The End of Life: Medical Considerations - The Study To Understand Prognoses And Preferences For Outcomes And Risks Of Treatments (support)

During the twentieth century in the United States, the process of dying shifted from the familiar surroundings of home to the hospital. While hospitalization ensures that the benefits of modern medicine are readily available, many patients dread leaving the comfort of their homes and losing, to some extent, control over their end-of-life decisions.

Between 1989 and 1994, in an effort to "improve end-of-life decision making and reduce the frequency of a mechanically supported, painful, and prolonged process of dying," a group of investigators from various disciplines undertook the largest study of death and dying ever conducted in the United States. The project, known as the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), included more than nine thousand patients who suffered

TABLE 4.1 Death rates for the 15 leading causes of death, 2003, and percent change, 2002–03 Donna L. Hoyert, et al., "Table 2. Percentage of Total Deaths, Death Rates, Age-Adjusted Death Rates for 2003, Percentage Change in Age-Adjusted Death Rates from 2002 to 2003 and Ratio of Age-Adjusted Death Rates by Race and Sex for the 15 Leading Causes of Death for the Total Population in 2003: United States," in Deaths: Final Data for 2003, Health E-Stats, Centers for Disease Control and Prevention, National Center for Health Statistics, January 19, 2006, http://www.cdc.gov/nchs/data/hestat/finaldeaths03_tables.pdf#2 (accessed February 27, 2006)

TABLE 4.1
Death rates for the 15 leading causes of death, 2003, and percent change, 2002–03
[Death rates on an annual basis per 100,000 population: age-adjusted rates per 100,000 U.S. standard population]
Rank*	Cause of death	Number	Percent of total deaths	2003 crude death rate	Age-adjusted death rate
					2003	Percent change	Ratio
						2002 to 2003	Male to female	Black to white	Hispanic to Non-Hispanic white
… Category not applicable.
*Rank based on number of deaths.
SOURCE: Donna L. Hoyert, et al., "Table 2. Percentage of Total Deaths, Death Rates, Age-Adjusted Death Rates for 2003, Percentage Change in Age-Adjusted Death Rates from 2002 to 2003 and Ratio of Age-Adjusted Death Rates by Race and Sex for the 15 Leading Causes of Death for the Total Population in 2003: United States," in Deaths: Final Data for 2003, Health E-Stats, Centers for Disease Control and Prevention, National Center for Health Statistics, January 19, 2006, http://www.cdc.gov/nchs/data/hestat/finaldeaths03_tables.pdf#2 (accessed February 27, 2006)
…	All causes	2,448,288	100.0	841.9	832.7	−1.5	1.4	1.3	0.8
1	Diseases of heart	685,089	28.0	235.6	232.3	−3.5	1.5	1.3	0.8
2	Malignant neoplasms	556,902	22.7	191.5	190.1	−1.8	1.5	1.2	0.7
3	Cerebrovascular diseases	157,689	6.4	54.2	53.5	−4.8	1.0	1.5	0.8
4	Chronic lower respiratory diseases	126,382	5.2	43.5	43.3	−0.5	1.4	0.7	0.4
5	Accidents (unintentional injuries)	109,277	4.5	37.6	37.3	1.1	2.2	1.0	0.8
6	Diabetes mellitus	74,219	3.0	25.5	25.3	−0.4	1.3	2.1	1.6
7	Influenza and pneumonia	65,163	2.7	22.4	22.0	−2.7	1.4	1.1	0.8
8	Alzheimer's disease	63,457	2.6	21.8	21.4	5.9	0.8	0.8	0.6
9	Nephritis, nephrotic syndrome and nephrosis	42,453	1.7	14.6	14.4	1.4	1.4	2.3	1.0
10	Septicemia	34,069	1.4	11.7	11.6	−0.9	1.2	2.3	0.8
11	Intentional self-harm (suicide)	31,484	1.3	10.8	10.8	−0.9	4.3	0.4	0.4
12	Chronic liver disease and cirrhosis	27,503	1.1	9.5	9.3	−1.1	2.2	0.9	1.6
13	Essential (primary) hypertension and hypertensive renal disease	21,940	0.9	7.5	7.4	5.7	1.0	2.8	1.0
14	Parkinson's disease	17,997	0.7	6.2	6.2	5.1	2.2	0.4	0.5
15	Assault (homicide)	17,732	0.7	6.1	6.0	−1.6	3.6	5.7	2.9
…	All other causes (residual)	416,932	17.0	143.4	…	…	…	…	…

