FIELDS Research

FIELDS investigators are organized around a common goal: to enhance the care patients receive near the end of their lives by increasing understanding of how patients, family members, and clinicians make end-of-life decisions.  Guided by these insights, we seek to develop and test interventions that improve the timing, content, and outcomes of these important choices.

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Default palliative care consultation for seriously ill hospitalized patients

Principal Investigator: Scott Halpern, MD, PhD

Inpatient palliative care consultative services (IPCS) hold great promise to improve care and reduce costs for patients with life-limiting illnesses. However, there is limited experimental evidence available to quantify the effects of IPCS in generalizable, real-world settings, and even less evidence about which types of services work best for which types of patients or how to insure timely IPCS delivery. This study consists of a large, pragmatic trial to assess the effects of default palliative care consultation for seriously ill patients on clinical, patient-centered, and economic outcomes. The trial will use a stepped-wedge, cluster randomized design to be conducted among 10 geographically dispersed hospitals within Ascension Health, the largest non-profit health system in the country.

Funding: National Institutes of Health

Perceptions of Disability in Survivors of the Intensive Care Unit/Patient-Centered Outcomes and Prognostication

Principal Investigators:Michael Detsky, MD, Dominique Bayard, MD, Scott Halpern, MD, PhD

Intensive care unit (ICU) providers make predictions about their patients’ recovery prospects throughout a given ICU stay, but the accuracy of these predictions has yet to be vigorously studied.  This study aims to better understand how well ICU physicians and nurses are able to prognosticate for physical, cognitive and function as well as mortality, return to original residence and quality of life. The study team is also looking to evaluate agreement in prognosis for a single patient between the doctors and nurses involved in the patient’s care.  The study will use a survey of ICU staff and observational data to assess findings.  During this same study, qualitativedata will be collected to determine the similarities and differences in the perceptions of disability from the perspectives of ICU patients, their families, and providers.

Funding: FIELDS Program funds made available through the Otto Haas Charitable Trust 

The Impact of Active Choice on Completion Rates of Advanced Directives in New Employees of an Academic University Hospital

Principal Investigators: Dominique Bayard, MD, MPPM, Scott Halpern, MD, PhD

Completing an advance directive (AD) can help inform providers, family members, and surrogates about a patient's preferences for end of life care, reducing the decision-making burden for designated proxies in the event of an adverse health situation.  Yet despite the benefits of completed an AD, many patients neglect to enact one.  This study is testing an approach whereby subjects are required to completed either an AD or a form declining to do so.  This does not force a particular outcome, but simply requires patients to make a decision, thereby countering the procrastination and inertia that often prevent people from doing things they actually want to do.

Funding: FIELDS Program funds made available through the Otto Haas Charitable Trust

A Randomized Trial of Expanded Choice Sets to Increase Completion of Advance Directives

Principal Investigators: Katherine Courtright, MD, Scott Halpern, MD, PhD

The way that different choices are framed (the “framing effect”) and the number of choices available often impacts the way people make decisions. In this study, we offer patients expanded options for completing advance directives, rather than compelling a simple yes/no choice. By expanding AD options, we predict that more patients will establish at least some form of advance care plan.

Funding: National Institutes of Health

Variability among US ICUs in managing patients admitted with pre-existing limits on life-sustaining therapies

Principal Investigators: Joanna Hart, MD, Scott Halpern, MD, PhD

Every acute care hospital in the United States has at least one intensive care unit (ICU), and approximately 55,000 critically ill patients are cared for throughout the country each day.  ICUs can vary widely in their method of caring for critically ill patients, particularly for those patients with pre-existing treatment limitations.  This study aims to dissect the variation that exists nationwide among ICUs in the management of these patients through a retrospective cohort study.  The team will use the Project IMPACT database, a large multi-year, national database of ICUs to identify patients with pre-existing treatment limitations to determine if and how their ICU treatment varied from unit to unit.

Funding: National Institutes of Health

Thinking Forward: The Role of Anticipated Regret in Patients and Surrogates Health Care Decisions

Principal Investigators: Joanna Hart, MD, Scott Halpern, MD, PhD

It is unclear how often patients and their caregivers think about the future when considering decisions that need to be made at the end of life.  This study uses qualitative interviews with patients and families to understand the factors that contribute to "forecasting" about the future with regards to healthcare decision making.

Funding: CHIBE Pilot Grant

A Qualitative Approach to Understanding Motivations behind Advance Directive Completion

Principal Investigator: Scott Halpern, MD, PhD

Completing an advance directive (AD) can be comforting for some and stress-inducing for others.  In order to promote the completion of ADs, providers and stakeholders must engage with and address the motivations that arise when patients consider completing an AD.  The goal of this qualitative study is to examine these motivations to better understand the decision making process of patients who decide to complete an AD, as well as those patients who opt out of completing one.  

Funding: FIELDS Program funds made available through the Otto Haas Charitable Trust

Patient- and Surrogate-Centered Outcomes in Critical Illness

Principal Investigators: Sarah Lyon, MS, MSCE, Catherine Auriemma, MD

Rising costs of critical care expenditures coupled with lack of improvements in mortality, error rates, and survivors’ quality of life highlight the need for comparative effectiveness research (CER) to identify outcomes that matter to patients, are efficient to measure, and can be analyzed validly. This study uses purposive sampling to conduct semi-structured, individual interviews of survivors of the Medical Intensive Care Unit (MICU) and their surrogates to understand which outcomes of critical illness matter most to them. Using questionnaires and follow-up interviews with some of the participants, we will also assess changes in preferences over time.

