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). The SUPPORT Principal Investigators.
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). The SUPPORT Principal Investigators.
复制标题
一项旨在改善重病住院患者护理的对照试验。
DOI：
10.1001/jama.274.20.1591
复制
发表时间：
1995
期刊：
影响因子：
--
通讯作者：
B. Kreling
中科院分区：
文献类型：
--
作者：
A. Connors;N. Dawson;N. Desbiens;W. Fulkerson;L. Goldman;W. Knaus;J. Lynn;R. Oye;M. Bergner;A. Damiano;Raymond Hakim;D. Murphy;J. Teno;B. Virnig;D. Wagner;A. W. Wu;Yutaka Yasui;Detra K. Robinson;B. Kreling
目标
改善临终决策，减少机械支持、痛苦和延长死亡过程的频率。
设计
一项包含4301例患者的2年前瞻性观察性研究（I期），随后是一项包含4804例患者及其医生的2年对照临床试验（II期），按专业组随机分配至干预组（n = 2652）或对照组（n = 2152）。
设置
美国的五所教学医院。
患者
共有9105名成年人因九种危及生命的诊断中的一种或多种而住院;总体6个月死亡率为47%。
干预
干预组的医生在6个月内每天接受6个月生存可能性的估计，心肺复苏（CPR）的结果和2个月时的功能障碍。经过专门培训的护士与患者、家属、医生和医院工作人员进行多次接触，以了解患者的偏好，提高对结局的理解，鼓励关注疼痛控制，并促进提前护理计划和医患沟通。
结果
第一阶段的观察记录了沟通、积极治疗的频率和医院死亡的特征方面的缺陷：只有47%的医生知道他们的患者何时倾向于避免心肺复苏术：46%的不要复苏（DNR）命令是在死亡后2天内写的; 38%的死亡患者在重症监护室（ICU）至少呆了10天;在医院死亡的有意识的病人中，有50%的病人的家属至少有一半的时间报告中度到重度疼痛。在II期干预期间，患者与医生的沟通没有改善（例如，37%的对照组患者和40%的干预组患者讨论了CPR偏好）或五个目标结局，即书面DNR命令的发生率或时间（校正比值，1.02; 95%置信区间[CI]，0.90至1.15），医生对患者不接受复苏的偏好的了解（校正比率，1.22; 95% CI，0.99 - 1.49），在ICU中度过的天数，接受机械通气，或死亡前昏迷（校正比率，0.97; 95% CI，0.87 - 1.07），或报告的疼痛水平（校正比率，1.15; 95% CI，1.00 - 1.33）。干预也没有减少医院资源的使用（调整后的比率，1.05; 95%CI，0.99至1.12）。
结论
对支助方案第一阶段的观察证实，在照顾重病住院的成年人方面存在重大缺陷。第二阶段干预未能改善护理或患者结局。增加更多的医患沟通的机会，虽然提倡作为改善病人的结果的主要方法，可能是不足以改变既定的做法。为了改善重病和垂死患者的体验，可能需要更大的个人和社会承诺以及更积极和有力的措施。
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 specifically 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 [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 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 measured may be needed.
影响因子：
9.6
作者：
KNAUS, WA;WAGNER, DP;HARRELL, FE
通讯作者：
HARRELL, FE
医生和配偶对老年患者复苏偏好的预测。
DOI：
10.1093/geronj/43.5.m115
发表时间：
1988
期刊：
Journal of gerontology
影响因子：
--
作者：
Uhlmann,RF;Pearlman,RA;Cain,KC
通讯作者：
Cain,KC