Improving Decision-Making about Feeding Options for Dementia Patients

描述(申请人提供)：当晚期痴呆症患者出现喂养问题时，他们的照顾者必须考虑辅助口腔喂养或管状喂养的治疗方案。管饲法不会改善存活率、功能或吸入风险。管饲的使用继续增加，特别是对年龄较大或非裔美国人的患者。对于利益不确定的严重临床决策，共享决策是推荐的沟通模式。目前的临床讨论很少达到这一标准。在一项对246项决定进行的前瞻性研究中，我们发现代孕决策者对临床益处的期望一直很高，他们需要更多的信息和更好的共享决策。我们现在建议对以前试行的决策辅助进行整群随机对照试验，以改善对晚期痴呆患者的喂养选择的决策。在按地点随机分组后，我们将从北卡罗来纳州的12家疗养院招募250名患有晚期痴呆症和喂养问题的患者，以及他们的代理决策者。我们预计非洲裔美国人的入学率为25%。干预地点的代理决策者将审查决策援助，并鼓励他们与医生讨论决定，而那些在对照疗养院的人则接受通常的护理。目的1.测试痴呆患者喂养选择的辅助决策是否能有效地为干预组的代孕决策者提供信息，即提高对治疗选择的认识，减少对管状喂养受益的预期，减少决策冲突。目的2.测试辅助决策是否能改善干预组代理决策者1个月和3个月的决策结果，包括增加沟通频率、增加决策满意度和减少决策后悔。目的3.检验辅助决策对1个月和3个月临床治疗决策的影响。这项拟议的研究将增加对共同决策和决策辅助作为提高决策质量和后续临床治疗决策的方法的有效性的科学理解。如果成功，这种干预将展示一种方法，在痴呆症护理的决策中具有更广泛的应用。

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.