Informing Decisions in Chronic Critical Illness: An RCT

慢性危重疾病的知情决策：随机对照试验

• 批准号: 8636915
• 负责人: Shannon S Carson
• 金额: $ 69.62万
• 依托单位: ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
• 依托单位国家: 美国
• 财政年份: 2010
• 资助国家: 美国
• 起止时间: 2010-04-05 至 2016-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8636915
• 关键词: Acute; Address; Adverse effects; Anxiety; Caring; Chronic; Chronic Phase; Clinical Trials; Communication; Communities; Community Hospitals; Consult; Critical Care; Critical Illness; Decision Making; Dependence; Distress; Effectiveness; Elderly; Emotional; Enrollment; Expenditure; Face; Family; Family Physicians; Functional disorder; Goals; Health; Health Care Costs; Hospitals; Impairment; Institution; Intensive Care; Intervention; Interview; Lead; Length; Length of Stay; Life; Malignant Neoplasms; Mechanical ventilation; Medical; Mental Depression; Modeling; Multi-Institutional Clinical Trial; Organ; Outcome; Palliative Care; Patient Preferences; Patient-Focused Outcomes; Patients; Personal Satisfaction; Physicians; Population; Post-Traumatic Stress Disorders; Printing; Process; Randomized; Randomized Controlled Clinical Trials; Randomized Controlled Trials; Recurrence; Research; Resources; Respiratory Failure; Schedule; Site; Specialist; Structure; Survivors; Syndrome; System; Testing; Time; aging population; base; clinical decision-making; cost; experience; family structure; human old age (65+); improved; meetings; mortality; patient population; primary outcome; programs; public health relevance; treatment as usual

DESCRIPTION (provided by applicant): Increasing use of intensive care therapies by an aging population has created a new medical syndrome - "chronic critical illness" - encompassing multi-system derangements, recurrent complications, and protracted/permanent dependence on mechanical ventilation and other life-supports. Numbering >100,000 at any point in time, the chronically critically ill are a growing population of older adults and a serious national health problem. Annual expenditures for these patients are estimated at $24 billion, mostly for patients e 65 years old. Yet 6-month mortality rates exceed those for most malignancies, impairments are severe among survivors, and return to the community is rare. Descriptive research has identified domains of information that are important for decision-making by patients/families about continuation of treatment in the chronic phase of critical illness, but has also revealed that decisions are often made without this information or patient goals of care as a context. In acute critical illness, scheduled, structured meetings and printed informational aids are effective for ICU families, but no study has tested an intervention to inform and support decision-making about chronic critical illness. This R01 application proposes a randomized, controlled, multi-center clinical trial of such an intervention. Specific Aims are: (1) To evaluate the impact on family- and patient-focused outcomes of a proactive program of protocolized, interdisciplinary, informational support meetings led by a palliative care physician, plus a printed informational aid, for families of chronically critically ill patients; and (2) To evaluate the impact of this intervention on utilization of critical care resources for the chronically critically ill. We hypothesize that as compared to usual care plus the printed aid, this intervention will effectively inform decision-making, improve family well-being, promote discussion of preferences for patient goals of care, and optimize critical care resource utilization, without increasing patient mortality. The research will be conducted in medical ICUs at 5 hospitals (4 academic centers/1 community hospital) over 5 years including 4 years of subject enrollment. Dyads of chronically critically ill patients and their families will be randomized within sites to receive either the intervention (Supportive Information Team [SIT] family meetings led by palliative care physician) plus the printed aid or usual care plus the printed aid. Communication between SIT and ICU physicians will be optimized through a structured and templated process. The ICU physician will also have the option to join intervention family meetings and, for all patients, decision-making will remain the responsibility of this physician with the family. Primary outcomes (collected by family interviews) are Family Anxiety/Depression, Family Post-Traumatic Stress Disorder, and Discussion of Preferences for Patient Goals of Care. We will also evaluate outcomes related to utilization of critical care resources including ICU and hospital lengths of stay.

