Improving Medical Decision Making for Older Patients with End Stage Renal Disease

由于生活水平的提高，越来越多的老年患者患有慢性肾病（CKD）- 延长技术和人口老龄化。随着CKD向终末期肾病进展 （ESRD），即使是延长生命的技术也不能无限期地延长生命，特别是对于患有 预后差，对他们来说，医疗干预的决定变得特别重要。 因此，患有晚期CKD的老年患者需要与他们的医生沟通， 关于CPR、透析和支持性肾脏护理的偏好（ 没有透析的晚期CKD），以便做出影响其治疗时间和质量的关键决定。 生活围绕医疗决策的沟通在高级护理计划（ACP）中正式化， 涉及口头或书面信息的过程，旨在告知患者可能的医疗选择，包括 心肺复苏术，透析和支持性肾脏护理。ESRD患者的传统ACP依赖于临时口头 治疗方案的描述。这种方法是有限的，因为这些选项是难以想象的。我们 开发了一种视频决策辅助工具，用于审查CPR、透析和非透析治疗偏好， 终末期肾病该工具有英语和西班牙语两种版本，还允许患者视频记录他们的 他们可以通过视频声明（“video declaration”）了解自己的偏好，并与他们的临床医生和护理人员分享他们的偏好。整体 本研究的目的是对视频干预（与常规护理相比）进行多中心随机试验， 测试这一假设，即视频更好地告知患有晚期CKD和预后不良的老年人， 治疗方案，并导致更多的ACP文件，知情决策，并提高质量 生活我们将比较600名年龄75岁或75岁以下的患者一年后（或死亡时）的ACP记录， 患有晚期CKD和预后不良的老年人被随机分配到视频干预或常规护理组 (Aim 1）。我们将比较ESRD治疗偏好、决策冲突、ACP参与和 对话，以及视频干预或ESRD常规护理后陈述的偏好一致性 一年后（或死亡时）的护理交付（目标2）。我们将探讨生活质量、寿命和成本 与视频中患者ESRD治疗决策相关的每质量调整生命年（QALY）与 对照组（目标3）。我们还将对视频声明进行定性评估， 干预成功的障碍和促进因素（目标4和5）。老年患者的ESRD涉及复杂的 决策。我们必须制定和评估早期干预措施，以提供更多的病人- 重点关注这一快速增长的人群。使用视频增强沟通服务 这是改善这一弱势患者群体护理的机会。视频是一个实用的，基于证据的， 创新的方法，有可能提高提供给成千上万的老年人的护理质量， 美国人

A growing number of older patients are living with chronic kidney disease (CKD) due to advances in life- prolonging technologies and the aging of the population. As CKD advances towards end-stage renal disease (ESRD), even life-prolonging technologies cannot extend life indefinitely, especially for patients who have a poor prognosis and for whom decisions about medical interventions become particularly important. Consequently, older patients with advanced CKD need to communicate with their physicians about their preferences regarding CPR, dialysis and supportive kidney care (medical management of symptoms of advanced CKD without dialysis) in order to make crucial decisions impacting the length and quality of their lives. Communication surrounding medical decision making is formalized in Advance Care Planning (ACP), a process involving verbal or written information designed to inform patients of possible medical options including CPR, dialysis and supportive kidney care. Traditional ACP for patients with ESRD relies on ad hoc verbal descriptions of treatment options. This approach is limited because these options are difficult to envision. We have developed a video decision aid for reviewing CPR, dialysis and non-dialytic treatment preferences in ESRD. The tool, which is available in both English and Spanish, also allows patients to video record their preferences ("video declaration") and share their preferences with their clinicians and caregivers. The overall objective of this study is to conduct a multi-center randomized trial of the video intervention (vs. usual care) to test the hypothesis that the video better informs older persons with advanced CKD and poor prognosis of their treatment options and leads to more ACP documentation, informed decision making, and improved quality of life. We will compare ACP documentation after one year (or at time of death) among 600 patients aged 75 or older with advanced CKD and poor prognosis randomly assigned to either the video intervention or usual care (Aim 1). We will compare ESRD treatment preferences, decisional conflict, ACP engagement and conversations, and concordance of preferences stated after the video intervention or usual care with ESRD care delivery after one year (or at time of death) (Aim 2). We will explore the quality of life, longevity, and cost per Quality Adjusted Life Year (QALY) associated with patients' ESRD treatment decisions in the video vs. control groups (Aim 3). We will also conduct a qualitative assessment of the video declarations as well as barriers and facilitators for intervention success (Aims 4 and 5). ESRD in older patients involves complex decision making. It is imperative that we develop and evaluate early interventions to deliver more patient- focused care to this rapidly growing segment of the population. Using videos to enhance communication offers an opportunity to improve care of this vulnerable group of patients. Video is a practical, evidence-based, and innovative approach that has the potential to improve the quality of care provided to tens of thousands of older Americans.