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

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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.