描述（由申请人提供）：老龄化人口对重症监护治疗的使用越来越多，产生了一种新的医学综合征-“慢性危重病”-包括多系统紊乱、复发性并发症和长期/永久依赖机械通气和其他生命支持。在任何时候，慢性重症患者的数量都超过10万人，老年人的数量越来越多，这是一个严重的国家健康问题。这些患者的年度支出估计为240亿美元，主要用于65岁以上的患者。然而，6个月的死亡率超过了大多数恶性肿瘤的死亡率，幸存者的损伤严重，返回社区的情况很少。描述性研究已经确定了对于患者/家庭在危重病慢性期继续治疗的决策至关重要的信息领域，但也揭示了决策通常是在没有这些信息或患者护理目标的情况下做出的。背景。在急性危重病中，安排好的、结构化的会议和印刷的信息辅助工具对ICU家庭是有效的，但没有研究测试过一种干预措施来告知和支持慢性危重病的决策。本R 01申请提出了一项针对此类干预的随机、对照、多中心临床试验。具体目标是：（1）评估由姑息治疗医生领导的协议化、跨学科、信息支持会议的前瞻性计划对慢性重症患者家属的影响;（2）评估这种干预对慢性重症患者重症护理资源利用的影响。我们假设，与常规护理加印刷援助相比，这种干预措施将有效地为决策提供信息，改善家庭福祉，促进对患者护理目标偏好的讨论，并优化重症监护资源利用，而不会增加患者死亡率。本研究将在5家医院（4个学术中心/1家社区医院）的医学ICU中进行，为期5年，包括4年的受试者入组。将在研究中心内随机分配成对的慢性危重患者及其家属，接受干预（由姑息治疗医生领导的支持性信息团队[SIT]家庭会议）加印刷辅助材料或常规治疗加印刷辅助材料。SIT和ICU医生之间的沟通将通过结构化和模板化的过程进行优化。ICU医生也可以选择参加干预家庭会议，对于所有患者，决策仍然是该医生与家庭的责任。主要结果（通过家庭访谈收集）是家庭焦虑/抑郁，家庭创伤后应激障碍，以及对患者护理目标偏好的讨论。我们还将评估与重症监护资源利用相关的结局，包括ICU和住院时间。

项目成果

Strategies to combat chronic critical illness.

• DOI: 10.1097/mcc.0b013e328364d65e
• 发表时间: 2013-10
• 期刊: Current opinion in critical care
• 影响因子: 3.3
• 作者: Maguire JM;Carson SS
• 通讯作者: Carson SS

Development and validation of a printed information brochure for families of chronically critically ill patients.

• DOI: 10.1097/ccm.0b013e31822d7901
• 发表时间: 2012-01
• 期刊: Critical care medicine
• 影响因子: 8.8
• 作者: Carson SS;Vu M;Danis M;Camhi SL;Scheunemann LP;Cox CE;Hanson LC;Nelson JE
• 通讯作者: Nelson JE

Persistent systemic inflammation in chronic critical illness.

• DOI: 10.4187/respcare.01719
• 发表时间: 2012-06
• 期刊: Respiratory care
• 影响因子: 2.5
• 作者: Cox CE

Risk Factors for Post-Traumatic Stress Disorder Symptoms in Surrogate Decision-Makers of Patients with Chronic Critical Illness.

慢性危重病患者替代决策者出现创伤后应激障碍症状的危险因素。

• DOI: 10.1513/annalsats.201806-420oc
• 发表时间: 2018
• 期刊: Annals of the American Thoracic Society
• 影响因子: 8.3
• 作者: Wendlandt,Blair;Ceppe,Agathe;Choudhury,Summer;Nelson,JudithE;Cox,ChristopherE;Hanson,LauraC;Danis,Marion;Tulsky,JamesA;Carson,ShannonS
• 通讯作者: Carson,ShannonS