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A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators.
JAMA 1995 Nov 22-29; 274(20):1591-8JAMA

Abstract

OBJECTIVES

To improve end-of-life decision making and reduce the frequency of a mechanically supported, painful, and prolonged process of dying.

DESIGN

A 2-year prospective observational study (phase I) with 4301 patients followed by a 2-year controlled clinical trial (phase II) with 4804 patients and their physicians randomized by specialty group to the intervention group (n = 2652) or control group (n = 2152).

SETTING

Five teaching hospitals in the United States.

PATIENTS

A total of 9105 adults hospitalized with one or more of nine life-threatening diagnoses; an overall 6-month mortality rate of 47%.

INTERVENTION

Physicians in the intervention group received estimates of the likelihood of 6-month survival for every day up to 6 months, outcomes of cardiopulmonary resuscitation (CPR), and functional disability at 2 months. A specifically trained nurse had multiple contacts with the patient, family, physician, and hospital staff to elicit preferences, improve understanding of outcomes, encourage attention to pain control, and facilitate advance care planning and patient-physician communication.

RESULTS

The phase I observation documented shortcomings in communication, frequency of aggressive treatment, and the characteristics of hospital death: only 47% of physicians knew when their patients preferred to avoid CPR: 46% of do-not-resuscitate (DNR) orders were written within 2 days of death; 38% of patients who died spent at least 10 days in an intensive care unit (ICU); and for 50% of conscious patients who died in the hospital, family members reported moderate to severe pain at least half the time. During the phase II intervention, patients experienced no improvement in patient-physician communication (eg, 37% of control patients and 40% of intervention patients discussed CPR preferences) or in the five targeted outcomes, ie, incidence or timing of written DNR orders (adjusted ratio, 1.02; 95% confidence interval [CI], 0.90 to 1.15), physicians' knowledge of their patients' preferences not to be resuscitated (adjusted ratio, 1.22; 95% CI, 0.99 to 1.49), number of days spent in an ICU, receiving mechanical ventilation, or comatose before death (adjusted ratio, 0.97; 95% CI, 0.87 to 1.07), or level of reported pain (adjusted ratio, 1.15; 95% CI, 1.00 to 1.33). The intervention also did not reduce use of hospital resources (adjusted ratio, 1.05; 95% CI, 0.99 to 1.12).

CONCLUSIONS

The phase I observation of SUPPORT confirmed substantial shortcomings in care for seriously ill hospitalized adults. The phase II intervention failed to improve care or patient outcomes. Enhancing opportunities for more patient-physician communication, although advocated as the major method for improving patient outcomes, may be inadequate to change established practices. To improve the experience of seriously ill and dying patients, greater individual and societal commitment and more proactive and forceful measured may be needed.

Pub Type(s)

Clinical Trial
Controlled Clinical Trial
Journal Article
Multicenter Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

7474243

Citation

"A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients. the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). the SUPPORT Principal Investigators." JAMA, vol. 274, no. 20, 1995, pp. 1591-8.
A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA. 1995;274(20):1591-8.
(1995). A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA, 274(20), pp. 1591-8.
A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients. the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). the SUPPORT Principal Investigators. JAMA. 1995;274(20):1591-8. PubMed PMID: 7474243.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. PY - 1995/11/22/pubmed PY - 1995/11/22/medline PY - 1995/11/22/entrez KW - Beth Israel Hospital (Boston) KW - Death and Euthanasia KW - Duke University Medical Center KW - Empirical Approach KW - Marshfield Clinic/St. Joseph's Hospital (Marshfield, WI) KW - MetroHealth Medical Center (Cleveland) KW - Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) KW - UCLA Medical Center (Los Angeles) SP - 1591 EP - 8 JF - JAMA JO - JAMA VL - 274 IS - 20 N2 - OBJECTIVES: To improve end-of-life decision making and reduce the frequency of a mechanically supported, painful, and prolonged process of dying. DESIGN: A 2-year prospective observational study (phase I) with 4301 patients followed by a 2-year controlled clinical trial (phase II) with 4804 patients and their physicians randomized by specialty group to the intervention group (n = 2652) or control group (n = 2152). SETTING: Five teaching hospitals in the United States. PATIENTS: A total of 9105 adults hospitalized with one or more of nine life-threatening diagnoses; an overall 6-month mortality rate of 47%. INTERVENTION: Physicians in the intervention group received estimates of the likelihood of 6-month survival for every day up to 6 months, outcomes of cardiopulmonary resuscitation (CPR), and functional disability at 2 months. A specifically trained nurse had multiple contacts with the patient, family, physician, and hospital staff to elicit preferences, improve understanding of outcomes, encourage attention to pain control, and facilitate advance care planning and patient-physician communication. RESULTS: The phase I observation documented shortcomings in communication, frequency of aggressive treatment, and the characteristics of hospital death: only 47% of physicians knew when their patients preferred to avoid CPR: 46% of do-not-resuscitate (DNR) orders were written within 2 days of death; 38% of patients who died spent at least 10 days in an intensive care unit (ICU); and for 50% of conscious patients who died in the hospital, family members reported moderate to severe pain at least half the time. During the phase II intervention, patients experienced no improvement in patient-physician communication (eg, 37% of control patients and 40% of intervention patients discussed CPR preferences) or in the five targeted outcomes, ie, incidence or timing of written DNR orders (adjusted ratio, 1.02; 95% confidence interval [CI], 0.90 to 1.15), physicians' knowledge of their patients' preferences not to be resuscitated (adjusted ratio, 1.22; 95% CI, 0.99 to 1.49), number of days spent in an ICU, receiving mechanical ventilation, or comatose before death (adjusted ratio, 0.97; 95% CI, 0.87 to 1.07), or level of reported pain (adjusted ratio, 1.15; 95% CI, 1.00 to 1.33). The intervention also did not reduce use of hospital resources (adjusted ratio, 1.05; 95% CI, 0.99 to 1.12). CONCLUSIONS: The phase I observation of SUPPORT confirmed substantial shortcomings in care for seriously ill hospitalized adults. The phase II intervention failed to improve care or patient outcomes. Enhancing opportunities for more patient-physician communication, although advocated as the major method for improving patient outcomes, may be inadequate to change established practices. To improve the experience of seriously ill and dying patients, greater individual and societal commitment and more proactive and forceful measured may be needed. SN - 0098-7484 UR - https://www.unboundmedicine.com/medline/citation/7474243/A_controlled_trial_to_improve_care_for_seriously_ill_hospitalized_patients__The_study_to_understand_prognoses_and_preferences_for_outcomes_and_risks_of_treatments__SUPPORT___The_SUPPORT_Principal_Investigators_ L2 - https://jamanetwork.com/journals/jama/fullarticle/vol/274/pg/1591 DB - PRIME DP - Unbound Medicine ER -