BACKGROUND:Frailty is the leading prognosticator for poor outcomes and palliative care among older adults. Delivery of negative prognostic information entails potentially difficult conversations about decline and death. OBJECTIVE:The study aims were to: 1) examine hospitalized older adults' and family caregivers' receptivity to general (vs. individualized) prognostic information about frailty, injury, and one-year outcomes; and 2) determine information needs based on prognostic information. DESIGN:Provision of general prognostic information followed by semi-structured interview questions. We deductively analyzed qualitative data within the context of problematic integration theory. SETTING:An academic medical center in the Southeast region of the U.S. PARTICIPANTS:Purposive sampling was utilized to obtain a distribution of patients across the frailty continuum (non-frail [N=10], pre-frail [N=9], frail [9=6]). Twenty-five older adults (≥ age 65) hospitalized for a primary injury (e.g. fall) and 15 family caregivers of hospitalized patients were enrolled. METHODS:Hospitalized older patients and family caregivers were shown prognostic information about one-year outcomes of injured older adults in the form of simple pictographs. Semi-structured interview questions were administered immediately afterwards. The interviews were audio-recorded, transcribed, and analyzed using qualitative content analysis. Demographic and medical information data were used to contextualize the responses during analysis. RESULTS:Overall, participants (patients [56%], caregivers [73%]) were open to receiving prognostic information. A small number of family caregivers (N=3) expressed reservations about the frankness of the information and suggested delivery through a softer approach or not at all. Qualitative data was coded using categories and constructs of problematic integration theory. Four codes (personalizing the evidence, vivid understanding, downhill spiral, realities of aging) reflected probabilistic and evaluative orientation categories of problematic integration theory. One code (fatalism vs. hope) represented manifestations of ambivalence and ambiguity in the theory; and another code (exceptionalism) represented divergence and impossibility. Two codes (role of thought processes, importance of faith) reflected forms of resolutions as described in problematic integration theory. Information needs based on prognostic information revealed four additional codes: give it to me straight, what can I do? what can I expect? and how can I prevent decline? A consistently reported desire of both patients and caregivers was for honesty and hope from providers. CONCLUSION:This study supports the use of general prognostic information in conversations about aging, injury, frailty and patient outcomes. Incorporating prognostic information into communication aids can facilitate shared decision making before end-of-life is imminent.

译文

背景:虚弱是老年人不良结局和姑息治疗的主要预后因素。阴性预后信息的传递带来了关于衰退和死亡的潜在困难对话。
目的:该研究旨在:1)检查住院的老年人和家庭护理人员对虚弱,受伤和一年预后的一般(相对于个体)预后信息的接受度; 2)根据预后信息确定信息需求。
设计:提供一般预后信息,然后提供半结构化面试问题。我们在问题积分理论的背景下演绎了定性数据。
地点:美国东南部的学术医学中心
参与者:采用有针对性的抽样方法来获得整个脆弱连续体的患者分布(非脆弱[N = 10],脆弱前[N = 9],脆弱[9 = 6])。招募了25名因原发性损伤(例如跌倒)住院的老年人(≥65岁),并招募了15名住院患者的家庭看护人。
方法:以简单的象形文字形式向住院老年患者和家庭护理人员显示有关受伤的成年人一年结局的预后信息。此后立即进行半结构化面试问题。使用定性内容分析对访谈进行录音,转录和分析。人口统计和医学信息数据用于分析期间的响应情况。
结果:总体而言,参与者(患者[56%],护理人员[73%])愿意接受预后信息。少数家庭护理员(N = 3)对信息的坦率性表示保留,并建议通过更柔和的方法或根本不采用这种方法。使用有问题的整合理论的类别和构造对定性数据进行编码。四个代码(个性化的证据,生动的理解,下坡的螺旋式增长,衰老的现实)反映了问题整合理论的概率和评估方向类别。一种代码(致命主义与希望)代表了理论中模棱两可和模棱两可的表现。另一个法则(例外主义)代表了分歧和不可能。如有问题的整合理论中所述,两个代码(思维过程,信念的重要性)反映了决议的形式。基于预后信息的信息需求显示了四个附加代码:直接给我,我该怎么办?我能期待什么?以及如何防止下降?患者和护理人员一致报告的愿望是提供者的诚实和希望。
结论:本研究支持在有关衰老,损伤,虚弱和患者预后的对话中使用一般预后信息。将预后信息纳入交流辅助工具可以促进临终前的共同决策。

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