from life-threatening illnesses. Patients enrolled in the study had about a 50% chance of dying within six months.

The researchers published the results of their study in "A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients" (Journal of the American Medical Association, vol. 274, no. 20, November 22/29, 1995). The SUPPORT investigators hypothesized that increased communication between patients and physicians, better understanding of patients' wishes, and the use of computer-based projections of patient survival would result in "earlier treatment decisions, reductions in time spent in undesirable states before death, and reduced resource use."

Phase I of the study was observational. The researchers reviewed patients' medical records and interviewed patients, surrogates (people who make decisions if patients became incompetent), and physicians. Discussions and decisions about life-sustaining measures were observed.

The researchers interviewed patients, families, and surrogates about the patients' thoughts on cardiopulmonary resuscitation (CPR), their perceptions of their quality of life, the frequency and severity of their pain, and their satisfaction with the care provided. The physicians who acknowledged responsibility for the patients' medical decisions were also interviewed to determine their understanding of patients' views on CPR and how patients' wishes influenced their medical care. The surrogates were again interviewed after the patients' deaths.

Problems with End-of-Life Care

Phase I of SUPPORT found a lack of communication between physicians and patients, showed aggressive treatment of dying patients, and revealed a disturbing picture of hospital death. Of the 4,301 patients, 31% expressed a desire that CPR be withheld. But only 47% of physicians reported knowledge of their patients' wishes. About half (49%) of patients who requested not to be resuscitated did not have a do-not-resuscitate (DNR) order in their medical charts. Of the 79% who died with a DNR order, 46% of the orders were written within only two days of death.

The patients' final days in the hospital included an average of eight days in "generally undesirable states"—in an intensive care unit (ICU), receiving artificial respiration, or in a coma. More than a third (38%) stayed ten days in the ICU, while almost half (46%) were mechanically ventilated within three days prior to death. Surrogates reported that 50% of conscious patients complained of moderate or severe pain at least half the time in their last three days.

