POST Facilitation for Community Dwelling Older Adults with and without Dementia

高级护理计划(ACP)是一个支持患者在严重疾病和生命末期的医疗保健决策的过程。虽然一些老年人保持独立的决策，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使决策能够在危机发生之前做出，并将患者的价值观和偏好纳入到过程中。尽管这样的计划对以患者为中心的护理至关重要，但许多患有包括ADRD在内的虚弱和复杂医疗条件的老年人从未获得参与高质量ACP的机会。生命维持治疗医嘱(POLST)是一种最先进的ACP工具，用于记录重症患者对几种医疗类型的偏好。尽管POLST的高质量咨询适用于数千名病情严重的老年人，但它是一个耗时的过程，不容易适应繁忙的门诊医学世界。一种解决方案是由非医生提供POLST表格，然后由医生进行审查和签名。最广泛使用的辅导员培训计划是尊重选择最后几步。然而，还没有对照试验测试Last Steps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促进对社区居住的有无ADRD的老年人的影响，这些老年人根据他们的健康状况有资格参加POLST。为了推广到临床环境，这项研究将包括自己做出决定的患者和那些因ADRD而需要代孕的患者。患者将从中西部大都市区的初级保健诊所登记，POLST便利化将由接受过Last Steps模式培训的注册护士在家中提供。主要目的是与注意控制组相比，测试高质量POLST促进对患者是否接受符合偏好的医疗的影响。我们还将在生命结束时衡量决策质量、成本和护理的结果。

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.