Meeting the Challenges of COVID-19 by Expanding the Reach of Palliative Care: Proactive Advance Care Planning with Videos for the Elderly and all Patients with Dementia

大部分65岁或以上的病人，以及阿尔茨海默氏症及相关痴呆症患者， （ADRD），从未将其偏好传达给临床医生或完成预先护理计划（ACP） 证件姑息治疗有可能改善ADRD护理，改善患者与临床医生的沟通 和以患者为中心的结果，同时减少不必要的繁重治疗和改善护理， 生命的终结2019年新型冠状病毒病（COVID-19）急剧升级了 将ACP和姑息治疗服务纳入医疗护理。对危重病的默认反应， ADRD患者（和所有其他患者）的治疗方法是插管、机械通气和积极护理， 死亡率结局无变化。ADRD患者及其护理人员可能更愿意避免这些干预措施。 为了解决这些差距，我们开发了一种COVID-19 ACP教育者主导的视频辅助姑息疗法， 护理干预，以改善患者-临床医生沟通，增加ACP记录，并导致 以病人为中心的临终关怀我们将确定所有65岁及以上的住院患者， 以及任何ADRD患者，然后ACP教育者将积极进行初级姑息治疗 ACP的服务，利用我们开发的认证视频决策辅助工具。ACP教育家将成为 本提案中的测试代表了姑息治疗团队的新角色和积极主动的功能。非加太 教育者，谁将是一个姑息治疗护士，将与老年患者或患者与ADRD和代理 决策者了解并记录患者的意愿。 总体目标是通过扩大住院姑息治疗的覆盖范围来减轻COVID-19的负担 特别是对ADRD患者。我们建议进行一项阶梯式楔形分组随机试验， 在65岁及以上住院患者或任何ADRD患者中进行ACP教育者干预， 他们的代理决策者在病房和ICU设置的两个主要医院：波士顿医疗中心和 北岸大学医院。将从电子健康记录中提取患者结局， 自然语言处理。我们将通过比较以下内容来评估干预的有效性 9，000名住院患者的结局：ACP记录;复苏偏好;姑息治疗 咨询;和，临终关怀使用。我们将描述ADRD患者的以患者为中心的结局， 包括：（1）知识，（2）对未来护理的信心，（3）沟通满意度，（4）决策 在600名ADRD患者的照顾者中确定住院。COVID-19造成了一个独特的困境 对于美国老年人和ADRD患者及其护理人员来说，他们必须平衡他们的生活愿望， 在医院里孤独地死去的风险视频决策支持是一个实用的，证据- 基于，创新的方法，以帮助患者面临这样的选择。如果证明有效，这种创新的护理 该模型可以立即部署在全国各地，以提高数百万美国人的护理质量。

The majority of patients aged 65 or over, and patients with Alzheimer's Disease and Related Dementias (ADRD), have never communicated their preferences to clinicians or completed advance care planning (ACP) documents. Palliative care has the potential to improve ADRD care, improve patient-clinician communication and patient-centered outcomes, while decreasing unwanted burdensome treatments and improving care at the end of life. The novel Coronavirus Disease 2019 (COVID-19) has acutely escalated the importance of integrating ACP and palliative care services into medical care. The default response to critical illness for patients with ADRD (and all others) is intubation, mechanical ventilation, and aggressive care despite having no change in mortality outcome. ADRD patients and their caregivers may prefer to avoid these interventions. To address these gaps, we have developed a COVID-19 ACP Educator-led, video-assisted palliative care intervention to improve patient-clinician communication, increase ACP documentation, and lead to more patient-centered care at the end of life. We will identify all hospitalized patients aged 65 and older, and any patient with ADRD, and then an ACP Educator will proactively proceed with primary palliative care services of ACP, leveraging certified video decision aids that we have developed. The ACP Educator to be tested in this proposal represents a new role and proactive function for the palliative care team. The ACP Educator, who will be a palliative care nurse, will work with older patients or patients with ADRD and proxy decision-makers to learn about and document patients' wishes. The overall objective is to reduce the burden of COVID-19 by expanding the reach of inpatient palliative care, especially for patients with ADRD. We propose to conduct a stepped wedge cluster randomized trial of an ACP Educator intervention among hospitalized patients aged 65 and over, or any patient with ADRD and their proxy decision-makers in the ward and ICU settings of two major hospitals: Boston Medical Center and North Shore University Hospital. Patient outcomes will be abstracted from electronic health records with Natural Language Processing. We will evaluate intervention effectiveness by comparing the following outcomes among 9,000 hospitalized patients: ACP documentation; preferences for resuscitation; palliative care consults; and, hospice use. We will characterize caregiver-centered outcomes of patients with ADRD, including: (1) knowledge, (2) confidence in future care, (3) communication satisfaction, and (4) decisional certainty in 600 caregivers of patients with ADRD admitted to the hospital. COVID-19 poses a unique dilemma for older Americans and patients with ADRD and their caregivers, who must balance their desire to live against the risk of a lonely and potentially traumatic hospital death. Video decision support is a practical, evidence- based, and innovative approach to assist patients facing such choices. If proven effective, this innovative care model can be immediately deployed across the country to improve the quality of care for millions of Americans.