Promoting Advance Care Planning as a Healthy Behavior

医学研究所最近的报告“在美国死亡：提高质量和尊重个人 生命末期的偏好”赞同提前护理计划（ACP）作为质量的关键组成部分 健康护理与只让患有严重疾病的人参与ACP的现行模式相反， 提出了一个持续的过程，从生命早期开始，个人健康状况良好。这样的 这种方法有助于为更深入的讨论和治疗决策做好准备， 严重的疾病发展。该项目响应了这一呼吁。它建立在校长早期的工作基础上 研究者（PI）为改善ACP过程提供了两个关键见解。其中第一个是改变 ACP的目的从治疗偏好的预先规范到为最佳治疗做准备 可能的“即时”医疗决策。这是通过将ACP概念化为以下行为来实现的 患者、代理人和临床医生之间的沟通。第二个是明确解决许多 参与ACP的态度、认知和行为障碍。这是通过将ACP视为 一个健康行为和干预使用健康行为变化的验证模型。PI开发了 并对基于跨理论模型的干预措施进行了试点测试。这次干预由一名专家组成， 评估个人参与ACP沿着的态度和信念的系统 影响参与的愿望、动机和能力。然后，它提供个性化的反馈 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）。这个项目还将利用一种形式的动机访谈所谓的动机增强 MET治疗，虽然也包括行为改变准备的概念，但与CTI不同。它 包括简短的咨询，探索个人的准备从事行为改变和帮助 个人确定变革的动力。 该项目的目标是研究CTI和MET对ACP退伍军人参与的影响。的 具体目的是：进行一项随机对照试验，检查以下因素的影响：a）常规护理; B）CTI; c） MET; d）CTI + MET关于在VA接受初级保健的中老年退伍军人的比例， 完成ACP的过程。将使用广泛的资格标准来确定55岁及以上的退伍军人 在VA康涅狄格州医疗保健系统内接受初级保健的人， ACP的4个关键行为：健康护理代理分配、生活意愿完成、与健康沟通 护理代理关于生活质量与数量的观点，与临床医生就这些观点进行沟通。的 将通过电话进行干预。对于接受CTI的退伍军人， 报告，一个阶段匹配的小册子，并为代理小册子将被邮寄。这将在2时重复 4个月。对于接受MI的退伍军人，退伍军人和代理人将参加二元访谈。 随访将在2个月和4个月时进行。对于接受CTI + MI的退伍军人，印刷材料将 面试将在两周内进行。基线措施，包括变化阶段 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统计学 变量，将获得所有参与者。6个月时获得的结局指标将是 完成4项ACP行为的参与者比例。该提案还将为 通过收集关于所需时间和努力的执行数据， 提供干预措施的成功和障碍，以及对其他人的溢出效应 临床服务。还将开展更多工作，以制定最有效的方法， 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.