Mentored Patient Oriented Research in Improving Surrogate Decision Making for Patients with Advanced Respiratory Failure

摘要 这项以病人为中心的研究生涯中期奖的目标是增强 Douglas White博士将培训、指导和支持专注于以下领域的临床医生-科学家的职业发展 开发和测试干预措施，以改善无行为能力患者的代孕决策 严重呼吸衰竭。急性呼吸衰竭和预后不良的患者经常接受 与他们的价值观和价值观不符的密集、繁重的临终治疗 偏好。这是一个重要的公共卫生问题，因为1)以患者为中心的护理接近尾声 生命是伦理和人道关怀的一个中心方面，而在生命即将结束时过度治疗有助于 在美国，濒临死亡的医疗保健费用不成比例。尽管 尽管问题被很好地记录下来了，但几乎没有循证干预措施来改善患者的预后。 解决这个问题将需要具有决策科学专业知识的科学家的合作， 组织行为学和卫生服务研究。怀特博士处于非常有利的领导地位 这些努力。他是一名职业生涯中期的调查员，拥有一个由NIH资助的成熟的代孕研究项目 急性呼吸衰竭的决策。他拥有广泛的成功指导记录 以病人为中心的研究。他召集了一支由资深科学家和合作者组成的团队来完成 建议的研究和指导计划。他将提高自己作为导师的技能，并扩大他的 通过参与有针对性的职业发展活动获得科学专业知识，指导、组织 科学，以及群体决策的心理学。这项提议的科学目标是为怀特博士 和他的学员使用其正在进行的R01的现有数据和基础设施来开发新的 研究探索跨专业团队运作和群体决策对 无行为能力的急性呼吸衰竭患者的预后。在目标1中，团队将进行混合 临床医生对跨专业团队的态度和实际行为特征的研究 协作为晚期呼吸衰竭患者的代理人提供决策支持(AIM 1A)，然后进行探索性分析，检查团队功能和结果之间的关联 晚期呼吸衰竭患者(目标1b)。在Aim 2中，他们将使用 是否存在关于ICU护理目标的有录音的临床医生-家庭会议，以确定 以及临床医生如何从代理人那里引出无行为能力患者的价值观和偏好(目标2a)， 然后进行探索性分析，检查与患者预后的关系(目标2b)。一起， 这些科学目标和职业发展活动将扩大怀特博士培训下一位 在开发干预措施以改进替代决策方面产生以患者为中心的研究人员 为晚期呼吸衰竭患者制作。

ABSTRACT The goal of this Midcareer Investigator Award in Patient-Oriented Research is to enhance the ability of Dr. Douglas White to train, mentor, and support the career development of clinician-scientists focused on developing and testing interventions to improve surrogate decision making for incapacitated patients with advanced respiratory failure. Patients with acute respiratory failure and a poor prognosis often receive intensive, burdensome treatments near the end of life that are inconsistent with their values and preferences. This is an important public health problem because 1) patient-centered care near the end of life is a central aspect of ethical, humane care, and 2) overtreatment near the end of life contributes to the disproportionate costs of medical care near the end of life in the U.S. Although the scope of the problems is well documented, there are few evidence-based interventions to improve patient outcomes. Solving this problem will require the collaboration of scientists with expertise in decision science, organizational behavior, and health services research. Dr. White is extremely well positioned to lead these efforts. He is a midcareer investigator with a mature, NIH-funded program of research on surrogate decision making in acute respiratory failure. He has an extensive track record of successful mentoring in patient-oriented research. He has assembled a team of senior scientists and collaborators to accomplish the proposed research and mentoring plan. He will increase his skills as a mentor and expand his scientific expertise by participating in targeted career development activities in mentoring, organizational science, and the psychology of group decision making. The scientific goal of this proposal is for Dr. White and his mentees to use the existing data and infrastructure of his ongoing R01s to develop new lines of research exploring the roles of interprofessional team functioning and group decision making on outcomes for incapacitated patients with acute respiratory failure. In Aim 1 the team will conduct a mixed methods study to characterize clinicians’ attitudes and actual practices related to interprofessional team collaboration in providing decision support to surrogates of patients with advanced respiratory failure (Aim 1a), then conduct exploratory analyses examining associations between team functioning and outcomes of patients with advanced respiratory failure (Aim 1b). In Aim 2 they will use the largest dataset in existence of audiorecorded clinician-family conferences about goals of care in ICUs to determine whether and how clinicians elicit the values and preferences of incapacitated patients from surrogates (Aim 2a), then conduct exploratory analyses examining associations with patient outcomes (Aim 2b). Together, these scientific aims and career development activities will expand Dr. White’s ability to train the next generation of patient-oriented researchers in developing interventions to improve surrogate decision making for patients with advanced respiratory failure.