The SUPPORT study:
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)
by The SUPPORT Principal Investigators
The Journal of the American Medical
Association
(November 22/29, 1995)
(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; and 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
specially 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 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,
i.e.,
incidence of 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 of 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, create individual and societal commitment and more
proactive
and forceful measures may be needed.
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© Copyright The SUPPORT Principal Investigators, 1995. All Rights
Reserved. No portion of this work may be reproduced or transmitted in any
form or by any
means, electronic or mechanical, including photocopying, recording, or any
information storage or retrieval system now or hereafter invented, without
permission in writing from the Publisher.
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