Characterization and Identification of Markers of Clinical Momentum in the Care of Older Adults with Advanced Dementia

摘要 在生命的最后6个月，患有严重疾病的老年人将经常接受侵入性治疗，尽管 偏好，以避免效果有限的繁重干预。例如，进料管不是 推荐给患有严重痴呆症的老年人，但近十分之一的人会收到一种。战略以实现 减少在生命末期接受过度治疗的情况主要集中在改善沟通上，但 系统层面的实践模式对病人护理的提供有很大的影响。上游事件和 临床规范可以产生即使使用高级通信也很难修改的护理轨迹 姑息治疗专家所使用的技能。 “临床动量标记物在老年糖尿病护理中的表征和鉴定 晚期痴呆“是一项为期两年的观察性研究，专门针对PA-18-503治疗 开发新工具、方法和模型的探索性或发展性研究建议 老年人群中的姑息治疗。我们的研究团队之前已经认识到系统级的实践 导致过度治疗的模式，并开发了一个概念框架来描述这种现象，我们 这就是临床动力。我们现在需要开发经验工具来识别和衡量临床动量。 并记录其与生命末期过度治疗的关系。这项建议的目的是 描述放置了喂养管的老年晚期痴呆患者的护理轨迹 以急性住院期间的临床动量为例进行研究。这项由两部分组成的研究旨在评估 并通过在实践中描述临床动量的组成部分来扩展我们的概念框架 在电子健康记录中识别临床势头的标记。对于目标1，我们将使用关键线人 访谈和定性分析，以描述事件、过程和潜在属性的轨迹 导致晚期痴呆症患者放置喂养管的急性护理。对于目标2，我们将确定 标记物和产生临床势头的事件序列在医疗记录中是明显的。 在完成这项工作后，我们希望对导致以下情况的护理轨迹有一个深刻的了解 进展期痴呆成人患者的喂养管放置。这项研究具有创新性，因为它使用了 以理论为导向的经验战略，以确定可能在提供 临终时的过度治疗。这项研究具有重要意义，因为表征临床势头可能 使我们能够识别错位的激励措施和护理轨迹中较早的特定时刻 可以采取干预措施来扰乱临床势头，提高老年人的护理质量。 我们的多学科团队有能力在这个奖项的范围内实现我们的目标，因为 我们环境中的资源，使我们能够在两个截然不同的医院环境中检查这个问题。

ABSTRACT In the final 6 months of life older adults with serious illness will frequently receive invasive treatments despite preferences to avoid burdensome interventions with limited efficacy. For example, feeding tubes are not recommended for older adults with advanced dementia, but nearly one in ten will receive one. Strategies to reduce receipt of overtreatment at the end of life have focused largely on improving communication, yet systems-level practice patterns have a strong influence on the delivery of patient care. Upstream events and clinical norms can produce a trajectory of care that is difficult to modify even with the advanced communication skills employed by palliative care specialists. “Characterization and Identification of Markers of Clinical Momentum in the Care of Older Adults with Advanced Dementia” is a two-year observational study that responds specifically to PA-18-503 for an exploratory or developmental research proposal to develop new tools, methods and models focused on palliative care in geriatric populations. Our research team has previously recognized systems-level practice patterns leading to overtreatment and developed a conceptual framework to describe this phenomenon that we call clinical momentum. We now need to develop empirical tools to identify and measure clinical momentum and document its relationship to overtreatment at the end of life. The objective of this proposal is to characterize the trajectory of care for older adults with advanced dementia who have a feeding tube placed during acute hospitalization as a case study of clinical momentum. This 2-part study is designed to evaluate and extend our conceptual framework by characterizing components of clinical momentum in practice and identifying markers of clinical momentum in the electronic health record. For aim 1, we will use key informant interviews and qualitative analysis to describe the trajectory of events, processes, and latent properties of acute care that lead to feeding tube placement for patients with advanced dementia. For aim 2, we will identify markers and the sequence of events generating clinical momentum that are evident in the medical record. Upon completion of this work we hope to have a deep understanding of the trajectory of care that leads to feeding tube placement in adults with advanced dementia. This research is innovative because it uses a theory-driven empirical strategy to identify practice patterns that may play a critical role in the provision of overtreatment at the end of life. This research is significant because characterizing clinical momentum could allow us to identify misaligned incentives and specific moments earlier in the trajectory of care where interventions could be employed to disrupt clinical momentum and improve the quality of care for older adults. Our multidisciplinary team is well positioned to achieve our objectives within the scope of this award given the resources in our environment, allowing us to examine this problem within 2 distinctly different hospital settings.