TABLE 4.2 Death rates, by age, for the 15 leading causes of death, 1999–2003

TABLE 4.2
Death rates, by age, for the 15 leading causes of death, 1999–2003
[Rates on an annual basis per 100,000 population in specified group; age-adjusted rates per 100,000 U.S. standard population. Rates are based on populations enumerated as of April 1 for 2000 and estimated as of July 1 for all other years.]
Cause of death and year	Age
	All agesa	Under 1 yearb	1-4 years	5-14 years	15-24 years	25-34 years	35-44 years	45-54 years	55-64 years	65-74 years	75-84 years	85 years and over	Age-adjusted rate
All causes
2003	841.9	700.0	31.5	17.0	81.5	103.6	201.6	433.2	940.9	2,255.0	5,463.1	14,593.3	832.7
2002	847.3	695.0	31.2	17.4	81.4	103.6	202.9	430.1	952.4	2,314.7	5,556.9	14,828.3	845.3
2001	848.5	683.4	33.3	17.3	80.7	105.2	203.6	428.9	964.6	2,353.3	5,582.4	15,112.8	854.5
2000	854.0	736.7	32.4	18.0	79.9	101.4	198.9	425.6	992.2	2,399.1	5,666.5	15,524.4	869.0
1999	857.0	736.0	34.2	18.6	79.3	102.2	198.0	418.2	1,005.0	2,457.3	5,714.5	15,554.6	875.6
Diseases of heart
2003	235.6	11.0	1.2	0.6	2.7	8.2	30.7	92.5	233.2	585.0	1,611.1	5,278.4	232.3
2002	241.7	12.4	1.1	0.6	2.5	7.9	30.5	93.7	241.5	615.9	1,677.2	5,466.8	240.8
2001	245.8	11.9	1.5	0.7	2.5	8.0	29.6	92.9	246.9	635.1	1,725.7	5,664.2	247.8
2000	252.6	13.0	1.2	0.7	2.6	7.4	29.2	94.2	261.2	665.6	1,780.3	5,926.1	257.6
1999	259.9	13.8	1.2	0.7	2.8	7.6	30.2	95.7	269.9	701.7	1,849.9	6,063.0	266.5
Malignant neoplasms
2003	191.5	1.9	2.5	2.6	4.0	9.4	35.0	122.2	343.0	770.3	1,302.5	1,698.2	190.1
2002	193.2	1.8	2.6	2.6	4.3	9.7	35.8	123.8	351.1	792.1	1,311.9	1,723.9	193.5
2001	194.4	1.6	2.7	2.5	4.3	10.1	36.8	126.5	356.5	802.8	1,315.8	1,765.6	196.0
2000	196.5	2.4	2.7	2.5	4.4	9.8	36.6	127.5	366.7	816.3	1,335.6	1,819.4	199.6
1999	197.0	1.8	2.7	2.5	4.5	10.0	37.1	127.6	374.6	827.1	1,331.5	1,805.8	200.8
Cerebrovascular diseases
2003	54.2	2.5	0.3	0.2	0.5	1.5	5.5	15.0	35.6	112.9	410.7	1,370.1	53.5
2002	56.4	2.9	0.3	0.2	0.4	1.4	5.4	15.1	37.2	120.3	431.0	1,445.9	56.2
2001	57.4	2.7	0.4	0.2	0.5	1.5	5.5	15.1	38.0	123.4	443.9	1,500.2	57.9
2000	59.6	3.3	0.3	0.2	0.5	1.5	5.8	16.0	41.0	128.6	461.3	1,589.2	60.9
1999	60.0	2.7	0.3	0.2	0.5	1.4	5.7	15.2	40.6	130.8	469.8	1,614.8	61.6
Chronic lower respiratory diseases
2003	43.5	0.8	0.3	0.3	0.5	0.7	2.1	8.7	43.3	163.2	383.0	635.1	43.3
2002	43.3	1.0	0.4	0.3	0.5	0.8	2.2	8.7	42.4	163.0	386.7	637.6	43.5
2001	43.2	1.0	0.3	0.3	0.4	0.7	2.2	8.5	44.1	167.9	379.8	644.7	43.7
2000	43.4	0.9	0.3	0.3	0.5	0.7	2.1	8.6	44.2	169.4	386.1	648.6	44.2
1999	44.5	0.9	0.4	0.3	0.5	0.8	2.0	8.5	47.5	177.2	397.8	646.0	45.4
Accidents (unintentional injuries)
2003	37.6	23.6	10.9	6.4	37.1	31.5	37.8	38.8	32.9	44.1	101.9	278.9	37.3
2002	37.0	23.5	10.5	6.6	38.0	31.5	37.2	36.6	31.4	44.2	101.3	275.4	36.9
2001	35.7	24.2	11.2	6.9	36.1	29.9	35.4	34.1	30.3	42.8	100.9	276.4	35.7
2000	34.8	23.1	11.9	7.3	36.0	29.5	34.1	32.6	30.9	41.9	95.1	273.5	34.9
1999	35.1	22.3	12.4	7.6	35.3	29.6	33.8	31.8	30.6	44.6	100.5	282.4	35.3

TABLE 4.2 Death rates, by age, for the 15 leading causes of death, 1999–2003 [CONTINUED]

