Characterization and Identification of Markers of Clinical Momentum in the Care of Older Adults with Advanced Dementia

在生命的最后6个月，患有严重疾病的老年人将经常接受侵入性治疗，尽管他们倾向于避免繁重的干预措施，但效果有限。例如，对于患有严重痴呆症的老年人，不建议使用喂养管，但近十分之一的人会接受喂养管。减少临终时接受过度治疗的战略主要侧重于改善沟通，但系统一级的做法模式对病人护理的提供有很大影响。上游事件和临床规范可能会产生一种护理轨迹，即使使用姑息治疗专家所使用的高级沟通技能也很难修改。 “老年晚期痴呆患者护理中临床动量标记物的特征和识别”是一项为期两年的观察性研究，专门针对PA-18-503提出探索性或发展性研究建议，以开发新的工具、方法和模式，重点关注老年人群的姑息治疗。我们的研究团队此前已经认识到导致过度治疗的系统层面的实践模式，并开发了一个概念框架来描述这种现象，我们将这种现象称为限制生命的疾病患者的临床势头，例如阿尔茨海默病和其他晚期痴呆患者。我们现在需要开发经验工具来识别和衡量临床势头，并记录其与这些患者生命末期过度治疗的关系。这项提案的目的是描述在急性住院期间放置喂养管的老年晚期痴呆患者的护理轨迹，作为临床势头的案例研究。这项由两部分组成的研究旨在通过描述实践中临床动量的组成部分并在电子健康记录中识别临床动量的标记来评估和扩展我们的概念框架。对于目标1，我们将使用关键的线人访谈和定性分析来描述导致晚期痴呆患者放置喂养管的事件、过程和急性护理的潜在性质的轨迹。对于目标2，我们将确定在阿尔茨海默病和其他晚期痴呆症患者的医疗记录中明显可见的标志物和产生临床势头的事件序列，并通过电子健康记录识别器确认。 在完成这项工作后，我们希望对导致成人晚期痴呆患者放置喂养管的护理轨迹有一个深刻的了解。这项研究具有创新性，因为它使用了一种理论驱动的经验策略来确定可能在提供生命末期过度治疗方面发挥关键作用的实践模式。这项研究具有重要意义，因为表征临床势头可以让我们识别错位的激励因素和护理轨迹中更早的特定时刻，在这些干预措施可以被用来扰乱临床势头并改善患有阿尔茨海默病、晚期痴呆的老年人以及最终患有限制生命的疾病的其他人的护理质量。考虑到我们环境中的资源，我们的多学科团队能够很好地在这个奖项的范围内实现我们的目标，使我们能够在两个截然不同的医院环境中检查这个问题。

In the final 6 months of life older adults with serious illness will frequently receive invasive treatments despite preferences to avoid burdensome interventions with limited efficacy. For example, feeding tubes are not recommended for older adults with Advanced Dementia, but nearly one in ten will receive one. Strategies to reduce receipt of overtreatment at the end of life have focused largely on improving communication, yet systems-level practice patterns have a strong influence on the delivery of patient care. Upstream events and clinical norms can produce a trajectory of care that is difficult to modify even with the advanced communication skills employed by palliative care specialists. “Characterization and Identification of Markers of Clinical Momentum in the Care of Older Adults with Advanced Dementia” is a two-year observational study that responds specifically to PA-18-503 for an exploratory or developmental research proposal to develop new tools, methods and models focused on palliative care in geriatric populations. Our research team has previously recognized systems-level practice patterns leading to overtreatment and developed a conceptual framework to describe this phenomenon that we call clinical momentum for patients with life-limiting illness, such as those with Alzheimer’s disease and other advanced dementias. We now need to develop empirical tools to identify and measure clinical momentum and document its relationship to overtreatment at the end of life for these patients. The objective of this proposal is to characterize the trajectory of care for older adults with advanced dementia who have a feeding tube placed during acute hospitalization as a case study of clinical momentum. This 2-part study is designed to evaluate and extend our conceptual framework by characterizing components of clinical momentum in practice and identifying markers of clinical momentum in the electronic health record. For aim 1, we will use key informant interviews and qualitative analysis to describe the trajectory of events, processes, and latent properties of acute care that lead to feeding tube placement for patients with advanced dementia. For aim 2, we will identify markers and the sequence of events generating clinical momentum that are evident in the medical record for patients with Alzheimer’s Disease and other advanced dementias as confirmed by electronic health record identifiers. Upon completion of this work we hope to have a deep understanding of the trajectory of care that leads to feeding tube placement in adults with advanced dementia. This research is innovative because it uses a theory-driven empirical strategy to identify practice patterns that may play a critical role in the provision of overtreatment at the end of life. This research is significant because characterizing clinical momentum could allow us to identify misaligned incentives and specific moments earlier in the trajectory of care where interventions could be employed to disrupt clinical momentum and improve the quality of care for older adults with Alzheimer’s Disease, advanced dementias, and ultimately others with life-limiting illness. Our multidisciplinary team is well positioned to achieve our objectives within the scope of this award given the resources in our environment, allowing us to examine this problem within 2 distinctly different hospital settings.