplished if we are to facilitate provision of essential palliative and EOL care to these vulnerable patients. The proposed study will be the first to apply the principles of complexity science in examining the processes that lead to EOL treatment decisions (ranging from maximizing survival to maximizing quality of life) for patients with advanced care. The research questions are: (1) How is aggressiveness of EOL care influenced by the focus of care (oncologist, patient, and dyad) over time?; (2) How is focus of care (oncologist, patient, and dyad) influenced by clinical triggers, EOL preferences, and evaluation of treatment effectiveness over time?; (3) How is evaluation of treatment effectiveness influenced by EOL preferences, clinical triggers, and focus of care (oncologist, patient) over time?; (4) Are EOL preferences influenced by evaluation of treatment effectiveness over time?; (5) Are EOL preferences influenced by characteristics (oncologist, patient)? The results of this novel approach to examining complex processes in EOL decision making can provide information that will allow the design and testing of tailored support strategies for patients with advanced cancer. In addition to clinical application, if new strategies can be developed that can provide meaningful support to these patients and their caregivers, then the potential to facilitate meaningful decisions about EOL care and to potentially reduce the personal and financial impact of the use of ineffective aggressive treatments will benefit not only patients but society as well.