Improving Palliative Care for Older Seriously Hospitalized Patients and Their Families: A Randomized Trial of an Informed Assent Communication Intervention about CPR

 描述(由申请人提供)：高质量的姑息治疗和老年患者的沟通改善了护理质量、患者和家人的满意度以及护理成本。交流的一个重要组成部分是讨论心肺复苏(CPR)，因为这是每次入院都需要的，而且大多数老年患者在住院前没有讨论过CPR。不幸的是，这些对话往往不够充分，让患者和家人感到负担、压力和担忧。尽管经过几十年的努力，慢性疾病老年患者在住院期间进行CPR后的结果仍然非常差。我们先前的工作表明，越来越多的住院老年人在死前接受CPR，但存活率仍然很低，而且CPR的长期好处正在减少，CPR后出院的患者越来越少。此外，与那些没有慢性病的人相比，患有晚期慢性病的老年患者在CPR后出院和长期存活的情况明显更差，而在幸存者中，直到死亡的再次住院人数更多，出院回家的可能性更小。我们最近成功地完成了两项关于讨论CPR的新的“知情同意”方法的试点研究，这是一种特定的沟通框架，通过这种框架，符合特定标准且不希望不惜一切代价存活的老年患者得到了通知。 他们不应该接受心肺复苏。我们的初步数据表明，这种干预是可行的，并受到患者、家庭成员和医生的欢迎。此外，在参加我们的试验性随机对照试验时想要心肺复苏的患者中，接受干预的患者明显更多的患者将他们的偏好改变为“不进行CPR”，而不是对照组患者。因此，我们提出了一项第二阶段概念验证随机对照试验，比较我们创新的知情同意干预与常规护理和注意力控制对患有严重生命限制疾病或功能或认知障碍的老年住院成年人的影响，纳入患者和家庭成员。我们假设知情同意将提高关于CPR的沟通的质量和满意度；减少潜在有害的CPR讨论的负担，包括减少患者和家人的抑郁、焦虑和决定后悔的症状；并降低护理和卫生保健利用的强度。提出这一项目的研究小组由一名早期调查员领导，在随机对照试验和患者招募方面拥有丰富的经验，并有多年的成功合作经验，包括最近完成的两项知情同意的试点研究。他们处于有利地位，可以进行这项研究，旨在改变与不太可能从CPR中受益的老年人讨论CPR的范式。如果有效，这种知情的同意干预有可能彻底改变与慢性病老年患者关于CPR的讨论。

 DESCRIPTION (provided by applicant): High quality palliative care and communication in older patients improves quality of care, patient and family satisfaction, and costs of care. One important component of communication is discussing cardiopulmonary resuscitation (CPR), as this is required for every hospital admission and most older patients have not discussed CPR prior to hospitalization. Unfortunately, these conversations are often inadequate and leave patients and families feeling burdened, stressed, and concerned. Outcomes after in-hospital CPR in chronically ill older patients continue to be very poor, despite decades of efforts toward improvement. Our prior work has shown that an increasing proportion of hospitalized older adults receive CPR before death with continued poor survival rates and that the longer-term benefits of CPR are decreasing with fewer patients discharged home after CPR. Additionally, when compared to those without chronic illness, older patients with advanced chronic illness have significantly worse hospital discharge and long-term survival after CPR, and among survivors, experience more hospital readmissions until death and are less likely to be discharged home. We have recently successfully completed two pilot studies of a novel "informed assent" approach to discussing CPR, a specific communication framework whereby older patients who meet specific criteria and do not wish to remain alive at all costs are informed that they should not receive CPR. Our preliminary data demonstrate that this intervention is feasible and well-received by patients, family members, and physicians. Additionally, among patients who wanted CPR at enrollment in our pilot RCT, significantly more patients receiving the intervention changed their preferences to "no CPR" than did control patients. We therefore propose a phase II proof-of-concept RCT comparing our innovative informed assent intervention versus usual care with attention control for older hospitalized adults with severe life-limiting illness or functional or cognitive impairment, enrolling patients and family members. We hypothesize that informed assent will improved quality of and satisfaction with communication about CPR; reduce the burden of potentially harmful CPR discussions, including reduced patient and family symptoms of depression, anxiety and decisional regret; and reduce intensity of care and health care utilization. The research team proposing this project, led by an Early Stage Investigator, has extensive experience with RCTs and patient recruitment, as well as years of successful collaboration, including recent completion of two pilot studies of informed assent. They are well positioned to conduct this study that aims to change the paradigm of CPR discussions with older adults unlikely to benefit from CPR. If effective, this informed assent intervention has the potential to revolutionize discussions about CPR with chronically ill older patients.