POST Facilitation for Community Dwelling Older Adults with and without Dementia

预先护理计划（ACP）是一个支持在严重疾病和生命结束时对患者的医疗护理做出决策的过程。虽然一些老年人保留独立决策，但由于阿尔茨海默病和相关痴呆症（ADRD），许多人需要代理决策者。高质量的ACP能够在危机发生之前做出决定，并将患者的价值观和偏好纳入流程。虽然这样的计划是以病人为中心的护理必不可少的，许多老年人与脆弱和复杂的医疗条件，包括ADRD从来没有提供机会从事高质量的ACP。生命维持治疗医嘱（POLST）是一种最先进的ACP工具，用于记录重病患者对几种类型医疗的偏好。虽然用于成千上万的重病老年人，高质量的咨询POLST是一个耗时的过程，不适合很容易进入忙碌世界的门诊医疗。一种解决方案是由非医生协助POLST表格，然后由医生审查和签名。最广泛使用的辅导员培训计划是尊重选择的最后步骤。然而，没有对照试验测试了最后步骤计划或其他POLST实施计划对重要患者结局的影响。我们将进行一项随机对照试验，研究高质量POLST促进对社区居住老年人的影响，这些老年人患有和不患有ADRD，根据他们的健康状况有资格接受POLST。为了推广到临床环境，本研究将包括自行决定的患者和因ADRD需要替代治疗的患者。患者将从中西部大都市地区的初级保健实践中招募，POLST促进将由接受过最后步骤模型培训的注册护士在家中提供。主要目的是测试高质量的POLST易化的效果，无论患者是否接受与偏好一致的医疗，与注意力控制组相比。我们还将衡量决策质量、成本和生命末期护理的结果。

Advance care planning (ACP) is a process that supports decision making about the patient’s medical care in serious illness and at the end of life. Although some older adults retain independent decision making, many require a surrogate decision maker due to Alzheimer’s Disease and Related Dementias (ADRD). High quality ACP enables decisions to be made before a crisis arises and incorporates patient values and preferences into the process. Although such planning is essential to patient-centered care, many older adults with frailty and complex medical conditions including ADRD are never offered the opportunity to engage in high quality ACP. The Physician Orders for Life Sustaining Treatment (POLST) is a state of the art ACP tool that is used to document the preferences of seriously ill patients for several types of medical treatment. Although used for thousands of seriously ill older adults, high quality counseling for POLST is a time consuming process that does not fit easily into the busy world of outpatient medicine. One solution is facilitation of POLST forms by a non-physician, followed by review and signature by a physician. The most widely used facilitator training program is Respecting Choices Last Steps. However, there are no controlled trials that have tested the impact of the Last Steps program or of other POLST implementation programs on important patient outcomes. We will conduct a randomized controlled trial to study the effect of high quality POLST Facilitation on a population of community dwelling older adults with and without ADRD who qualify for POLST based on their health status. In order to be generalizable to the clinical setting, the study will include patients making their own decisions and those who require a surrogate due to ADRD. Patients will be enrolled from primary care practices in a Midwest metropolitan area and POLST Facilitation will be delivered in the home by registered nurses trained in the Last Steps model. The primary aim is to test the effects of high quality POLST Facilitation on whether or not patients receive medical treatment concordant with preferences, compared to an attention control group. We will also measure outcomes of decision quality, cost, and care at the end of life.