Promoting Advance Care Planning as a Healthy Behavior

美国医学研究所最近的报告《在美国死亡：提高质量和对个人的荣誉》 生命接近尾声时的偏好“认可高级护理计划(ACP)是质量的关键组成部分 医疗保健。与在机场核心计划中只邀请患有严重疾病的个人参与的流行模式相反，它 提出了一个持续的过程，从健康的人的生命周期的早期开始。这样的一种 方法有助于为个人做好更深入的讨论和治疗决策的准备 会发展成严重的疾病。该项目响应了这一号召。它建立在校长早期的工作基础上 调查员(PI)为改进非加太进程提供了两个关键见解。其中第一个是将 ACP的目的不再是预先指定治疗方案，而是为实现最佳效果做准备 可能的“即时”医疗决策。这是通过将机场核心工程概念化为 患者、代理人和临床医生之间的沟通。第二个是明确地解决许多 参与ACP的态度、认知和行为障碍。这是通过将机场核心工程视为 使用经过验证的健康行为改变模型进行健康行为和干预。PI已经发展成 并对基于跨理论模型的干预措施进行了试点测试。这次干预由一位专家组成 一种评估个人参与非物质文化遗产的准备情况以及态度和信念的系统 影响参与的欲望、动机和能力。然后，它提供个别定制的反馈 提供信息、动机和/或行为改变策略的材料(计算机定制信息 或CTI)。该项目还将使用一种称为激励增强的激励面试形式 治疗(MET)，虽然也包括为行为改变做好准备的概念，但不同于CTI。它 包括简短的咨询，探索个人参与行为改变的准备情况，并帮助 确定变革的动力的个人。 该项目的目标是检查CTI和MET对退伍军人参与非加太项目的影响。这个 具体目标是：进行一项随机对照试验，检查：a)常规护理；b)CTI；c) D)CTI就退伍军人管理局接受初级保健的中老年退伍军人比例问题举行了会议 完成ACP的流程。将使用广泛的资格标准来识别55岁及以上的退伍军人 哪些人正在接受弗吉尼亚州康涅狄格州医疗系统的初级保健，并且尚未完成所有 4个关键的ACP行为：医疗代理分配、生前遗嘱完成、与健康人沟通 关怀代理人对生活质量和数量的看法，与临床医生就这些观点进行沟通。这个 干预(S)将通过电话传达。对于接受CTI的退伍军人，个人量身定做的反馈 将邮寄报告、与阶段匹配的小册子和代孕宣传册。这将在2点重复 再过4个月。对于接受MI的退伍军人，退伍军人和代孕母亲将参加二元面试。 后续访谈将在2个月和4个月进行。对于接受CTI MI的退伍军人，印刷材料将 邮寄，面试将在两周内进行。基线措施，包括变革阶段 对于4个关键的ACP行为，行为改变的利弊，以及健康状况和社会人口 变量，将获得所有参与者的。在6个月时获得的结果衡量标准将是 完成4项ACP行为的参与者比例。这项提议也将奠定基础 通过收集有关以下方面所需时间和精力的实施数据，实现更广泛的实施 提供干预措施、实施干预措施的成功和障碍以及对其他人的溢出影响 临床服务。还将进行其他工作，以制定最有效的嵌入 对现有临床服务的干预。

The recent Institute of Medicine report “Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life” endorses advance care planning (ACP) as a key component of quality healthcare. In contrast to the prevailing model of engaging only individuals with serious illness in ACP, it proposes a continuous process, starting earlier in the lifespan with individuals in good health. Such an approach helps to prepare the individual for more in-depth discussions and treatment decision making as more serious illness develops. This project is responsive to this call. It builds upon earlier work of the Principal Investigator (PI) providing two key insights for improving the process of ACP. The first of these is shifting the purpose of ACP away from the pre-specification of treatment preferences to preparation for making the best possible “in-the-moment” healthcare decisions. This is accomplished by conceptualizing ACP as acts of communication among patients, surrogates, and clinicians. The second is explicitly addressing the many attitudinal, cognitive, and behavioral barriers to engagement in ACP. This is accomplished by treating ACP as a health behavior and intervening using validated models for health behavior change. The PI has developed and pilot-tested an intervention based on the Trans-Theoretical Model. This intervention consists of an expert system that assesses an individual's readiness to engage in ACP along with the attitudes and beliefs influencing the desire, motivation, and ability to engage. It then provides individually tailored feedback materials providing information, motivation, and/or behavior change strategies (computer-tailored information or CTI). This project will also utilize a form of motivational interviewing called motivational enhancement therapy (MET), which, while also including the concept of readiness for behavior change, is distinct from CTI. It consists of brief counseling exploring an individual's readiness to engage in behavior change and helping the individual to identify motivators for change. The objective of the project is to examine the effects of CTI and MET on Veteran engagement in ACP. The specific aim is: To conduct a randomized controlled trial examining the effects of: a) usual care; b) CTI; c) MET; d) CTI + MET on the proportion of middle-age and older Veterans receiving primary care at the VA who complete the process of ACP. Broad eligibility criteria will be used to identify Veterans age 55 years and older who are receiving primary care within VA Connecticut Healthcare System and who have not completed all of the 4 key ACP behaviors: health care proxy assignment, living will completion, communication with the health care proxy about views on quality vs. quantity of life, communication with the clinician about these views. The intervention(s) will be delivered over the phone. For Veterans receiving CTI, an individually tailored feedback report, a stage-matched brochure, and a pamphlet for the surrogate will be mailed. This will be repeated at 2 and 4 months. For Veterans receiving MI, the Veteran and surrogate will participate in a dyadic interview. Follow-up interviews will occur at 2 and 4 months. For Veterans receiving CTI + MI, the printed materials will be mailed, and the interview will be conducted within 2 weeks. Baseline measures, including stage of change for the 4 key ACP behaviors, pros and cons of behavior change, and health status and sociodemographic variables, will be obtained for all participants. The outcome measure, obtained at 6 months, will be the proportion of participants who have completed the 4 ACP behaviors. The proposal will also lay the groundwork for more widespread implementation by collecting implementation data on the time and effort required to deliver the interventions, success of and barriers to delivering the interventions, and spill-over effects on other clinical services. Additional work will be done to strategize about the most efficient ways to embed the interventions into existing clinical services.