TABLE 4.2
Death rates, by age, for the 15 leading causes of death, 1999–2003 [CONTINUED]
[Rates on an annual basis per 100,000 population in specified group; age-adjusted rates per 100,000 U.S. standard population. Rates are based on populations enumerated as of April 1 for 2000 and estimated as of July 1 for all other years.]
Cause of death and year	Age
	All agesa	Under 1 yearb	1-4 years	5-14 years	15-24 years	25-34 years	35-44 years	45-54 years	55-64 years	65-74 years	75-84 years	85 years and over	Age-adjusted rate
Diabetes mellitus
2003	25.5	d	d	0.1	0.4	1.6	4.6	13.9	38.5	90.8	181.1	317.5	25.3
2002	25.4	d	d	0.1	0.4	1.6	4.8	13.7	37.7	91.4	182.8	320.6	25.4
2001	25.1	d	d	0.1	0.4	1.5	4.3	13.6	37.8	91.4	181.4	321.8	25.3
2000	24.6	d	d	0.1	0.4	1.6	4.3	13.1	37.8	90.7	179.5	319.7	25.0
1999	24.5	d	d	0.1	0.4	1.4	4.3	12.9	38.3	91.8	178.0	317.2	25.0
Influenza and pneumonia
2003	22.4	8.0	1.0	0.4	0.5	0.9	2.2	5.2	11.2	37.3	151.1	666.1	22.0
2002	22.8	6.5	0.7	0.2	0.4	0.9	2.2	4.8	11.2	37.5	156.9	696.6	22.6
2001	21.8	7.4	0.7	0.2	0.5	0.9	2.2	4.6	10.7	36.3	148.5	685.6	22.0
2000	23.2	7.6	0.7	0.2	0.5	0.9	2.4	4.7	11.9	39.1	160.3	744.1	23.7
1999	22.8	8.4	0.8	0.2	0.5	0.8	2.4	4.6	11.0	37.2	157.0	751.8	23.5
Alzheimer's disease
2003	21.8	d	d	d	d	d	d	0.2	2.0	20.9	164.4	802.4	21.4
2002	20.4	d	d	d	d	d	d	0.1	1.9	19.7	158.1	752.3	20.2
2001	18.9	d	d	d	d	d	d	0.2	2.1	18.7	147.5	710.3	19.1
2000	17.6	d	d	d	d	d	d	0.2	2.0	18.7	139.6	667.7	18.1
1999	16.0	d	d	d	d	d	d	0.2	1.9	17.4	129.5	601.3	16.5
Nephritis, nephrotic syndrome and nephrosis
2003	14.6	4.5	d	0.1	0.2	0.7	1.8	4.9	13.6	40.1	109.5	293.1	14.4
2002	14.2	4.3	d	0.1	0.2	0.7	1.7	4.7	13.0	39.2	109.1	288.6	14.2
2001	13.9	3.3	d	0.0	0.2	0.6	1.7	4.6	13.0	40.2	104.2	287.7	14.0
2000	13.2	4.3	d	0.1	0.2	0.6	1.6	4.4	12.8	38.0	100.8	277.8	13.5
1999	12.7	4.4	d	0.1	0.2	0.6	1.6	4.0	12.0	37.1	97.6	268.9	13.0
Septicemia
2003	11.7	6.9	0.5	0.2	0.4	0.8	2.1	5.3	13.1	32.6	85.0	202.5	11.6
2002	11.7	7.3	0.5	0.2	0.3	0.8	1.9	5.2	12.6	34.7	86.5	203.0	11.7
2001	11.3	7.7	0.7	0.2	0.3	0.7	1.8	5.0	12.3	32.8	82.3	205.9	11.4
2000	11.1	7.2	0.6	0.2	0.3	0.7	1.9	4.9	11.9	31.0	80.4	215.7	11.3
1999	11.0	7.5	0.6	0.2	0.3	0.7	1.8	4.6	11.4	31.2	79.4	220.7	11.3
Intentional self-harm (suicide)
2003	10.8	…	…	0.6	9.7	12.7	14.9	15.9	13.8	12.7	16.4	16.9	10.8
2002	11.0	…	…	0.6	9.9	12.6	15.3	15.7	13.6	13.5	17.7	18.0	10.9
2001c	10.8	…	…	0.7	9.9	12.8	14.7	15.2	13.1	13.3	17.4	17.5	10.7
2000	10.4	…	…	0.7	10.2	12.0	14.5	14.4	12.1	12.5	17.6	19.6	10.4
1999	10.5	…	…	0.6	10.1	12.7	14.3	13.9	12.2	13.4	18.1	19.3	10.5

