Deciding about Dialysis: Improving Decision-Making Among Older Adults with ESRD

70岁及以上的人是终末期肾病（ESRD）患者增长最快的群体。 研究表明，关于开始透析的决策受到沟通不畅的影响， 缺乏对ESRD管理选项的了解。一些小型研究表明， 老年人，与保守治疗相比，透析可能与更长的预期寿命相关 没有透析。然而，关于老年人在开始透析后对患者的期望却知之甚少- 以功能状态和认知功能等结果为中心。此外，很少有研究 患者、家庭和临床医生对这一决策过程的看法。 该提案有以下三个互补的目标，以应对与以下方面有关的这些挑战： 透析决策：1）定义70岁以上成人的功能状态和认知功能轨迹， 与未接受透析的成年人的轨迹相比，老年ESRD患者在开始透析之前和之后。（二） 探索在成人中决定开始透析（与保守治疗相比）的观点70 以及他们的家人和临床医生3)为即将发生ESRD的老年患者开发决策辅助工具。 第一个项目是利用全国代表性的纵向调查数据进行定量分析， 健康与退休研究第二个项目的特点是对病人、家属、 和临床医生关于透析决策过程的信息。第三个项目将利用从 目的1和2为预期需要透析的70岁及以上成人提供决策辅助设计。 K23职业发展奖（CDA）的总体目标是支持博士的早期职业生涯。 Melissa Wachterman是哈佛医学院的姑息治疗医生和健康服务研究员。 博士Wachterman是一位很有前途的初级研究员，专门从事与老年姑息治疗相关的研究。 她的职业目标是成为一名独立资助的临床调查员，进行研究，改善 护理质量和以患者为中心的治疗决策，为重病的老年人及其家人。 该K23奖项将帮助Wachterman博士实现以下目标：1）获得高级 生物统计学培训，包括使用具有全国代表性的纵向调查数据的分析技能; 2） 获得定性研究方法的培训; 3）发展决策辅助开发的技能; 4）发展 作为调查员，确保从CDA成功过渡到独立的R 01级资助。 为了实现这些目标，Wachterman博士有一个指导团队，致力于她作为临床医生的成功 调查员她的主要导师是南希·基廷博士，医学和卫生政策副教授， 哈佛医学院和国际公认的卫生服务研究员， 姑息治疗她的共同导师是爱德华·马尔坎托尼奥博士，一位老年病学家和国际知名的老龄化 研究员Wachterman博士将从哈佛充满活力的研究社区中受益匪浅。

Individuals 70 and older are the fastest growing group of patients with end-stage renal disease (ESRD). Research shows that decision-making regarding initiation of dialysis is impaired by poor communication and lack of understanding about the options for management of ESRD. Some small studies suggest that, among older adults, dialysis is likely associated with longer life expectancy compared to conservative management without dialysis. Yet little is known about what older adults can expect after initiating dialysis in terms of patient- centered outcomes such as functional status and cognitive function. Furthermore, there has been little research into patient, family, and clinician perspectives on this decision-making process. This proposal has the following three complementary aims that address these challenges related to dialysis decision-making: 1) Define the trajectories of functional status and cognitive function for adults 70 and older with ESRD before and after initiation of dialysis, compared to the trajectories of adults not on dialysis. 2) Explore perspectives about the decision to initiate dialysis (versus conservative management) among adults 70 and older, their families, and clinicians. 3) Develop a decision aid for older patients with impending ESRD. The first project is a quantitative analysis using nationally-representative longitudinal survey data from the Health and Retirement Study. The second project features qualitative interviews with patients, families, and clinicians about the dialysis decision-making process. The third project will use the knowledge gained from Aims 1 and 2 to inform the design of a decision aid for adults 70 and older who are expected to need dialysis. The overall objective of this K23 Career Development Award (CDA) is to support the early career of Dr. Melissa Wachterman, a palliative care physician and health services researcher at Harvard Medical School. Dr. Wachterman is a promising junior investigator specializing in research related to geriatric palliative care. Her career goal is to become an independently-funded clinician-investigator conducting research that improves quality of care and patient-centered treatment decision-making for seriously-ill older adults and their families. This K23 award will help Dr. Wachterman accomplish the following goals: 1) to obtain advanced training in biostatistics, including analytic skills using longitudinal nationally-representative survey data; 2) to acquire training in qualitative research methods; 3) to develop skills in decision aid development; 4) to develop as an investigator to ensure a successful transition from this CDA to independent R01-level funding. To achieve these goals, Dr. Wachterman has a mentoring team committed to her success as a clinician investigator. Her primary mentor is Dr. Nancy Keating, Associate Professor of Medicine and Health Policy at Harvard Medical School and an internationally-recognized health services researcher with expertise in palliative care. Her co-mentor is Dr. Edward Marcantonio, a geriatrician and internationally-renowned aging researcher. Dr. Wachterman will benefit greatly from working in Harvard’s vibrant research community.