Communication and decision-making in seriously ill patients: Findings of the SUPPORT project

OBJECTIVES: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) represents one of the largest and most co mprehensive efforts to describe patient preferences in seriously ill patien ts, and to evaluate how effectively patient preferences are communicated. O ur objective was to review findings from SUPPORT describing the communicati on of seriously ill patients' preferences for end-of-life care. METHODS: We identified published reports from SUPPORT describing patient pr eferences and the communication of those preferences. We abstracted finding s that addressed each of the following questions: What patient characterist ics predict patient preferences for end of life care? How well do physician s, nurses, and surrogates understand their patients' preferences, and what variables are correlated wish this understanding? Does increasing the docum entation of existing advance directives result in care more consistent with patients' preferences? RESULTS: Patients who are older, have cancer, are women, believe their prog noses are poor, and are more dependent in ADL function are less likely to w ant CPR. However, there is considerable variability and geographic variatio n in these preferences. Physician, nurse, and surrogate understanding of th eir patient's preferences is only moderately better than chance. Most patie nts do not discuss their preferences with their physicians, and only about half of patients who do not wish to receive CPR receive DNR orders. Factors other than the patients' preferences and prognoses, including the patient' s age, the physician's specialty, and the geographic site of care were stro ng determinants of whether DNR orders were written. In SUPPORT patients, th ere was no evidence that increasing the rates of documentation of advance d irectives results in care that is more consistent with patients' preference s. CONCLUSIONS: SUPPORT documents that physicians and surrogates are often una ware of seriously ill patients' preferences. The care provided to patients Is often not consistent with their preferences and is often associated with factors other than preferences or prognoses. Improving these deficiencies in end-of-life care may require systematic change rather than simple interv entions.