A Trial of Expanded Choice Sets in Advance Directives for Hemodialysis Patients

 描述(申请人提供)：终末期肾病维持性血液透析(ESRD-HD)患者想要的护理与他们在生命末期得到的护理之间存在很大差距。不幸的是，血液透析患者在生命即将结束时经历了频繁的住院和积极的医疗护理，尽管如果他们病情严重，他们更倾向于以舒适为重点的护理。这在一定程度上是由于历史上不令人满意的提前护理计划，包括这一人群中提前指示完成率较低。对于ESRD-HD患者来说，及时参与提前护理计划尤其重要，他们的中位五年生存期比许多癌症患者短，而且在生命的最后一个月功能明显迅速下降。提前指令为患者提供了一个机会来表达特定的临终偏好，以避免不必要的护理。尽管提前指令在提高临终护理质量方面可能很有希望，但完成率仍然很低，以前鼓励完成这些指令的努力收效甚微。此外，在确实完成了预先指令的患者中，四分之一的患者没有在其中为替代决策者提供足够的指导，以提供与他们的目标和价值观一致的护理。行为经济学的原理，如决策框架效应，可能提供一种新的方法来解决先前指令实施中的缺陷，并弥合临终关怀方面的差距。例如，在可预见的未来，以危重疾病或死亡的可识别危险因素为目标的患者增加了患者所陈述的偏好在需要提前指令时仍然适用的可能性。这项研究的目标是测试改变关于提前指令完成的决策的背景是否可以增加血液透析患者完成提前指令的概率，并在提前指令中指定可操作的选择。首先，我们的目标是确定通过提供不同版本的提前指令来扩大完成指令的选择是否会增加完成指令的患者的比例。其次，我们的目标是确定在预先指令内扩大接受或不接受生命支持治疗的选择范围是否会减少没有具体说明任何偏好的患者的比例。该项目将为计划中的NIH K23职业发展奖提供必要的初步数据，该奖项将(1)更明确地检查这一决定和其他决策推动如何影响ESRD-HD患者的决策，(2)比较患者报告的纵向生活质量、功能状况和在生命末期完成或不完成提前指导的ESRD-HD患者的医疗利用模式，以及(3)比较其他行为经济干预措施，以提高更多接受维持性血液透析治疗的患者提前指导的完成率。

 DESCRIPTION (provided by applicant): There is a large gap between the care patients with end-stage renal disease on maintenance hemodialysis (ESRD-HD) want and the care they receive near the end-of-life. Unfortunately, hemodialysis patients experience frequent hospitalizations and aggressive medical care near the end of life despite a preference for comfort-focused care if they are seriously ill. This, in part, is explained by historically unsatisfactory advance care planning including low rates of advance directive completion in this population. Timely engagement in advance care planning is particularly important for ESRD-HD patients who have a median five-year survival shorter than many patients with cancer and have a distinctly rapid functional decline in the final month of life. Advance directives offer an opportunity for patients to express specific end-of-life preferences to avoid unwanted care. As promising as advance directives may be for improving the quality of care near the end of life, rates of completion remain low and previous efforts to encourage their completion have had limited success. Moreover, among patients who do complete an advance directive, one in four do not provide sufficient guidance in it for surrogate decision makers to provide care consistent with their goals and values. Principles of behavioral economics, such as decision framing effects, may offer a novel approach to address previous shortcomings in advance directive implementation and bridge the gap in end-of-life care. For example, targeting patients with identifiable risk factors for critical illness or death in the foreseeable future increases the probability that patients' stated preferences will still apply when the advance directive is needed The goal of this study is to test whether changing the context of decisions regarding advance directive completion can increase the probability that hemodialysis patients will complete, and specify actionable choices within, advance directives. First, we aim to determine if expanding the choices for completing an advance directive by offering different versions of them will increase the proportion of patients who complete one. Second, we aim to determine if expanding the range of choices for receipt or not of life-supportive therapies within an advance directive will decrease the proportion of patients who do not specify any preference. This project will provide essential preliminary data for a planned NIH K23 Career Development Award that would (1) examine more definitively how this and other decision nudges influence ESRD-HD patients' decisions, (2) compare longitudinal patient-reported quality of life, functional status, and healthcare utilization patterns near the end of life among ESRD-HD patients who do or do not complete advance directives, and (3) compare other behavioral economic interventions for improving advance directive completion among a larger population of patients receiving maintenance hemodialysis therapy.