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November 22, 1995

A Controlled Trial to Improve Care for Seriously III Hospitalized Patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT)

Alfred F. Connors Jr, MD; Neal V. Dawson, MD; Norman A. Desbiens, MD; et al William J. Fulkerson Jr, MD; Lee Goldman, MD, MPH; William A. Knaus, MD; Joanne Lynn, MD; Robert K. Oye, MD; Marilyn Bergner, PhD; Anne Damiano, ScD; Rosemarie Hakim, PhD; Donald J. Murphy, MD; Joan Teno, MD; Beth Virnig, PhD; Douglas P. Wagner, PhD; Albert W. Wu, MD, MPH; Yutaka Yasui, PhD; Detra K. Robinson, MA; Barbara Kreling, BA; Jennie Dulac, BSN, RN; Rose Baker, MSHyg; Sam Holayel, BS; Thomas Meeks, BA; Mazen Mustafa, MS; Juan Vegarra, BS; Carlos Alzola, MS; Frank E. Harrell Jr, PhD; E. Francis Cook, ScD; Mary Beth Hamel, MD; Lynn Peterson, MD; Russell S. Phillips, MD; Joel Tsevat, MD; Lachlan Forrow, MD; Linda Lesky, MD; Roger Davis, ScD; Nancy Kressin, MS,; Jeanmarie Solzan, BA; Ann Louise Puopolo, BSN, RN; Laura Quimby Barrett, BSN, RN; Nora Bucko, BSN, RN; Deborah Brown, MSN, RN; Maureen Burns, BSN, RN; Cathy Foskett, BSN, RN; Amy Hozid, BSN, RN; Carol Keohane, BSN, RN; Colleen Martinez, BSN, RN; Dorcie McWeeney, BSN, RN; Debra Melia, BSN, RN; Shelley Otto, MSN, RN; Kathy Sheehan, BSN, RN; Alice Smith, BSN, RN; Lauren Tofias, MS, RN; Bernice Arthur, BA; Carol Collins, BA; Mary Cunnion, BA; Deborah Dyer, BA; Corinne Kulak, BS; Mary Michaels, BA; Maureen O'Keefe, BA; Marian Parker, AB, MBA; Lauren Tuchin, BA; Dolly Wax, BA; Diana Weld, BA; Liz Hiltunen, MS, RN, CS; Georgie Marks, MS, MEd, RN; Nancy Mazzapica, MSN, RN; Cindy Medich, MS, RN; Jane Soukup, MS; Robert M. Califf, MD; Anthony N. Galanos, MD; Peter Kussin, MD; Lawrence H. Muhlbaier, PhD; Maria Winchell, MS; Lee Mallatratt, RN; Ella Akin, BA; Lynne Belcher, RN; Elizabeth Buller, BSN, RN; Eileen Clair, RN; Laura Drew, BSN, RN; Libby Fogelman, BSN, RN; Dianna Frye, BSN, RN; Beth Fraulo, BSN, RN; Debbie Gessner, BSN, RN; Jill Hamilton, BSN, RN; Kendra Kruse, BSN, RN; Dawn Landis, BSN, RN; Louise Nobles, BSN, RN; Rene Oliverio, BSN, RN; Carroll Wheeler, BSN, RN; Nancy Banks, MA; Steven Berry, BA; Monie Clayton; Patricia Hartwell, MAT; Nan Hubbard; Isabel Kussin, BA; Barbara Norman, BA; Jackie Noveau, BSN; Heather Read, BA; Barbara Warren, MSW; Jane Castle, MSN, RN; Kathy Turner, MSN, RN; Rosalie Perdue; Claudia Coulton, PhD; C. Seth Landefeld, MD; Theodore Speroff, PhD; Stuart Youngner, MD; Mary J. Kennard, MSN; Mary Naccaratto, MSN; Mary Jo Roach, PhD; Maria Blinkhorn, RN; Cathy Corrigan, RNC; Elsie Geric, RN; Laura Haas, RN; Jennifer Ham, RN; Julie Jerdonek, RN; Marilyn Landy, RN; Elaine Marino, RN; Patti Olesen, RN; Sherry Patzke, RN; Linda Repas, RN; Kathy Schneeberger, RN; Carolyn Smith, RN; Colleen Tyler, RN; Mary Zenczak, RN; Helen Anderson, BA; Pat Carolin; Cindy Johnson, BA; Pat Leonard, BA; Judy Leuenberger; Linda Palotta, BA; Millie Warren; Jane Finley, RN; Toni Ross, RN; Gillian Solem, MSN; Sue Zronek, RN; Sara Davis, BS; Steven Broste, MS; Peter Layde, MD, MSc; Michael Kryda, MD; Douglas J. Reding, MD; Humberto J. Vidaillet Jr, MD; Marilyn Folien, RN, MSN; Patsy Mowery, BBA; Barbara E. Backus; Debra L. Kempf, BSN; Jill M. Kupfer; Karen E. Maassen, LPN; Jean M. Rohde, LPN; Nancy L. Wilke; Sharon M. Wilke, LPN; Elizabeth A. Albee, BA; Barbara Backus; Angela M. Franz, BS; Diana L. Henseler; Juanita A. Herr; Irene Leick; Carol L. Lezotte, BS; Laura Meddaugh; Linda Duffy, RN, MSN; Debrah Johnson, RN, BSN; Susan Kronenwetter, RN, BSN; Anne Merkel, RN, BSN; Paul E. Bellamy, MD; Jonathan Hiatt, MD; Neil S. Wenger, MD, MPH; Margaret Leal-Sotelo, MSW; Darice Moranville-Hawkins, RN, MN; Patricia Sheehan, RN; Diane Watanabe, MS; Myrtle C. Yamamoto, RN; Allison Adema, RN; Ellen Adkins, RN; Ann-Marie Beckson, RN; Mona Carter, RN; Ellen Duerr, RN; Ayam El-Hadad, RN, MN; Ann Farber, RN, MA; Ann Jackson, RN; John Justice, RN; Agnes O'Meara, RN; Lee Benson; Lynette Cheney; Carlo Medina; Jane Moriarty; Kay Baker, RN, MN; Cleine Marsden, RN, MN; Kara Watne, RN, MPH; Diane Goya, MA; Norman Desbiens, MD; William J. Fulkerson, MD; Charles C. J. Carpenter, MD; Ronald A. Carson, PhD; Don E. Detmer, MD; Donald E. Steinwachs, PhD; Vincent Mor, PhD; Robert A. Harootyan, MS, MA; Alex Leaf, MD; Rosalyn Watts, EdD, RN; Sankey Williams, MD; David Ransohoff, MD
Author Affiliations

