SUPPORT After All These Years

From GeriPal, an article on the legacy of the SUPPORT study:

November 2010 marks the 15th anniversary of the publication of the SUPPORT Project, the largest study of end of life care ever conducted. This study that shook the medical world. SUPPORT was an ambitious effort sponsored by the Robert Wood Johnson Foundation to improve the quality of care towards the end of life in patients with serious illness. The finding that this $29 million effort had absolutely no impact on improving the quality of end of life care was stunning.

The failure of the intervention to improve end of life care and the strikingly poor quality of end of life care documented by SUPPORT led to calls for action in the lay media and by advocates of better end of life care. SUPPORT remains the most influential study of end of life care ever published, and with over 1300 citations in the peer-reviewed literature, by far the most cited.

The SUPPORT intervention study randomized over 4000 patients hospital at 5 US hospitals to usual care or the SUPPORT intervention. Patients had one of 9 index conditions, such as sepsis with organ system failure, or metastatic lung cancer, and clinical characteristics suggesting a 50% or greater 6 month mortality. Physicians of patients in the intervention received received estimates of the probability of survival over six months, estimates of the outcomes of CPR, and estimates of the probability of severe functional disability at 2 months. The intervention also provided documentation of patient and family care preferences and provided access to a nurse interventionist to facilitate communication, including helping to carry out needed communication and facilitating meetings.

The effect of this intervention? NADA. Nothing. There was no impact on each of these key outcome measures:

• Earlier writing of DNR orders
• Physicians knowledge of their patients' preferences for CPR
• Number of days spent in an ICU before death
• Patient reports of moderate or severe pain
• Use of hospital resources

The SUPPORT project showed that the provision of prognostic information, and enhancing communication were insufficient in the 1995 care environment to improve outcomes at the end of life. The investigators suggested that "more forceful measures" may be needed. Several of the SUPPORT leaders noted that the efforts to improve end of life care were inhibited by a medical structure that made it very difficult to provide high quality end of life care and argued that improvements were unlikely without a major societal commitment to improve end of life care.