Intensive Communication for Chronically Critically Ill

描述(申请人提供)：治疗危及生命的疾病的进步导致越来越多的“慢性危重”(CCI)患者从最初的危重疾病中康复，但随后需要在医院长时间使用机械呼吸机。CCI的死亡率、发病率和再入院风险很高。CCI的家庭面临着巨大的挑战，因为他们面临着关于护理目标以及福利和负担的决定。确定和经常重新评估护理目标被认为是与危重病人家属进行支持性沟通和决策的重要组成部分，但往往被忽视。然而，我们对在这一过程中帮助家属的具体方式以及沟通如何影响患者结局知之甚少。就CCI的护理目标达成共识可能会带来特殊的挑战，因为CCI通常不被认识，CCI的预后不被很好地接受，ICU不具备考虑生存以外的目标的能力。对这些患者的重症监护的一个关键组成部分是密集的沟通。缺乏向临床医生提供具体指导所需的了解和证据是改善临终关怀的一个重大障碍。因此，有必要开发和测试干预措施，以更有效和一致地促进与CCI患者家属的共享沟通和决策。这项提案的具体目的是检查实施密集沟通系统(ICS)对CCI患者和家庭结局以及不同专科ICU资源使用的影响。研究问题是：(A)为CCI患者家属实施ICS对ICU资源使用有何影响？(B)对CCI患者家属实施ICS对家庭抑郁、沟通满意度和护理满意度有何影响？(C)实施ICS对患者结局(死亡率、再入院)有何影响？(D)干预措施的有效性与家庭人口统计数据(年龄、与患者的关系)之间有何关联。族裔)；(E)ICS通信的主要进程特征是什么？

DESCRIPTION (provided by applicant): Advances in the treatment of patients with life-threatening illnesses have resulted in a growing population of "chronically critically ill" (CCI) patients who have recovered from an initial critical illness, but go on to require prolonged periods of time on mechanical ventilators in the hospital. The CCI are at high risk for mortality, morbidity, and readmission. Families of the CCI confront enormous challenges as they face decisions about goals of care, as well as benefits and burdens. Identification and frequent re-evaluation of goals of care have been recognized as essential yet often neglected components of supportive communication and decision making with families of the critically ill. We know very little, however, about specific ways to assist families in this process and how communication affects patient outcomes. Reaching consensus about goals of care in CCI may present particular challenges because CCI is often not recognized, prognosis of CCI is not well accepted, and ICUs are poorly equipped for consideration of goals other than survival. A key component of intensive care for these patients is intensive communication. Lack of understanding and evidence needed to provide specific directions to clinicians is a significant barrier to improving end of life care. Thus, there is a need to develop and test interventions that can more effectively and consistently promote shared communication and decision making with families of CCI patients. The specific aims of this proposal are to examine the effect of implementing an intensive communication system (ICS) on CCI patient and family outcomes and resource use in ICUs of varying specialties. The research questions are: (a) what is the effect of implementation of an ICS for families of CCI patients on ICU resource use? (b) What is the effect of implementation of an ICS for families of CCI patients on family depression, satisfaction with communication, and satisfaction with care? (c) What is the effect of implementation of an ICS on patient outcomes (mortality, readmission)? (d) What is the association between effectiveness of the intervention and family demographics (age, relationship to patient. ethnicity); (e) What are the key process characteristics of communication in ICS?