Rethinking fundamental assumptions: SUPPORT's implications for future reform

BACKGROUND: The intervention in SUPPORT, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, was ineffective in ch anging communication, decision-making, and treatment patterns despite evide nce that counseling and information were delivered as planned. The previous paper in this volume shows that modest alterations in the intervention des ign probably did not explain the lack of substantial effects. OBJECTIVE: To explore the possibility that improved individual, patient-lev el decision-making is not the most effective strategy for improving end-of- life care and that improving routine practices may be more effective. DESIGN: This paper reflects our efforts to synthesize findings from SUPPORT and other sources in order to explore our conceptual models, their consist ency with the data, and their leverage for change. RESULTS: Many of the assumptions underlying the model of improved decision- making are problematic. Furthermore, the results of SUPPORT suggest that im plementing an effective intervention based on a normative model of shared d ecision-making can be quite difficult. Practice patterns and social expecta tions may be strong influences in shaping patients' courses of care. Innova tions in system function, such as quality improvement or changing the finan cing incentives, may offer more powerful avenues for reform. CONCLUSIONS: SUPPORT's intervention may have failed to have an impact becau se strong psychological and social forces underlie present practices. Syste m-level innovation and quality improvement in routine care may offer more p owerful opportunities for improvement.