Decision Making in Patients with Cardiac Defibrillators

Goldstein博士的职业目标是成为一名独立的研究人员，其研究将通过更好地了解他们对先进医疗技术的使用来改善老年人的护理。该K23奖项的目的是支持一系列职业发展活动，其中包括正式的教学课程，正式的指导计划和有针对性的临床研究。本申请中提出的工作涉及研究植入式心律转复除颤器（ICD）的通信。这些装置可以通过电击来终止潜在的致命性心律失常，虽然它们降低了心源性猝死的发生率，但植入ICD的患者最终还是会死亡。随着患者疾病的加重，生理变化导致更多的心律失常，增加了电击的频率。由于ICD的放电可能会导致疼痛和焦虑，并且可能不会延长可接受质量的生命，因此当患者的临床状态恶化且死亡临近时，考虑停用ICD是适当的。Goldstein博士指出，临床医生和患者很少讨论如何停用ICD。考虑到现在和可预见的未来植入老年人体内的ICD数量呈指数增长（自1995年以来> 225，000），成千上万的老年人可能会因ICD未能及时停用而经历痛苦和可怕的死亡。本申请中提出的一系列项目的目的是确定接近生命终点的ICD老年患者的流行病学护理模式;评价医生对ICD停用讨论的触发因素和障碍的看法;并调查患者/家属是否愿意讨论ICD停用及其在做出这些决定时的首选角色。这些项目的目的是：1）确定植入ICD的老年患者的数量，并记录他们在生命末期的医疗保健利用情况; 2）更好地了解医生对禁止/提示停用对话的障碍/触发因素的看法; 3）描述患者对这些讨论的体验，评估他们参与讨论的意愿，并评估他们对设备在生命结束时停用的必要性的理解。为了实现第一个目标，候选人将分析医疗保险数据集，以描述ICD患者在生命结束时接受护理的临床情况。接下来，他将对随机选择的临床医生进行全国范围的电话调查，以验证他之前的定性工作，并进一步澄清停用讨论的障碍/触发因素。最后，他将创建一个符合临终关怀标准的ICD患者的国家队列，并与他们及其家人进行访谈，以确定可能改善ICD沟通的因素。这些研究将产生初步数据，使Goldstein博士能够获得R 01级资金，以创建一个决策工具，支持及时和适当的ICD停用，以减少垂死患者的电击频率。

DESCRIPTION (provided by applicant): Dr. Goldstein's career goal is to become an independent investigator whose research will improve the care of older adults by better understanding their use of advanced medical technologies. The purpose of this K23 award is to support a series of career development activities that will include formal didactic coursework, a program of formal mentoring, and targeted clinical research. The work proposed in this application involves studying communication about Implantable Cardioverter-Defibrillators (ICDs). These devices can deliver a shock to terminate a potentially lethal arrhythmia, and while they reduce the incidence of sudden cardiac death, patients with ICDs do eventually die. As a patient's disease worsens, physiologic changes lead to more arrhythmias, increasing the frequency of shocks. Since discharges from the ICD can cause pain and anxiety and may not prolong a life of acceptable quality, it is appropriate to consider deactivation of the ICD as a patient's clinical status worsens and death is near. Dr. Goldstein has shown that clinicians and patients rarely engage in discussions about deactivating ICDs. Given the exponential increase in the number of ICDs (>225,000 since 1995) implanted in older individuals now and in the foreseeable future, tens of thousands of aging adults may experience a painful and frightening death as a consequence of failure of timely ICD deactivation. The purpose of the series of projects proposed in this application is to determine the epidemiologic patterns of care of older patients with ICDs near the end of life; to evaluate physicians' perceptions of triggers and barriers to discussion about ICD deactivation; and to survey patients/families as to their willingness to discuss ICD deactivation and their preferred role in making these decisions. The aims of these projects are 1) to determine the number of older patients with ICDs and document their healthcare utilization near the end of life; 2) to better understand physicians' perceptions of the barriers/triggers that prohibit/prompt deactivation conversations; and 3) to describe patients' experience of these discussions, evaluate their willingness to engage in them, and assess their understanding of the need for device deactivation near life's end. To achieve the first aim, the candidate will analyze Medicare datasets to characterize the clinical circumstances of care received by ICD patients at the end of life. Next, he will perform a nationwide telephone survey of randomly selected clinicians to validate his previous qualitative work and further clarify the barriers/triggers to deactivation discussions. Finally, he will create a national cohort of patients with ICDs who meet criteria for hospice and perform interviews with them and their families to determine factors which might improve communication about ICDs. These studies will generate preliminary data that will allow Dr. Goldstein to secure R01 level funding to create a decision tool to support timely and appropriate ICD deactivation in order to reduce the frequency of shocks in dying patients.