Funding: University of Pennsylvania Institute for Translational Medicine and Therapeutics

Knowledge and Perceptions of Advance Directives Among Seriously Ill Older Patients

Principal Investigator: Scott Halpern, MD, MPH 

The quality and perhaps quantity of end-of-life care is compromised by the tendency for patients, family members, and clinicians to pursue aggressive treatment unless or until someone actively requests a transition to palliative care. Advance directives (AD) allow patients to formally express their preferences for end-of-life care, but rates of AD completion remain low. This study uses semi-structured, individual interviews with seriously ill patients older than 50 years who have and have not completed ADs to identify motivations for and barriers to AD completion.

Clinicians' Understanding of the Determination of Death

Principal Investigators: Vanessa Madrigal, MD, Paul Shore, MD

Despite legal and conceptual definitions of death, we lack specific understanding of clinicians' practices and attitudes on how death is determined. In the setting of organ donation after circulatory determination of death (DCDD), some argue that death must be established precisely and unambiguously. We therefore designed a paper and on-line survey of pediatric clinicians caring for critically ill infants and children in two large pediatric hospitals in Philladelphia, PA. The study investigates what parameters clinicians use to determine death, how timing influences the defining moment and a clinicians' willingness to donate organs using four vignettes of terminally ill children undergoing withdrawal of support.

Variations on Decisions to Limit Life-Sustaining Therapy in the ICU

Principal Investigators: Caroline Quill, MD, Scott Halpern, MD, PhD

Decisions to limit life-sustaining therapy and do not resuscitate (DNR) orders are becoming increasingly common among hospitalized patients. This study is intended to investigate patient- and intensive care unit (ICU)-level sources of variation in decisions to limit life-sustaining therapy (DLST). This retrospective cohort study examines patterns of DLST among ICU patients in the Project Impact (PI) database. PI is a network of over 150 ICUs throughout the United States. In addition, we are evaluating the effects of ICU characteristics, including general ICU practice styles or "culture", on the rates of DLST among patients who do and do not survived their ICU stays.

Decision Fatigue in the Intensive Care Unit

Principal Investigator: Mary McKenzie, MD, MA, Scott Halpern, MD, PhD

Just as skeletal muscles fatigue after repeated motion, decision-making capacity fatigues after making many decisions. When decision fatigue sets in, subsequent decisions may become biased toward the status quo, resulting in resistance to change and preference for choices that preserve future options, even if they run counter to the decision-maker's goals or interests. Although well-established in non-healthcare settings, the role of decision fatigue in medicine has not yet been explored. We will be assessing the presence of decision fatigue in the Medical Intensive Care Unit through direct observation of critical care physicians during physician rounds. We will evaluate how decision type and quantity influence tendencies toward the status quo.

Funding: University of Pennsylvania Research Foundation

The Role of Decision Fatigue in Patients' and Surrogates' End-of-Life Care Choices

Principal Investigators: Mary McKenzie, MD, MA, Scott Halpern, MD, PhD

In this study, we will evaluate whether decision fatigue influences the end-of-life care choices of cancer patients undergoing chemotherapy and their surrogates. Patients and surrogates will be randomized into groups and asked to contemplate or make hypothetical decisions with varying physician-assistance.  Following the completion of this fatiguing task, the level of decision fatigue will be assessed using a standardized measure.  The influence of decision fatigue on end-of-life care choices will then be determined by asking patients and surrogates a final, hypothetical decision about a life-sustaining therapy.

Funding: Penn-CMU Roybal Center on Behavioral Economics and Health Pilot Fund

Focusing the Rationale for Advance Directive Completion

Principal Investigator: Scott Halpern, MD, PhD

This randomized trial explores how focusing on different rationales for advance directive (AD) completion impacts the rates of completion of ADs among patients with advanced respiratory, cardiac, and oncological diseases. Specifically, we are testing if focusing the rationale for AD completion on  protecting of surrogates from decision-making burden or on  controlling future care promotes higher AD completion rates.

Funding: University of Michigan and University of Pennsylvania's Centers for Excellence in Cancer Communication Research

Default Options in Advance Directives for Veterans with Serious Illnesses

Principal Investigator: Joshua Kayser, MD, MPH, Scott Halpern, MD, PhD

Veterans with severe pulmonary, cardiac, and oncological disease will be randomized to receive 1 of 3 advance directives which differ in the default framing of what plans of care and interventions would be enacted if patients did not make decisions to the contrary. Completed advance directives will be used if patients become so ill that they lose decision-making capacity.  We will evaluate how defaults influence seriously ill veterans' preferred goals of care (comfort-oriented vs. life-extending), desires to receive specific life-sustaining interventions, and satisfaction with advance care planning. In addition, this study will be the first to evaluate how default options in advance directives influence subsequent healthcare utilization and hospitalizations.

Funding: Veterans' Affairs Healthcare Network - VISN 4 Competitive Pilot Project Fund