ICU Triage Decisions for Elders with End Stage Cancer: the Role of Patient Race

描述（由申请人提供）：五分之一的美国人死于重症监护（ICU）服务，尽管主流文化倾向于在家中死亡。黑人，特别是那些患有癌症的黑人，比白人更有可能死在ICU里，尽管大多数黑人老年人倾向于反对积极的临终治疗。对于晚期癌症患者，寻求或推迟ICU入院是一个关键的单事件决定。虽然有一些证据表明，黑人可能比白人更喜欢积极的生命维持治疗，但围绕临终ICU使用的沟通中基于种族的差异也可能导致现有的差异。以往的研究表明，医生对常见疾病的决策在诊断和治疗中存在基于种族的差异，从公开的偏见，刻板印象和歧视到不确定性背景下条件概率规则的应用。拟议研究的目标是加强对影响临终ICU使用的决策过程以及导致临终ICU使用中现有种族差异的因素的理解。我们的三个具体目标是：1）使用高保真模拟测试患者种族对医生决定的影响，以推荐终末期癌症患者进入ICU。2)使用模拟相遇的定性内容分析来测试患者-提供者沟通是否以及如何介导患者种族对医生ICU入院决策的影响。3)探讨ICU入院决策中种族差异的原因。更好地了解医生的决策过程以及他们如何导致患者偏好和临终治疗之间的不匹配，可以用来设计干预措施，以改善医生的行为。公共卫生相关性：拟议项目与公共卫生的相关性来自于更好地了解医生如何在生命结束时对重症监护使用的种族差异做出贡献。如果能够记录黑人与白色模拟患者的治疗决策差异，并生成解释这些观察到的差异的假设，则拟议的项目将是成功的。未来的工作可能包括测试这些假设，并为医生开发教育模块，旨在提高他们为终末期癌症重症患者做出以患者为中心的决定的能力。

DESCRIPTION (provided by applicant): One in five Americans die using intensive care (ICU) services despite a dominant cultural preference for dying at home. Blacks, especially those with cancer, are more likely to die in an ICU than whites, despite the fact that the majority of black elders have a preference against aggressive end-of-life treatment. For patients with end-stage cancer, seeking or deferring ICU admission is a critical single-event decision. While there is some evidence that blacks may be more likely to prefer aggressive life-sustaining treatment than whites, race-based differences in communication around end-of-life ICU use likely also contribute to existing disparities. Previous studies of physician decision making for common medical conditions have demonstrated race-based differences in diagnosis and treatment, ranging from overt prejudice, stereotyping and discrimination to the application of rules of conditional probability in the context of uncertainty. The goal of the proposed study is to enhance understanding of decision-making processes that impact end-of-life ICU use and factors which contribute to existing racial disparities in end-of-life ICU use. Our three specific aims are: 1) To test the effect of patient race on physician decisions to recommend ICU admission for a patient with end-stage cancer using high-fidelity simulation. 2) To test whether and how patient-provider communication mediates the effect of patient race on physician ICU admission decisions using qualitative content analysis of simulation encounters. 3) To explore the causes of race-based differences in ICU admission decision-making. A better understanding of physicians' decision-making processes and how they may contribute to a mismatch between patient preferences and end-of-life treatment could be used to design interventions to improve physician behavior. Public Health Relevance: The relevance of the proposed project to public health derives from a better understanding of how physicians contribute to racial variations in intensive care use at the end of life. The proposed project will be a success if can document differences in treatment decisions for black versus white simulated patients and generate hypotheses explaining these observed differences. Future work might include testing these hypotheses and developing educational modules for physicians aimed at improving their ability to make patient-centered decisions for critically ill patients with end-stage cancer.