Intensive Palliative Care: Improving the Process of Palliative Ventilator Withdrawal Among Critically Ill Older Adults

近25%的美国人死于重症监护病房(ICU)，其中最大比例是老年人 患有晚期疾病。预计ICU中的大多数死亡都涉及呼吸机支架的移除，或者 姑息性呼吸机停用(PVW)。首席调查员(PI)之前的工作发现超过三分之二 接受PVW的ICU患者中60岁以上。此外，还有独特的管理考虑因素 当将老年ICU患者过渡到舒适护理时，包括PVW过程(例如，选择和剂量 缓解痛苦症状和接近焦虑性精神错乱的药物)。在进行研究的同时 在过去的15年里，ICU姑息治疗的几个方面都得到了启发，但这些工作相对较少 专注于PVW。因此，PVW的做法差异很大，患者的痛苦很常见；30%-59%的晚期患者 拔管的患者会出现呼吸困难。因此，专家和国家组织呼吁提供证据 告知关于PVW的指南，这是一个与老年患者特别相关的领域。最重要的目标是 建议的研究是为改善老年ICU患者的PVW提供证据基础。具体目标 是：1.为了更好地了解患者的体验和提供者的观点，150名患者接受了机械通气 60岁以上的ICU患者将被招募，并在波士顿的两家医院(180张床位)进行前瞻性跟踪。 正在经历新一轮战争。2.开发和完善舒适度措施仅超时(CMOT)干预，包括 为ICU团队(护士、内科医生、呼吸治疗师)制定有计划的休息时间和检查表协议，以便 改进PVW工艺。3.在40个ICU中的4个ICU(2个内科/2个外科)试行CMOT干预 PVW患者。影响：通过严格描述接受PVW的老年ICU患者的经历，以及 开发和试点测试一种新型的CMOT干预措施，拟议的工作将产生极大的需求 改善向这一弱势群体提供的护理的证据基础。调查结果将直接告知 设计一个更大的随机对照试验(R01)，以全面评估干预措施。这项工作将使PI成为一种 具有独特技能的独立调查员在老年人中进行姑息治疗干预研究 在重症监护室的环境中。

Nearly 25% of Americans die in intensive care units (ICUs), the largest proportion of whom are older persons with advanced illness. Most deaths in ICUs are expected and involve the removal of ventilator support, or palliative ventilator withdrawal (PVW). Prior work by the Principal Investigator (PI) found more than two-thirds of ICU patients undergoing PVW were over age 60. Moreover, there are unique management considerations when transitioning an older ICU patient to comfort care, including for the PVW process (e.g. choice and dose of drugs to alleviate distressing symptoms and approach to agitated delirium). While research conducted over the past 15 years has informed several aspects of palliative care in the ICU, relatively little of that work has focused on PVW. As such, PVW practices vary widely, and patient suffering is common; 30-59% of terminally extubated patients experience dyspnea. Thus, experts and national organizations have called for evidence to inform guidelines for PVW, an area of particular relevance to older patients. The over-riding objective of the proposed research is to generate the evidence-base to improve PVW in older ICU patients. The Specific Aims are: 1. To better understand the patient experience and providers’ perspectives, 150 mechanically ventilated ICU patients over 60 years old will be recruited and prospectively followed in two Boston hospitals (180 beds) undergoing PVW. 2. To develop and refine a Comfort Measures Only Time out (CMOT) intervention consisting of a structured time out with check-list protocol for the ICU team (nurse, physician, respiratory therapist) to improve the process of PVW. 3. To pilot test the CMOT intervention in 4 ICUs (2 medical/2 surgical) among 40 PVW patients. Impact: By rigorously characterizing the experience of older ICU patients undergoing PVW, and developing and pilot testing a novel CMOT intervention, the proposed work will generate the much need evidence base to improve the care provided to this vulnerable population. Findings will directly inform the design of a larger RCT (R01) to fully evaluate the intervention. This work will establish the PI as an independent investigator with unique skills conducting palliative care intervention research among older adults in the ICU setting.