TABLE 4.2 Death rates, by age, for the 15 leading causes of death, 1999–2003 [CONTINUED] "Table 9. Death Rates by Age and Age-Adjusted Death Rates for the 15 Leading Causes of Death in 2003: United States, 1999–2003," unpublished table from Centers for Disease Control and Prevention, National Center for Health Statistics, February 27, 2006

TABLE 4.2
Death rates, by age, for the 15 leading causes of death, 1999–2003 [CONTINUED]
[Rates on annual basis per 100,000 population in specified group; age-adjusted rates per 100,000 U.S. standard population. Rates are based on populations enumerated as of April 1 for 2000 and estimated as of July 1 for all other years.]
Cause of death and year	Age
	All agesa	Under 1 yearb	1-4 years	5-14 years	15-24 years	25-34 years	35-44 years	45-54 years	55-64 years	65-74 years	75-84 years	85 years and over	Age-adjusted rate
Note: "…"=Category not applicable.
aFigures for age not stated included in "all ages" but not distributed among age groups.
bDeath rates for "under 1 year" (based on population estimates) differ from infant mortality rates (based on live births).
cFigures include September 11, 2001 related deaths for which death certificates were filed as of October 24, 2002.
dFigure does not meet standards of reliability or precision.
SOURCE: "Table 9. Death Rates by Age and Age-Adjusted Death Rates for the 15 Leading Causes of Death in 2003: United States, 1999–2003," unpublished table from Centers for Disease Control and Prevention, National Center for Health Statistics, February 27, 2006
Chronic liver disease and cirrhosis
2003	9.5	d	d	d	d	0.9	6.8	18.3	23.0	29.5	30.0	20.1	9.3
2002	9.5	d	d	d	0.1	0.9	7.0	18.0	22.9	29.4	31.4	21.4	9.4
2001	9.5	d	d	d	0.1	1.0	7.4	18.5	22.7	30.0	30.2	22.2	9.5
2000	9.4	d	d	d	0.1	1.0	7.5	17.7	23.8	29.8	31.0	23.1	9.5
1999	9.4	d	d	d	0.1	1.0	7.3	17.4	23.7	30.6	31.9	23.2	9.6
Essential (primary) hypertension and hypertensive renal disease
2003	7.5	d	d	d	0.1	0.2	0.8	2.5	6.3	16.9	51.7	188.9	7.4
2002	7.0	d	d	d	0.1	0.2	0.8	2.3	5.7	16.0	48.2	180.4	7.0
2001	6.8	d	d	d	0.1	0.3	0.7	2.4	5.8	15.5	47.7	171.9	6.8
2000	6.4	d	d	d	d	0.2	0.8	2.3	5.9	15.1	45.5	162.9	6.5
1999	6.1	d	d	d	d	0.2	0.7	2.2	5.5	15.2	43.6	152.1	6.2
Parkinson's disease
2003	6.2	d	d	d	d	d	d	0.2	1.3	12.7	67.8	138.2	6.2
2002	5.9	d	d	d	d	d	d	0.1	1.2	12.2	63.9	135.2	5.9
2001	5.8	d	d	d	d	d	d	0.1	1.2	11.7	64.6	134.2	5.9
2000	5.6	d	d	d	d	d	d	0.1	1.1	11.5	61.9	131.9	5.7
1999	5.2	d	d	d	d	d	d	0.1	1.0	11.0	58.2	124.4	5.4
Assault (homicide)
2003	6.1	8.5	2.4	0.8	13.0	11.3	7.0	4.9	2.8	2.4	2.5	2.2	6.0
2002	6.1	7.5	2.7	0.9	12.9	11.2	7.2	4.8	3.2	2.3	2.3	2.1	6.1
2001c	7.1	8.2	2.7	0.8	13.3	13.1	9.5	6.3	4.0	2.9	2.5	2.4	7.1
2000	6.0	9.2	2.3	0.9	12.6	10.4	7.1	4.7	3.0	2.4	2.4	2.4	5.9
1999	6.1	8.7	2.5	1.1	12.9	10.5	7.1	4.6	3.0	2.6	2.5	2.4	6.0

