Improving Advance Care Planning in Oncology: A Pragmatic, Cluster-Randomized Trial Integrating Patient Videos and Clinician Communication Training

项目总结/摘要 每年有太多患有晚期癌症的美国老年人在最后接受积极的干预措施时死亡 不反映他们的价值观，目标和偏好的生活。提前护理计划（ACP）是最重要的 与更好的临终沟通和目标一致的护理相关的一致的可修改因素。 然而，临床医生通常不具备高质量ACP对话所需的沟通技巧 并且患者通常无法想象他们对医疗护理的选择以做出明智的决定。解决 这一差距，我们已经制定了一个全面的ACP计划，结合两个久经考验的证据- 基础和补充干预：临床医生沟通技能培训和患者视频决策 艾滋病这种包容性的ACP方法将患者和临床医生视为平等的利益相关者， 在最艰难的选择出现之前做出最佳明智决策所需的沟通技能和工具。 我们已在数个小型机场， 老年癌症患者的随机对照试验。本建议的总体目标是开展一项 在三个大型医疗保健系统中进行的实用性阶梯楔形簇随机试验（SW-CRT）：杜克健康， 马约诊所和诺斯韦尔健康中心。在UG 3的第一年，我们将建立组织，流程， 和必要的基础设施，以发展一个务实的SW-CRT的干预措施的各个方面，为4500 65岁以上的晚期癌症患者，并在每个系统的一个肿瘤诊所对研究方案进行初步测试 (Aim 1）。在UH 3阶段的四年中，我们将在三个国家的36个肿瘤诊所进行SW-CRT。 系统，并通过比较以下结果来评估干预的有效性：1.提前 护理计划完成; 2.复苏偏好的医疗命令; 3.姑息治疗咨询;和4。 临终关怀使用（目标2）。我们将在每个卫生系统使用已建立的电子健康记录系统， 结果。我们假设干预阶段（与对照组相比）有更高比例的患者将： 完整的预先护理计划（主要试验结局），有记录的电子医嘱， 复苏偏好，在姑息治疗咨询中看到，并在临终关怀中注册。我们还将 描述450例患者亚组中详细的以患者为中心的结局，包括 个人偏好（目标3）。临床医生沟通培训沿着视频决策支持是 实用、循证和创新的方法，以统一提供强大的ACP。这项工作有 有可能提高为数百万患有癌症的美国老年人提供的护理质量。

Project Summary/Abstract Too many older Americans with advanced cancer die every year receiving aggressive interventions at the end of life that do not reflect their values, goals, and preferences. Advance Care Planning (ACP) is the most consistent modifiable factor associated with better end-of-life communication and goal-concordant care. However, clinicians often do not possess the communication skills needed for high-quality ACP conversations and patients are often unable to imagine their options for medical care to make informed decisions. To address this gap, we have developed a Comprehensive ACP Program that combines two well-tested, evidence- based, and complementary interventions: clinician communication skills training and patient video decision aids. This inclusive ACP approach treats patients and clinicians as equal stakeholders providing both with the communication skills and tools needed to optimally make informed decisions before the toughest choices arise. We have shown the efficacy of the elements of the Comprehensive ACP intervention in several small randomized controlled trials for older patients with cancer. The overall objective of this proposal is to conduct a pragmatic stepped wedge cluster randomized trial (SW-CRT) in three large health care systems: Duke Health, the Mayo Clinic, and Northwell Health. During the first UG3 year, we will establish the organization, processes, and infrastructure necessary to develop all aspects of a pragmatic SW-CRT of the intervention for 4,500 patients over 65 with advanced cancer and pilot test the study protocol in one oncology clinic in each system (Aim 1). During the four years of the UH3 stage, we will conduct a SW-CRT in 36 oncology clinics in the three systems and evaluate the effectiveness of the intervention by comparing the following outcomes: 1. Advance care plans completion; 2. Medical orders for resuscitation preferences; 3. Palliative care consultations; and 4. Hospice use (Aim 2). We will use established electronic health record systems at each health system to obtain outcomes. We hypothesize that a higher proportion of patients in the intervention phase (vs. control) will: complete advance care plans (primary trial outcome), have documented electronic medical orders for resuscitation preferences, be seen in palliative care consultations, and enroll in hospice. We will also characterize detailed patient-centered outcomes in a subgroup of 450 patients, including video declarations of individual preferences (Aim 3). Clinician communication training along with video decision support is a practical, evidence-based, and innovative approach to uniformly provide robust ACP. This work has the potential to improve the quality of care provided to millions of older Americans with cancer.