A Trial of Expanded Choice Sets in Advance Directives for Hemodialysis Patients

 描述（由申请人提供）：终末期肾病维持性血液透析（ESRD-HD）患者所需的护理与他们在生命末期接受的护理之间存在很大差距。不幸的是，血液透析患者经历频繁的住院治疗和积极的医疗护理接近生命的尽头，尽管偏好舒适为重点的护理，如果他们是重病。这在一定程度上是由于历史上不令人满意的提前护理规划，包括在这一人群中提前完成指令的比例很低。及时参与预先护理计划对于ESRD-HD患者尤为重要，这些患者的中位五年生存期短于许多癌症患者，并且在生命的最后一个月功能明显快速下降。预先指示为患者提供了一个表达特定临终偏好的机会，以避免不必要的护理。尽管预先指示可能对改善临终护理质量大有希望，但完成率仍然很低，以前鼓励完成护理的努力成效有限。此外，在完成预先指令的患者中，四分之一的患者没有为代理决策者提供足够的指导，以提供与其目标和价值观一致的护理。行为经济学的原则，如决策框架效应，可能会提供一种新的方法来解决以前的缺陷，在预先指令的实施和桥梁的差距差距在临终关怀。例如，针对在可预见的未来具有可识别的危重疾病或死亡风险因素的患者，增加了患者所陈述的偏好在需要预先指令时仍然适用的可能性。本研究的目标是测试改变关于预先指令完成的决策的背景是否可以增加血液透析患者完成的可能性，并在其中指定可操作的选择，预先指示首先，我们的目标是确定通过提供不同版本的预先指令来扩大完成预先指令的选择是否会增加完成预先指令的患者比例。其次，我们的目标是确定是否扩大选择范围内接受或不接受生命支持治疗的预先指令将减少患者的比例谁不指定任何偏好。该项目将为计划中的NIH K23职业发展奖提供重要的初步数据，该奖项将（1）更明确地研究这种和其他决策助推如何影响ESRD-HD患者的决策，（2）比较完成或未完成预先指示的ESRD-HD患者在生命末期的纵向患者报告的生活质量，功能状态和医疗保健利用模式，和（3）在接受维持性血液透析治疗的较大患者人群中，比较其他行为经济干预措施对提高预先指导完成率的影响。

 DESCRIPTION (provided by applicant): There is a large gap between the care patients with end-stage renal disease on maintenance hemodialysis (ESRD-HD) want and the care they receive near the end-of-life. Unfortunately, hemodialysis patients experience frequent hospitalizations and aggressive medical care near the end of life despite a preference for comfort-focused care if they are seriously ill. This, in part, is explained by historically unsatisfactory advance care planning including low rates of advance directive completion in this population. Timely engagement in advance care planning is particularly important for ESRD-HD patients who have a median five-year survival shorter than many patients with cancer and have a distinctly rapid functional decline in the final month of life. Advance directives offer an opportunity for patients to express specific end-of-life preferences to avoid unwanted care. As promising as advance directives may be for improving the quality of care near the end of life, rates of completion remain low and previous efforts to encourage their completion have had limited success. Moreover, among patients who do complete an advance directive, one in four do not provide sufficient guidance in it for surrogate decision makers to provide care consistent with their goals and values. Principles of behavioral economics, such as decision framing effects, may offer a novel approach to address previous shortcomings in advance directive implementation and bridge the gap in end-of-life care. For example, targeting patients with identifiable risk factors for critical illness or death in the foreseeable future increases the probability that patients' stated preferences will still apply when the advance directive is needed The goal of this study is to test whether changing the context of decisions regarding advance directive completion can increase the probability that hemodialysis patients will complete, and specify actionable choices within, advance directives. First, we aim to determine if expanding the choices for completing an advance directive by offering different versions of them will increase the proportion of patients who complete one. Second, we aim to determine if expanding the range of choices for receipt or not of life-supportive therapies within an advance directive will decrease the proportion of patients who do not specify any preference. This project will provide essential preliminary data for a planned NIH K23 Career Development Award that would (1) examine more definitively how this and other decision nudges influence ESRD-HD patients' decisions, (2) compare longitudinal patient-reported quality of life, functional status, and healthcare utilization patterns near the end of life among ESRD-HD patients who do or do not complete advance directives, and (3) compare other behavioral economic interventions for improving advance directive completion among a larger population of patients receiving maintenance hemodialysis therapy.