TABLE 4.3 Estimated numbers of deaths of persons with AIDS, by year of death and selected characteristics, 2000–04 "Table 7. Estimated Numbers of Deaths of Persons with AIDS, by Year of Death and Selected Characteristics, 2000–2004—United States," in HIV/AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States, 2004, vol. 16, November 2005, http://www.cdc.gov/hiv/stats/2004SurveillanceReport.pdf (accessed November 17, 2005)

TABLE 4.3
Estimated numbers of deaths of persons with AIDS, by year of death and selected characteristics, 2000–04
	Year of death					Cumulative through 2004a
	2000	2001	2002	2003	2004
Note: These numbers do not represent reported case counts. Rather, these numbers are point estimates, which result from adjustments of reported case counts. The reported case counts are adjusted for reporting delays and for redistribution of cases in persons initially reported without an identified risk factor. The estimates do not include adjustment for incomplete reporting.
aIncludes persons who died with AIDS, from the beginning of the epidemic through 2004.
bIncludes hemophilia, blood transfusion, perinatal, and risk factor not reported or not identified.
cIncludes hemophilia, blood transfusion, and risk factor not reported or not identified.
dIncludes persons of unknown race or multiple races and persons of unknown sex. Cumulative total includes 836 persons of unknown race or multiple races. Because column totals were calculated independently of the values for the subpopulations, the values in each column may not sum to the column total.
SOURCE: "Table 7. Estimated Numbers of Deaths of Persons with AIDS, by Year of Death and Selected Characteristics, 2000–2004—United States," in HIV/AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States, 2004, vol. 16, November 2005, http://www.cdc.gov/hiv/stats/2004SurveillanceReport.pdf (accessed November 17, 2005)
Age at death (years)
<13	52	46	32	28	18	5,094
13-14	8	4	11	7	16	266
15-19	41	44	39	43	32	1,055
20-24	167	215	167	175	184	8,808
25-29	710	635	595	569	505	44,516
30-34	1,993	1,744	1,555	1,373	1,157	96,357
35-39	3,346	3,292	3,108	2,969	2,404	116,206
40-44	3,523	3,835	3,726	3,800	3,378	100,633
45-49	3,081	3,121	3,364	3,432	3,016	67,842
50-54	1,966	2,152	2,396	2,524	2,314	39,936
55-59	1,007	1,141	1,228	1,403	1,343	22,452
60-64	593	655	621	726	701	12,946
≥65	652	728	702	801	730	13,004
Race/ethnicity
White, not Hispanic	5,325	5,194	5,210	5,091	4,316	229,220
Black, not Hispanic	8,605	9,011	8,974	8,950	7,978	201,045
Hispanic	3,025	3,195	3,117	3,537	3,228	93,163
Asian/Pacific Islander	95	100	91	81	82	3,272
American Indian/Alaska Native	66	81	84	73	91	1,578
Transmission category
Male adult or adolescent
Male-to-male sexual contact	5,955	6,068	6,016	5,990	5,450	256,053
Injection drug use	4,070	4,074	4,062	4,116	3,308	109,070
Male-to-male sexual contact and injection drug use	1,324	1,366	1,323	1,322	1,180	39,467
Heterosexual contact	1,389	1,528	1,513	1,634	1,548	24,268
Otherb	195	166	167	160	113	9,843
Subtotal	12,933	13,202	13,080	13,222	11,599	438,701
Female adult or adolescent
Injection drug use	1,892	1,907	1,977	1,989	1,744	41,178
Heterosexual contact	2,150	2,342	2,331	2,470	2,327	39,576
Otherb	87	91	91	101	67	4,142
Subtotal	4,129	4,340	4,400	4,560	4,138	84,897
Child (<13 years at diagnosis)
Perinatal	72	66	59	61	57	4,982
Otherc	5	3	6	6	4	533
Subtotal	77	69	65	67	61	5,515
Region of residence
Northeast	5,200	5,130	5,213	5,654	4,019	169,693
Midwest	1,622	1,646	1,623	1,199	1,234	50,333
South	7,078	7,386	7,361	7,839	7,192	181,690
West	2,567	2,683	2,585	2,428	2,540	108,183
U.S. dependencies, possessions, and associated nations	672	766	763	730	814	19,214
Totald	17,139	17,611	17,544	17,849	15,798	529,113

