PROJECT SUMMARY/ABSTRACT Patients with chronic life-limiting illness who develop acute respiratory failure are at high risk of death and disability. Because some such patients would choose to forego life-sustaining treatments in certain conditions, it is important that ICU clinicians assess patients’ values, goals, and treatment preferences, and incorporate these findings into shared decision-making to provide goal-concordant care. Unfortunately, my preliminary data as well as qualitative studies of other hospitalized populations suggest that ICU clinicians often miss opportunities to assess or incorporate patients’ goals of care into decision-making. This may lead to the delivery of unwanted intensive care and life-sustaining treatments, which is harmful to both patients and families, and results in the delivery of high-cost, low-value care. The proposed research in this application will use multimethod and mixed-methods approaches to: (1) examine current implementation of goals-of-care discussions for patients with acute respiratory failure and chronic life- limiting illness; (2) identify potentially modifiable clinician behavioral determinants that underlie deficiencies in goals-of-care communication, and iteratively redesign an existing outpatient communication-priming intervention toward the goal of promoting high-quality goals-of-care discussions in the ICU; and, (3) conduct a pilot randomized trial of the redesigned communication-priming intervention to improve the occurrence and quality of documented goals-of-care discussions for patients with acute respiratory failure and chronic life- limiting illness. Through a combination of mentored research activities and formal research training, I will receive valuable research training in analytical methods to enhance the validity of studies that use “real-world” data, application of mixed-methods research to inform health intervention design, and clinical trials. The proposed research and training activities will prepare me for a career as an independent clinical investigator, and will form the foundation for a body of research designed to improve outcomes for patients with acute respiratory failure. These research and training activities will be facilitated by the academically rich research environments of the University of Washington Schools of Medicine, Nursing, and Public Health, as well as the Cambia Palliative Care Center of Excellence at UW Medicine.

PROJECT NARRATIVE Patients with chronic illness who develop acute respiratory failure have a high risk of death or disability; as such, clinicians who treat these patients should always engage patients and families to ascertain their goals of care. However, prior studies and my preliminary data suggest that this important conversation often does not take place—and, when it does take place, the quality of the discussion is often poor. In this K23, I will examine existing deficiencies in clinicians’ communication practices, and design and evaluate novel strategies to improve communication for patients with chronic illness and acute respiratory failure; these activities will train me to become an independent physician-scientist conducting patient-oriented research to improve patient outcomes.