Racial disparities in shared decision making for patients with acute respiratory failure

项目摘要/摘要 重症急性呼吸衰竭(ARF)患者的护理涉及生死攸关的决定。 理想情况下，重症监护病房(ICU)临床医生应该让患者或他们的家人参与共同的决策， 这促进了目标一致的护理，减少了家庭和临床医生的心理痛苦，以及 缩短了ICU的住院时间。然而，种族差异在共享的所有组件中都有记录 决策及其相关结果。在门诊环境中，临床医生以不同的方式对待黑人患者 来自白人患者，提供更少的治疗选择，更少的预后信息，更少的情感支持， 对患者的偏好做出假设，而不是引出他们的偏好。共同决策中的种族差异 可能会在ICU中被放大，因为临床医生通常与 家庭，和决定是时间压力和高度情绪化。为了促进公平的ICU护理，我们必须填补 两个关键的知识差距：(1)我们不完全理解ICU临床医生如何或为什么以不同的方式接触Black 和白人家庭共同制定关于ARF的决策，因此(2)我们不知道如何发展共享 减少ARF患者SDM中种族差异的决策干预。 为了解决这些证据差距，我提出了三个具体目标：(1)比较ICU医生如何参与 用混合方法分析急性肾功能衰竭患者黑白家庭存在的问题 ICU医生-家庭会议的文字记录；(2)获取家庭和ICU医生的决策经验 通过焦点小组和访谈了解ARF，以确定ICU医生层面共享决策的障碍 与黑人家庭一起制作；以及(3)使用以人为中心的设计方法，该方法由以下反馈指导 家庭和ICU医生对现有共享决策干预进行适应和可行性测试 (“JumpStart”)，以减轻急性肾衰患者及其家人的种族差异。这部作品的主题是 NHLBI的一个关键优先事项是“更好地整合姑息治疗概念，如尊重治疗偏好 急性呼吸衰竭患者的管理。 我将得到杜克大学强大的研究环境和跨学科团队的支持 敬业的、受全国尊敬的导师：克里斯托弗·考克斯博士、金伯利·约翰逊博士、莎伦·多切蒂博士和 米塔·科林。在拟议的项目完成时，我将在临床试验中培养关键的科学技能， 健康差距研究、混合方法研究和干预发展。我也会收集初步的 进行适应性干预的临床试验的后续R01奖所需的数据。总而言之，这款K23 获奖对我的职业发展至关重要，其结果将对公共卫生产生重大影响 促进急性呼吸衰竭患者及其家属公平分享决策。

PROJECT SUMMARY/ABSTRACT The care of critically ill patients with acute respiratory failure (ARF) involves life-or-death decisions. Ideally, intensive care unit (ICU) clinicians should include patients or their families in shared decision making, which promotes goal-concordant care, reduces psychological distress for both families and clinicians, and shortens ICU length of stay. However, racial disparities have been documented in all components of shared decision making and its associated outcomes. In outpatient settings, clinicians treat Black patients differently from White patients, providing fewer treatment options, less prognostic information, and less emotional support, and making assumptions about rather than eliciting patient preferences. Racial disparities in shared decision making are likely to be amplified in the ICU because clinicians often do not have long-standing relationships with families, and decisions are time-pressured and highly emotional. To promote equitable ICU care, we must fill two critical knowledge gaps: (1) we do not fully understand how or why ICU clinicians differently engage Black and White families in shared decision making about ARF, therefore (2) we do not know how to develop a shared decision making intervention to reduce racial disparities in SDM for patients with ARF. To address these evidence gaps, I propose three specific aims: (1) Compare how ICU physicians engage Black and White families of patients with ARF in decision making using mixed methods to analyze existing transcripts of ICU physician-family meetings; (2) Elicit family and ICU physician experiences with decision making about ARF through focus groups and interviews to identify ICU physician-level barriers to shared decision making with Black families; and (3) Use a human-centered design approach that is guided by feedback from families and ICU physicians to adapt and feasibility test an existing shared decision making intervention (“Jumpstart”) in order to mitigate racial disparities for patients with ARF and their families. This work addresses a key NHLBI priority to “better integrate palliative care concepts, such as respect for treatment preferences, in the management of patients” with acute respiratory failure. I will be supported by the robust research environment at Duke University and an interdisciplinary team of dedicated, nationally respected mentors: Drs. Christopher Cox, Kimberly Johnson, Sharron Docherty, and Meeta Kerlin. At the completion of the proposed project, I will have developed key scientific skills in clinical trials, health disparities research, mixed methods research, and intervention development. I will also collect preliminary data necessary for a follow-up R01 Award to conduct a clinical trial of the adapted intervention. In sum, this K23 Award is critical to my career development, and the results will have a substantial public health impact by promoting equitable shared decision making for patients with acute respiratory failure and their families.