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室（ICU），其中老年人所占比例最大 患有晚期疾病ICU中的大多数死亡是预期的，涉及呼吸机支持的移除，或 姑息性呼吸机撤离（PVW）。主要研究者（PI）的先前工作发现， 的ICU患者接受PVW，年龄超过60岁。此外，还有独特的管理考虑 当老年ICU患者过渡到舒适护理时，包括PVW过程（例如， 减轻痛苦症状的药物和接近激动性谵妄）。虽然在研究中， 过去的15年已经告知了ICU姑息治疗的几个方面，相对而言， 专注于PVW因此，PVW的做法差异很大，患者的痛苦是常见的; 30-59%的晚期 拔管的患者经历呼吸困难。因此，专家和国家组织呼吁提供证据， 为PVW提供信息指南，这是一个与老年患者特别相关的领域。的首要目标， 拟议的研究是为了产生证据基础，以改善老年ICU患者的PVW。具体目标 是：1.为了更好地了解患者体验和提供者的观点，150名机械通气患者 将招募60岁以上的ICU患者，并在波士顿两家医院（180张床位）进行前瞻性随访 经历PVW。2.制定并完善仅舒适度措施暂停（CMOT）干预措施，包括 ICU团队（护士、医生、呼吸治疗师）的结构化暂停与检查表协议， 改进PVW工艺。3.在40个ICU中的4个ICU（2个内科/2个外科）中对CMOT干预进行试点测试 PVW患者影响：通过严格描述接受PVW的老年ICU患者的经历， 开发和试点测试一种新的CMOT干预，拟议的工作将产生大量的需求， 以证据为基础，改善向这一弱势群体提供的护理。调查结果将直接告知 设计一个更大的随机对照试验（R 01），以充分评价干预措施。这项工作将建立PI作为一个 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 在重症监护室里

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.