Goals of Care Discussions in Older Adults with Heart Failure and Their Caregivers

我的职业目标是成为一名独立调查员，他的工作改善了 临床医生和老年晚期心力衰竭(HF)患者及其照顾者。此应用程序提出了一种 五年课程和研究计划，旨在促进我发展为一名独立调查员 以病人为中心的老龄化研究。在五年的获奖期间，我将扩大我的研究培训和 通过有指导的研究、正规的课程和自我指导的学习活动获得经验和发展 通过领导力和网络机会实现独立。本申请中建议的工作包括 老年晚期心力衰竭患者护理讨论目标的研究。作为导致 死亡、住院、再入院和医疗保险费用，心力衰竭与与健康相关的生活质量差有关， 患者及其照顾者的显著心理困扰和增加的医疗支出。 晚期心力衰竭复杂多变的轨迹以及可用的生命维持治疗使 与其他严重疾病相比，老年人的决策更加复杂。最近的数据在 晚期癌症患者表明，GOCD可以改善患者和照顾者的预后。不像 癌症， 生活方式 至 心力衰竭患者的预后具有很高的变异性，与主要的 变化和不可预测的症状危机，这使得很难推断癌症的结果 高频。这项提议旨在解决这一差距。 S 我们假设，改进的GOCD将导致改进 患者结果(接受与偏好一致的治疗、更好的生活质量、更少的抑郁和 焦虑和使用率降低)和照顾者结果(较少的抑郁、焦虑和照顾者负担，以及 与没有GOCD的患者相比，满意度提高)。这些项目的目标是：(SA1- 已完成)确定患有晚期心力衰竭的老年人GOCD的障碍和促进者，并确定患者 与GOCD相关的照顾者健康相关结果；(SA2-已完成)以制定和完善层次- 姑息治疗，一种创新的姑息治疗提供模式，以满足患者的独特需求 晚期心力衰竭或癌症；以及(SA3)进行一项一级姑息治疗的试点RCT，以确定 招生，改善症状和生活质量的疗效。为了实现第一个目标，我将分析一个 对晚期心力衰竭患者及其照顾者进行多中心队列研究，以确定预测GOCD和 这些对话的结果。接下来，我将采访患者/照顾者双方，以确定障碍和 全球疾病的促进者。使用SA1数据，我开发和改进了一级姑息治疗(SA2-完成)。 最后，在补充资料的支持下，我将进行一级姑息治疗(SA3)的试点RCT，以 确定其可行性和有效性。这些研究将产生数据，使我能够获得R01资金 在多中心随机对照试验中测试分级姑息治疗。拟议的研究和职业发展计划是 改善对患有晚期心力衰竭和癌症的老年人及其照顾者的护理的初步步骤。

My career goal is to become an independent investigator whose work improves conversations between clinicians and older patients with advanced heart failure (HF) and their caregivers. This application proposes a five-year curriculum and research plan designed to facilitate my development to an independent investigator in patient-oriented aging research. During the five years of the award, I will expand my research training and experience through mentored research, formal coursework and self-directed learning activities and develop independence through leadership and networking opportunities. The work proposed in this application involves studying goals of care discussions (GOCD) in older adults with advanced HF. As one of the leading causes of death, hospitalization, readmission and Medicare costs, HF is associated with poor health-related quality of life, significant psychological distress and increased healthcare spending for patients and their caregivers.The complex and changing trajectory of advanced HF along with the available life-sustaining therapies makes decision-making more complex in older adults as compared to other serious illnesses. Recent data in advanced cancer patients demonstrate that GOCD result in improved patient and caregiver outcomes. Unlike cancer, lifestyle to HF patients have highly variable prognoses, i nvasive potential treatments associated with major changes, and unpredictable ymptom crises, which make it difficult to extrapolate findings from cancer HF. This proposal aims to address this gap. s We hypothesize that improved GOCD will result in improved patient outcomes (receipt of treatments aligned with preferences, better quality of life, less depression and anxiety and decreased utilization) and caregiver outcomes (less depression, anxiety and caregiver burden, and improved satisfaction) as compared to patients who do not have GOCD. The aims of these projects are: (SA1- completed) to identify barriers and facilitators to GOCD in older adults with advanced HF and to identify patient and caregiver health-related outcomes associated with GOCD; (SA2-completed) to develop and refine TIER- PALLIATIVE CARE, an innovative palliative care delivery model to meet the unique needs of patients with advanced HF or cancer; and (SA3) to conduct a pilot RCT of TIER-PALLIATIVE CARE to determine feasibility of enrollment, efficacy to improve symptoms and quality of life. To achieve the first aim, I will analyze a multicenter cohort of advanced HF patients and their caregivers to identify the factors that predict GOCD and outcomes of these conversations. Next, I will interview patient/caregiver dyads to identify barriers and facilitators of GOCDs. Using SA1 data, I developed and refined TIER-PALLIATIVE CARE (SA 2-completed). Finally, with support from the supplement, I will conduct a pilot RCT of TIER-PALLIATIVE CARE (SA3) to determine its feasibility and efficacy. These studies will generate data that will allow me to secure R01 funding to test TIER-PALLIATIVE CARE in a multicenter RCT. The proposed research and career development plan are initial steps toward improving the care of older adults with advanced HF and cancer and their caregivers.