CAN CLINICAL INTERVENTIONS CHANGE CARE AT THE END OF LIFE

Purpose: To review clinical interventions designed to change care at t he end of life. Data Sources: Published results of clinical trials ide ntified by MEDLINE searches, review of abstracts from meetings, and se lected bibliographies. Study Selection: Studies were included if data were presented on a clinical intervention designed to change medical c are at the end of life. Studies done in nonclinical settings or outsid e the United States were excluded. Data Extraction: Interventions were classified as targeting patients, physicians, or both and were analyz ed by their effect on four common clinical goals: increasing use of pa tient preferences, decreasing pain and suffering, reducing use of life -sustaining treatments, and reducing costs. Positive and negative tria l results were compared for differences in intervention, target group, and strength of study methods. Data Synthesis: Educational interventi ons usually increased expression of patient treatment preferences. Suc cess rates were higher when more severely ill patients were targeted a nd when written materials were combined with repeated discussions in c linical encounters. Educational interventions with physicians led to i ncreased use of patient preferences, but sophisticated educational tec hniques were needed to motivate physicians to change their behavior. T hree studies provided limited evidence that physician education reduce d the use of life-sustaining treatments. No clinical intervention had an effect on pain, suffering, or cost of medical care. Conclusion: To change care at the end of life, intensive educational interventions fo r physicians and broad institutional programs seem more promising than advance directives. Future innovations should seek to change physicia n practices, reduce costs, and improve patient-centered out comes, suc h as pain control and satisfaction.