Phase II: Intervention to Improve Care

Phase II of SUPPORT was implemented to address the shortcomings documented in Phase I. It tested an intervention delivered by experienced nurses and lasted another two years, involving patient participants with characteristics similar to those in Phase I. This time, however, the doctors were given printed reports about the patients and their wishes regarding life-sustaining treatments. SUPPORT nurses facilitated the flow of information among patients, families, and health care personnel, and helped manage patients' pain. To determine if the intervention worked in addressing problems in the care of seriously ill hospitalized patients at medical centers, researchers measured outcomes on five quantitative outcomes: incidence and timing of DNR orders; patient-physician agreement on CPR preferences; days in an intensive care unit in a comatose condition or receiving mechanical ventilation; pain; and hospital resource use.

RESULTS OF PHASE II

The SUPPORT intervention failed to produce changes in the outcomes that were measured (Patricia A. Murphy et al, "Under the Radar: Contributions of the SUPPORT Nurses," Nursing Outlook, vol. 49, no. 5, September/October 2001). Bernard Lo ("Improving Care Near the End of Life: Why Is It So Hard?," Journal of the American Medical Association, vol. 274, no. 20, November 22/29, 1995) believes that the results reported in the SUPPORT study raise more questions than answers. Among other issues, Lo claims that while Phase I showed poor doctor-patient communication, Phase II, instead of directly addressing this shortcoming, added a third party, the SUPPORT nurses, to do the physicians' job.

Patricia Murphy and her colleagues note that their analysis of SUPPORT nurses' narratives suggests, however, that the nurses made a difference during the intervention in ways that were not acknowledged by the measurement of the five quantitative outcomes. The nurses supported patients and their families, brought them information, and helped them interpret it. They note that many of the nurses' narratives suggest that effective communication is a precondition of patient or family readiness "to hear a grave prognosis, engage in serious decision making, or 'let go' of a loved one."

B. A. Ditillo in "The Emergence of Palliative Care: A New Specialized Field of Medicine Requiring an Interdisciplinary Approach" (Critical Care Nursing Clinics of North America, vol. 14, no. 2, June 2002) suggests that the movement in the United States to improve end-of-life care (the palliative care movement) is a result of the SUPPORT study. Ditillo notes that "the delivery of effective palliative care requires an interdisciplinary team approach in order to meet the complex needs of patients and families." These complex needs include help in understanding various life-sustaining treatments and support to decide whether to accept or refuse such treatments at the end of life.