A Randomized Clinical Trial of Scenario Planning for Older Adults with Serious Injury

摘要 对于老年人来说，对严重伤害和限制生命的疾病缺乏沟通会产生以下后果 患者和家属、临床医生和医疗保健系统。每年折磨着500,000名老年人，治疗 创伤性损伤经常涉及繁重的干预措施(如延长生命支持)，主要变化 功能或认知状态，以及高死亡率。外科医生使用死亡率统计数据来交流关于 疾病的严重性，但目前的沟通标准往往导致目标不协调的关怀，精神上的痛苦 临床医生，以及延长死亡过程。鉴于较高的治疗负担和贫困人口的频率 预后，严重受伤的老年人将受益于沟通干预，以澄清患者的 目标，缓解ICU中的冲突，减少对临终病人不必要的侵入性程序。 老年严重创伤患者情景规划的随机临床试验 专门响应NOSI-AG-20-041的R01临床试验，用于评估决策支持工具和 为重病老年患者及其代理决策者提供沟通辅助工具，以实现目标- 和谐的关怀。我们开发了一种名为Best Case/Worst Case-ICU的新型通信工具，它使用 情景规划-对可能的未来的叙述性描述-以及说明以下信息的图形辅助 患者的护理轨迹和总体预后在创伤ICU的日常使用。我们对此进行了初步测试 干预后发现，外科医生可以使用这一工具来支持家庭，它可能会提高质量 沟通，减少临床医生的精神痛苦。我们现在已经准备好大规模测试干预措施 有效性研究。我们提出了一项实用的多点随机临床试验，跟踪调查了4500名患有 创伤性损伤。我们的目的是测试最好情况/最坏情况-ICU干预措施的有效性 沟通(目标1)、临床医生精神困扰(目标2)和在ICU的住院时间(目标3)。 这一奖项将使我们能够测试一种易于扩展和快速传播的干预措施 适用于患有严重疾病的老年人。这项研究具有创新性，因为它测试了情景规划-a 已成功应用于商业和政府的决策策略--但并不广泛 用于医疗保健。这项研究意义重大，因为如果我们证明了有效性，它就有可能 改变外科医生和其他ICU临床医生与患者和家人谈论治疗和预后的方式 并极大地改善老年人在创伤ICU接受的护理。我们的多学科团队有很长的 合作的历史，并处于有利地位，以实现我们的目标。增强了本研究的可行性。 由国家创伤研究联盟提供支持，该联盟由主要的创伤专业人员组成 在美国的组织和使用美国外科医生学院的创伤质量改进 程序作为数据采集平台。

ABSTRACT For older adults, poor communication about serious injury and life-limiting illness has consequences for patients and families, clinicians, and healthcare systems. Afflicting 500,000 older adults annually, treatment for traumatic injury frequently involves burdensome interventions (like prolonged life support), major changes in functional or cognitive status, and high mortality. Surgeons use mortality statistics to communicate about the gravity of illness, but current communication standards often lead to goal discordant care, moral distress for clinicians, and prolongation of the dying process. Given high treatment burdens and frequency of poor prognosis, seriously injured older adults would benefit from communication interventions that clarify patients' goals, alleviate conflict in the ICU, and reduce unwanted invasive procedures for dying patients. A Randomized Clinical Trial of Scenario Planning for Older Adults with Serious Injury is a 5-year R01 Clinical Trial that responds specifically to NOSI-AG-20-041 for evaluation of decision support tools and communication aids for seriously ill older patients and their surrogate decision-makers to achieve goal- concordant care. We have developed a novel communication tool called Best Case/Worst Case-ICU that uses scenario planning—narrative description of plausible futures—and a graphic aid to illustrate information about the patient's care trajectory and overall prognosis for daily use in the trauma ICU. We pilot tested this intervention and found that surgeons can use this tool to support families and it may improve quality of communication and reduce clinician moral distress. We are now ready to test the intervention in a large-scale effectiveness study. We propose a pragmatic multisite randomized clinical trial following 4,500 older adults with traumatic injury. We aim to test the effectiveness of the Best Case/Worst Case-ICU intervention on quality of communication (Aim 1), clinician moral distress (Aim 2), and length of stay in the ICU (Aim 3). This award will allow us to test an intervention that is easily scalable and can be disseminated rapidly for use with older adults with serious illness. The research is innovative because it tests scenario planning —a decision-making strategy that has been successfully applied in business and government—but is not widely used in healthcare. The research is significant because, if we demonstrate effectiveness, it has the potential to transform how surgeons and other ICU clinicians talk with patients and families about treatment and prognosis and dramatically improve care older adults receive in the trauma ICU. Our multidisciplinary team has a long history of collaboration and is well positioned to achieve our objectives. The feasibility of this study is enhanced by support from the Coalition for National Trauma Research, which comprises the major trauma professional organizations in the United States and uses the American College of Surgeons' Trauma Quality Improvement Program as a data collection platform.