Randomized Trial of a Scalable, Interactive Tool to Support Surrogate Decision-makers of Elderly Critically Ill Patients

摘要 美国国家医学科学院和美国国立卫生研究院呼吁紧急 行动，以改善提供给近100万老年美国人谁死在 重症监护室（ICU）每年，或生存与严重残疾。这些问题包括：1） 预后不良的患者通常接受比他们更有创性的，负担更重的治疗。 会为自己选择; 2）家庭成员作为代理决策者发现， 经历情感上的压倒性和遭受持久的心理痛苦;和3）治疗 重症监护室中的高血压导致了高昂的临终医疗费用。这些问题尤其 这对老年患者很重要，他们愿意接受侵入性，延长生命的治疗， 变化和高度依赖于个人的价值观和偏好。尽管人们普遍认为， 这些问题，没有现成的可扩展的干预措施被证明是有效的，以帮助 监护室里的代理人在过去3年（R21 AG 050252）中，我们使用了多利益相关方流程 首先开发，然后反复完善家庭支持工具，这是一个基于网络的互动工具， 帮助老年人，无行为能力的病人的家庭成员导航情感，心理， 和认知的复杂性。然后，我们在一个 单中心随机对照试验表明，干预措施可行，可接受，提高了临床医生的质量， 家庭沟通，被ICU的代理人认为是非常有益的。我们 建议对家庭支持进行适当的随机临床试验 在450名老年重症患者的代理人中， 残疾。在目标1和2中，我们将确定家庭支持工具对患者的影响。 临床结果，代理人的心理结果，决策质量的衡量标准，以及最终- 终身医疗保健利用率。在目标3中，我们将与RCT平行进行定性研究 识别可能影响有效性的环境因素、障碍和促进因素， 家庭支持工具。这项研究非常重要，因为它将确定一种 低成本，可扩展的干预措施，以克服影响数百人的重大公共卫生问题， 成千上万的美国人每年。这项建议是创新的，因为干预 挑战现有的范式，如何支持代理人面临困难的决定附近， 生命的终结这项工作在我们手中是可行的，因为我们的调查团队 成功开发并试用了家庭支助工具， 成功在ICU进行试验，并获得所有研究中心的参与支持。

ABSTRACT The National Academy of Medicine and the National Institutes of Health have called for urgent action to improve the care delivered to the nearly 1,000,000 elderly Americans who die in intensive care units (ICUs) annually, or survive with severe disabilities. The problems include: 1) patients with a poor prognosis often receive more invasive, burdensome treatment than they would choose for themselves; 2) family members acting as surrogate decision-makers find the experience emotionally overwhelming and suffer lasting psychological distress; and 3) treatment in ICUs contributes to high end-of-life health care costs. These problems are especially important to elderly patients, whose willingness to undergo invasive, life-prolonging treatments varies and hinges on highly personal values and preferences. Despite widespread recognition of these problems, there are no readily-scalable interventions that are proven effective to assist surrogates in ICUs. Over the last 3 years (R21AG050252), we used a multi-stakeholder process to first develop, then iteratively refine the Family Support Tool, an interactive, web-based tool to help family members of elderly, incapacitated patients navigate the emotional, psychological, and cognitive complexities of being a surrogate decision-maker. We then established in a single-center RCT that the intervention is feasible, acceptable, improves the quality of clinician- family communication, and is perceived to be highly beneficial by surrogates in ICUs. We propose to conduct an appropriately powered randomized clinical trial of the Family Support Tool among the surrogates of 450 elderly, critically ill patients at high risk of death or severe disability. In Aims 1 and 2, we will determine the effect of the Family Support Tool on patients’ clinical outcomes, surrogates’ psychological outcomes, measures of decision quality, and end- of-life healthcare utilization. In Aim 3, we will conduct a qualitative study in parallel with the RCT to identify the contextual factors, barriers, and facilitators that may influence the efficacy of the Family Support Tool. The research is highly significant because it will establish the efficacy of a low-cost, scalable intervention to overcome major public health problems that affect hundreds of thousands of Americans annually. This proposal is innovative because the intervention challenges the existing paradigm of how to support surrogates facing difficult decisions near the end of life. The work is feasible in our hands because our team of established investigators successfully developed and pilot tested the Family Support Tool, has a proven record of success conducting trials in ICUs, and has buy-in for participation from all sites.