A CONTROLLED TRIAL TO IMPROVE CARE FOR SERIOUSLY ILL HOSPITALIZED-PATIENTS - THE STUDY TO UNDERSTAND PROGNOSES AND PREFERENCES FOR OUTCOMESAND RISKS OF TREATMENTS (SUPPORT)

Objectives.-To improve end-of-life decision making and reduce the freq uency of a mechanically supported, painful, and prolonged process of d ying. 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 grou p to the intervention group (n=2652) or control group (n=2152). Settin g.-Five teaching hospitals in the United States. Patients.-A total of 9105 adults hospitalized with one or more of nine life-threatening dia gnoses; an overall 6-month mortality rate of 47%. Intervention.-Physic ians in the intervention group received estimates of the likelihood of 6-month survival for every day up to 6 months, outcomes of cardiopulm onary resuscitation (CPR), and functional disability at 2 months. A sp ecially trained nurse had multiple contacts with the patient, family, physician, and hospital staff to elicit preferences, improve understan ding of outcomes, encourage attention to pain control, and facilitate advance care planning and patient-physician communication. Results.-Th e phase I observation documented shortcomings in communication, freque ncy of aggressive treatment, and the characteristics of hospital death : only 47% of physicians knew when their patients preferred to avoid C PR; 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 intens ive care unit (ICU); and for 50% of conscious patients who died in the hospital, family members reported moderate to severe pain at least ha lf the time. During the phase II intervention, patients experienced no improvement in patient-physician communication (eg, 37% of control pa tients 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 re suscitated (adjusted ratio, 1.22; 95% CI, 0.99 to 1.49), number of day s spent in an ICU, receiving mechanical ventilation, or comatose befor e death (adjusted ratio, 0.97; 95% CI, 0.87 to 1.07), or level of repo rted pain (adjusted ratio, 1.15, 95% CI, 1.00 to 1.33). The interventi on 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 SUPPO RT confirmed substantial shortcomings in care for seriously ill hospit alized adults. The phase II intervention failed to improve care or pat ient outcomes. Enhancing opportunities for more patient-physician comm unication, although advocated as the major method for improving patien t outcomes, may be inadequate to change established practices. To impr ove the experience of seriously ill and dying patients, greater indivi dual and societal commitment and more proactive and forceful measures may be needed.