MetroHealth Medical Center, Cleveland, Ohio; Marshfield (Wis) Medical Research Foundation; Duke University Medical Center, Durham, NC; Beth Israel Hospital, Boston, Mass; George Washington University Medical Center, Washington, DC; Dartmouth Medical School, Hanover, NH; University of California at Los Angeles Medical Center; George Washington University Medicai Center, Washington, DC; Dartmouth Medical School, Hanover, NH; Johns Hopkins University, Baltimore, Md; George Washington University Medical Center; Presbyterian-St Lukes Medical Center, Denver, Colo; Dartmouth Medical School; George Washington University Medical Center; Johns Hopkins University; George Washington University Medical Center; George Washington University Medical Center; Dartmouth Medical School; George Washington University Medical Center; National Statistical Center, Duke University Medical Center, Durham, NC; Beth Israel Hospital, Boston, Mass; Duke University Medical Center, Durham, NC; MetroHealth Medical Center, Cleveland, Ohio; Marshfield Medical Research Foundation/St Joseph's Hospital, Marshfield, Wis; University of California at Los Angeles Medical Center; Brown University/The Miriam Hospital, Providence, RI; University of Texas, Galveston; University of Virginia, Charlottesville; The Johns Hopkins University, Baltimore, Md; Brown University; American Association of Retired Persons, Washington, DC; Massachusetts General Hospital, Boston; University of Pennsylvania, Philadelphia; Hospital of the University of Pennsylvania; University of North Carolina at Chapel Hill

JAMA. 1995;274(20):1591-1598. doi:10.1001/jama.1995.03530200027032

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; an 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 the 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, ie, incidence or timing of written DNR orders (adjusted ratio, 1.02; 95% confidence interval [Cl], 0.90 to 1.15), physicians' knowledge of their patients'preferences not to be resuscitated (adjusted ratio, 1.22; 95% Cl, 0.99 to 1.49), number of days spent in an ICU, receiving mechanical ventilation, or comatose before death (adjusted ratio, 0.97; 95% Cl, 0.87 to 1.07), or level of reported pain (adjusted ratio, 1.15; 95% Cl, 1.00 to 1.33). The intervention also did not reduce use of hospital resources (adjusted ratio, 1.05; 95% Cl, 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 or 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, greater individual and societal commitment and more proactive and forceful measures may be needed.(JAMA. 1995;274:1591-1598)

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