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

大多数65岁或以上的患者以及阿尔茨海默病和相关痴呆症患者 (ADRD)，从未将他们的偏好传达给临床医生或完成先期护理计划(ACP) 文件。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，同时减少不必要的负担治疗和改善护理 生命的终结。新的冠状病毒疾病2019(新冠肺炎)急剧升级了 将非典和姑息治疗服务整合到医疗服务中。对危重疾病的默认响应 ADRD患者(和所有其他患者)正在接受插管、机械通气和积极的护理，尽管有 死亡率结果没有变化。ADRD患者和他们的照顾者可能倾向于避免这些干预。 为了解决这些差距，我们开发了一种由新冠肺炎非典教育者主导、视频辅助的姑息疗法 护理干预，以改善患者与临床医生的沟通，增加ACP文档，并引导 更多以病人为中心的临终关怀。我们将确定所有65岁及以上住院患者的身份， 任何患有ADRD的患者，然后ACP教育者将主动进行初级姑息治疗 ACP的服务，利用我们开发的认证视频决策辅助工具。未来的机场核心计划教育者 在这项提案中经过测试，代表了姑息治疗团队的新角色和积极主动的功能。机场核心计划 教育者将成为一名姑息护理护士，他将与老年患者或患有ADRD和Proxy的患者一起工作 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新冠肺炎的负担 护理，特别是对ADRD患者。我们建议进行阶梯式楔形整群随机试验 对65岁及以上住院患者或任何ADRD患者进行ACP教育者干预 他们在两家主要医院的病房和ICU环境中的代理决策者：波士顿医疗中心和 北岸大学医院。患者的结果将从电子健康记录中提取出来， 自然语言处理。我们将通过比较以下各项来评估干预效果 9000名住院患者的结果：ACP文件；对复苏的偏好；姑息治疗 会诊；以及临终关怀使用。我们将描述ADRD患者以照顾者为中心的结果， 包括：(1)知识，(2)对未来护理的信心，(3)沟通满意度，(4)决策 在住院的600名ADRD患者的照顾者中确定了这一点。新冠肺炎带来了独特的两难境地 对于年长的美国人和ADRD患者及其照顾者来说，他们必须平衡他们生活的愿望和 孤独和潜在创伤的医院死亡的风险。视频决策支持是一个实际的证据- 以创新的方法来帮助面临这种选择的患者。如果被证明有效，这种创新的护理 该模式可以立即在全国范围内部署，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.