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

描述（由申请人提供）：三十年来对美国临终关怀的研究表明，患者经常死于疼痛和其他症状的沉重负担，并且经常接受他们不愿选择的护理。关于临终关怀的医患沟通是提高以病人为中心的临终关怀质量的重要焦点。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，通过干预来提高临床医生关于临终关怀的沟通技巧可以改善患者的预后。此外，尽管我们知道临终关怀最好在跨学科的背景下进行，但大多数研究并没有纳入跨学科的培训。我们建议建立一个最先进的干预，通过国家癌症研究所资助的R25奖为肿瘤学研究员开发和实施，旨在提高临床医生就临终关怀进行沟通的技能。我们将调整干预措施用于内科和护士执业培训项目，一个在西北，一个在东南，并纳入一个创新的跨学科培训组成部分。我们将使用一份问卷来评估在先前的RO1中开发和验证的临终关怀质量，以患者水平的结果来评估干预措施。评价对象为癌症患者、慢性心、肺、肝疾病患者和老年人。对于内科住院医师（n=291），研究设计为随机试验。对于执业护士（NP）学生（n=96），我们将采用前后研究设计来适应样本量的限制。本研究的主要目的是评估沟通干预对改善住院医师和NP学生提供的临终关怀的有效性。主要结果测量是患者和家属对临终关怀的评分。作为次要结果，我们将检查由护士评估的患者症状和临终关怀。次要目的是：1)评估干预的成功使用过程措施，包括一个有效的知识测试和态度调查，标准化的病人，和学习者自我评估；2)通过过程（知识、态度和行为）和结果测量（患者和家属评分）来评估促进或阻碍沟通干预提高临终关怀质量的学习者因素。本研究将为医师和护士提供跨学科沟通技巧干预的实施和有效性方面的重要信息，以改善患者及其家属的临终关怀并减轻症状。该研究将通过患者和家庭层面的结果来测试干预的有效性。如果干预是有效的，它提供了一个机会，以改善病人和他们的家人在美国接受临终关怀。

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.