greater patient estimate of two-month prognosis. Of the patients who preferred not to receive CPR, less than half had a do-not-resuscitate (DNR) note or order written. Physicians incorrectly identified patient CPR preferences in 30 percent of cases.

A similar study (Covinsky et al., 2000) examined the characteristics of patients who do request DNR orders. Patients who are older, have cancer, are women, believe their prognoses are poor, and are more dependent in activities of daily living functioning are less likely to want CPR. However, there are considerable variability and geographic variation in these preferences. Physician, nurse, and surrogate understanding of their patients’ preferences is only moderately better than chance. Most patients do not discuss their preferences with their physicians, and only about half of patients who do not wish to receive CPR receive DNR orders.

Weeks and colleagues (1998) examined the hypothesis that among terminally ill cancer patients, an accurate understanding of a poor prognosis is associated with a preference for therapy that focuses on comfort over attempts at life extension, using SUPPORT data. Subjects were 917 adults hospitalized with Stage III or IV non-small cell lung cancer or colon cancer metastatic to liver. Patients who thought they were going to live for at least six months were more likely to favor life-extending therapy over comfort care, compared with patients who thought there was at least a 10 percent chance that they would not live six months. (Patients overestimated their chances of surviving six months, while physicians estimated prognosis quite accurately.) Patients who preferred life-extending therapy were more likely to undergo aggressive treatment, but their six-month survival was no better than similar patients who did not seek aggressive treatment.

The effects of the Patient Self Determination Act (PSDA; mandated patient education about advance directives at hospital entry) have also been examined within the context of SUPPORT (Teno et al., 1997). There was no evidence that the PSDA substantially increased documentation of advance directives, and it appears that documentation of advance directives is unlikely to be a substantial element in improving the care of seriously ill patients.

Examples of Studies to Change Practice and Improve End-of-Life Care and Symptom Control

The most ambitious research project to understand and improve care at the end of life was the well-publicized SUPPORT (1990). The descriptive information from SUPPORT (reviewed above) is the best information we have about the dying process. Approximately 20 percent of the sample were patients with cancer. The intervention study, supported by the Robert Wood Johnson Foundation, was designed to improve end-of-life decisionmaking

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