To the Editor.
—The similarity between the SUPPORT1 intervention and the way many hospitals responded to the Patient Self-determination Act (PSDA) is striking.2 Many hospitals' PSDA policies use clerks, nurses, social workers, and other nonphysician staff to promote advance directive use, often without significant impact. Physicians remain disengaged from these PSDA efforts. The advance directive effort appears to be tolerated by physicians almost because they expect it to have little impact on their usual practice. Likewise, the SUPPORT intervention used computer models, written materials for the medical record, and nurse specialists. Despite the participating physicians' willingness to be part of SUPPORT, I wonder if they simply tolerated the intervention because it did not interfere too much with existing practice, rather than being committed to improving the designated outcomes. It would be interesting to have had a measure that reflected the extent to which participating physicians embraced the notion
Sachs GA. The SUPPORT Project and Improving Care for Seriously III Patients. JAMA. 1996;275(16):1229. doi:10.1001/jama.1996.03530400015023