Developing a Web and Tablet based Tool to Improve Communication and Shared Decision Making between Clinicians and Surrogates in ICUs

开发基于网络和平板电脑的工具，以改善 ICU 中临床医生和代理人之间的沟通和共享决策

• 批准号: 8881427
• 负责人: Douglas B White
• 金额: $ 19.24万
• 依托单位: UNIVERSITY OF PITTSBURGH AT PITTSBURGH
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-07-01 至 2017-02-28
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8881427
• 关键词: Address; Adult; Advance Care Planning; Affect; American; Anxiety; Caring; Cessation of life; Communication; Computer software; Consultations; Critical Care; Critical Illness; Data; Decision Making; Distress; Elderly; Elements; Emotions; Evaluation; Eye; Face; Family; Family health status; Family member; Galvanic Skin Response; Goals; Health system; Healthcare; Intensive Care Units; Internet; Intervention; Interview; Letters; Life; Measurement; Measures; Medical; Methods; Multicenter Trials; Nurses; Outcome; Outcome Measure; Pain; Palliative Care; Patients; Perception; Physicians; Physiological; Preparation; Procedures; Process; Professional counselor; Public Health; Questionnaires; Research; Research Personnel; Role; Suggestion; Tablets; Techniques; Testing; Time; United States; Vulnerable Populations; Work; base; clinical research site; cognitive load; cost; depressive symptoms; design; end of life; evidence base; expectation; group intervention; health care service utilization; high risk; improved; innovation; instrument; novel; outcome forecast; preference; prevent; prototype; psychological distress; psychological outcomes; public health relevance; randomized trial; shared decision making; success; successful intervention; tool; treatment as usual; usability; user centered design

 DESCRIPTION (provided by applicant): Three decades of research in the United States indicates that Americans who are dying often spend their final days in pain and receiving treatments they would not choose. One in five deaths among adults occurs in or shortly after discharge from an intensive care unit (ICU), where there are well-documented problems with clinician-family communication and end-of-life care. These deficiencies are associated with poorly informed treatment decisions, lasting psychological distress among patients' surrogates, and high utilization of expensive, burdensome treatments at the end of life. Unfortunately, there are no practical, generalizable interventions proven effective in mitigating these three public health problems. In this application, we propose to address this gap by developing a web and tablet-based tool to enhance communication and shared decision making in ICUs, then conducting a pilot RCT among 100 patients assessing the interventions' impact on key elements of decision making quality. In preparation for this application, we conducted in-depth interviews with surrogates and clinicians to assess the acceptability of a web and tablet-based tool, which revealed broad support for the intervention, as well as valuable design suggestions: the tool should be accessible on-line at multiple time-points, and it should be designed to enhance rather than replace clinician-family communication. In Aim 1, We will engage surrogates, clinicians, and experts in a highly iterative process of user- centered design to develop a tool that is usable, accessible, and poses low cognitive load for surrogates. In Aim 2, we will conduct detailed usability and acceptability evaluations of the prototype tool among surrogates of patients with advanced critical illness and critical care physicians and nurses. In Aim 3, we conduct a pilot RCT, using validated instruments to assess the intervention's impact on key elements of decision quality and the patient-centeredness of care decisions. We will also finalize procedures to collect long-term outcome data on patient, family, and health care utilization outcomes, which will be the main outcome measures of the anticipated multi-center trial that will follow. This project will have high impact if successful because it will yield a rigorously developed intervention and crucial preliminary data needed to conduct a multi-center trial to assess the interventions impact on patient and family outcomes. The tool has the potential to overcome major public health problems that affect the more than 600,000 Americans annually who die in ICUs and their family members. This proposal is innovative because it will produce a novel tool that challenges the existing paradigm of how decision support is provided in ICUs. The work is feasible in our hands because our team of established investigators has a proven record of success conducting trials in ICUs, have successfully used all methods proposed in this application, and have obtained buy-in for participation from the clinical sites.

 描述(由申请人提供)：美国30年的研究表明，垂死的美国人通常在痛苦中度过最后的日子，接受他们不会选择的治疗。成人中有五分之一的死亡发生在重症监护病房(ICU)出院或出院后不久，在重症监护病房(ICU)，临床医生与家庭的沟通和临终关怀存在着有据可查的问题。这些缺陷与缺乏信息的治疗决策、患者代理人持续的心理痛苦以及在生命末期对昂贵而繁重的治疗的高度利用有关。不幸的是，没有任何实际的、可推广的干预措施被证明能有效地缓解这三个公共卫生问题。在这项应用中，我们建议通过开发基于网络和平板电脑的工具来加强ICU中的沟通和共享决策，然后在100名患者中进行一项试点随机对照试验，评估干预措施对决策质量关键要素的影响，以解决这一差距。为了准备这项应用，我们对代理人和临床医生进行了深入的访谈，以评估基于网络和平板电脑的工具的可接受性，这表明干预得到了广泛的支持，并提出了有价值的设计建议：该工具应该可以在多个时间点在线访问，它的设计应该是为了加强而不是取代临床医生与家庭的沟通。在目标1中，我们将让代孕者、临床医生和专家参与以用户为中心的高度迭代设计过程，以开发一种可用的、可访问的工具，并对代孕者造成低认知负荷。在目标2中，我们将在晚期危重病患者和危重病护理医生和护士的代理人中对原型工具进行详细的可用性和可接受性评估。在目标3中，我们进行了一项试验性随机对照试验，使用经过验证的工具来评估干预对决策质量关键要素和以患者为中心的护理决策的影响。我们还将最终确定收集患者、家庭和医疗保健利用结果的长期结果数据的程序，这将是随后预期的多中心试验的主要结果衡量标准。该项目如果成功将产生很高的影响，因为它将产生严格制定的干预措施和关键的初步数据，这些数据是进行多中心试验以评估干预措施对患者和家庭结局的影响所需的。该工具有可能克服主要的公共卫生问题，这些问题影响着每年死于重症监护病房的60多万美国人及其家人。这一提议是创新的，因为它将产生一种新的工具，挑战如何在重症监护病房提供决策支持的现有范例。这项工作在我们手中是可行的，因为我们的成熟研究团队有在ICU成功进行试验的已被证明的记录，成功地使用了本申请中提出的所有方法，并从临床现场获得了参与。