Improving patient outcomes in end-of-life care provided by physicians and nurses

描述（由申请人提供）：美国三十年的临终关怀研究表明，患者死亡时常常承受着巨大的疼痛和其他症状，并且经常接受他们不愿选择的护理。患者与临床医生关于临终关怀的沟通是提高以患者为中心的临终关怀质量的一个重要焦点。研究表明，临床医生可以通过体验式培训来提高他们的沟通技巧，但没有研究表明，提高临床医生临终关怀沟通技巧的干预措施可以改善患者的治疗结果。此外，尽管人们知道临终关怀最好在跨学科背景下提供，但大多数研究并未纳入跨学科培训。我们建议通过国家癌症研究所资助的 R25 奖项为肿瘤学研究员开发和实施最先进的干预措施，该奖项旨在提高临床医生沟通临终关怀的技能。我们将调整干预措施以用于内科和护士执业培训项目（一个在西北地区，一个在东南地区），并纳入创新的跨学科培训内容。我们将使用问卷来评估对患者层面结果的干预措施，以评估在之前的 RO1 中开发和验证的临终关怀的质量。该评估将针对癌症患者、患有慢性心脏病、肺病或肝病的患者以及老年人。对于内科住院医师 (n=291)，研究设计将是一项随机试验。对于执业护士 (NP) 学生 (n=96)，我们将使用前后研究设计来适应样本量的限制。主要目的是评估沟通干预的有效性，以改善住院医师和 NP 学生提供的临终关怀。主要结果指标是患者和家属对临终关怀的评价。作为次要结果，我们将检查护士评估的患者症状和临终关怀。次要目标是： 1）使用过程测量来评估干预的成功，包括经过验证的知识测试和态度调查、标准化患者和学习者自我评估； 2) 检查促进或阻碍沟通干预有效性的学习者因素，以提高临终关怀的质量，并通过过程（知识、态度和行为）和结果测量（患者和家庭评分）进行评估。这项研究将为医生和护士提供有关跨学科沟通技巧干预措施的实施和有效性的重要信息，其目标是改善患者及其家人的临终关怀并减少症状。该研究将测试干预措施对患者和家庭层面结果的有效性。如果干预措施有效，它将为改善美国各地患者及其家人接受的临终关怀提供机会。

DESCRIPTION (provided by applicant): Three decades of research on end-of-life care in the U.S. indicate that patients frequently die with a significant burden of pain and other symptoms and often receive care that they would not choose. Patient- clinician communication about end-of-life care is an important focus for improving quality of patient-centered end-of-life care. Studies suggest that clinicians can improve their communication skills with experiential training, but no studies have shown that an intervention to improve clinician communication skill about end- of-life care improves patient outcomes. Furthermore, despite the knowledge that end-of-life care is best delivered in an interdisciplinary context, most studies do not incorporate interdisciplinary training. We propose to build on a state-of-the-art intervention, developed and implemented for oncology fellows through an R25 award funded by the National Cancer Institute, which is designed to improve clinician skills at communicating about end-of-life care. We will adapt the intervention for use in internal medicine and nurse practitioner training programs, one in the Northwest and one in the Southeast, and incorporate an innovative interdisciplinary training component. We will evaluate the intervention with patient-level outcomes using a questionnaire for assessing the quality of end-of-life care developed and validated in a prior RO1. The evaluation will target patients with cancer, patients with chronic heart, lung, or liver disease, and older adults. For internal medicine residents (n=291), the study design will be a randomized trial. For nurse practitioner (NP) students (n=96), we will use a before-after study design to accommodate sample size limitations. The primary aim is to evaluate the effectiveness of the communication intervention to improve the end-of- life care delivered by residents and NP students. The primary outcome measures are patient and family ratings of end-of-life care. As secondary outcomes, we will examine patient symptoms and end-of-life care as assessed by nurses. Secondary aims are: 1) to assess the intervention's success using process measures, including a validated knowledge test and attitudes survey, standardized patients, and learner self- assessment; and 2) to examine learner factors that facilitate or impede the effectiveness of the communication intervention to improve the quality of end-of-life care as assessed with both process (knowledge, attitudes, and behaviors) and outcome measures (patient and family ratings). This study will provide important information regarding the implementation and effectiveness of an interdisciplinary communication skills intervention for physicians and nurses with the goal of improving end- of-life care for patients and their families and reducing symptoms. The study will test the effectiveness of the intervention with patient- and family-level outcomes. If the intervention is effective, it offers the opportunity to improve the end-of-life care received by patients and their families throughout the US.