Improving Decision-Making about Feeding Options for Dementia Patients

描述（由申请人提供）：当晚期痴呆患者出现进食问题时，其护理人员必须考虑辅助口服喂养或管饲的治疗选择。管饲不会改善生存率、功能或误吸风险。管饲的使用持续增加，尤其是对于老年患者或非裔美国人。对于效益不确定的重大临床决策，建议采用共享决策沟通模式。目前的临床讨论很少符合这一标准。在一项对246项管饲决策的前瞻性研究中，我们发现代理决策者对临床益处有着持续的高期望，并且需要更多的信息和改进的共同决策。我们现在提出了一个集群随机对照试验，以前试点的决策援助，以改善决策的喂养选择晚期痴呆症患者。按研究中心随机分组后，我们将从北卡罗来纳州的12家疗养院招募n=250例晚期痴呆和喂养问题患者，沿着还有他们的代理决策者。我们预计25%的非裔美国人入学。干预地点的代理决策者将审查决策辅助工具，并鼓励他们与医生讨论决策，而对照疗养院的代理决策者则接受常规护理。目标1.测试有关痴呆症喂养选择的决策辅助工具是否有效地为干预组中的代理决策者提供信息，定义为提高对治疗选择的了解、降低对管饲益处的期望以及减少决策冲突。目标二。测试决策辅助工具是否改善了干预组中替代决策者与对照组相比的1个月和3个月决策结果，定义为增加沟通频率，增加决策满意度和减少决策遗憾。目标3。测试决策辅助工具对1个月和3个月临床治疗决策的影响。拟议的研究将增加对共同决策的科学理解和决策辅助工具的有效性，作为提高决策质量和后续临床治疗决策的方法。如果成功，这种干预将展示一种方法，可更广泛地应用于痴呆症护理的决策。

DESCRIPTION (provided by applicant): When patients with advanced dementia develop feeding problems their caregivers must consider treatment options of assisted oral feeding or tube feeding. Tube feeding does not result in improved survival, function or aspiration risk. Use of tube feeding continues to increase, especially for patients who are older or are African-American. Shared decision-making is the recommended model of communication for serious clinical decisions with uncertain benefit. Current clinical discussions rarely meet this standard. In a prospective study of 246 decisions to tube feed, we found surrogate decision-makers had persistently high expectations of clinical benefit, and had needs for more information and improved shared decision-making. We now propose a cluster randomized controlled trial of a previously piloted decision aid to improve decisions about feeding options for patients with advanced dementia. After randomization by site, we will enroll n=250 patients with advanced dementia and feeding problems from 12 nursing homes in North Carolina, along with their surrogate decision-makers. We project 25% African-American enrollment. Surrogate decision-makers in the intervention sites will review the decision aid and be encouraged to discuss the decision with the physician, while those in the control nursing homes receive usual care. Aim 1. To test whether a decision aid on feeding options in dementia effectively informs surrogate decision- makers in the intervention group, defined as improved knowledge of treatment options, reduced expectation of benefit from tube feeding and reduced decisional conflict. Aim 2. To test whether the decision aid improves 1 and 3 month decision-making outcomes for surrogate decision-makers in the intervention group compared to controls, defined as increased frequency of communication, increased decisional satisfaction, and decreased decisional regret. Aim 3. To test the impact of the decision aid on 1 and 3 month clinical treatment decisions. The proposed study will add to scientific understanding of shared decision-making and the effectiveness of decision aids as a method for improving the quality of decision-making and subsequent clinical treatment decisions. If successful, this intervention will demonstrate a methodology with broader application to decision-making in dementia care.