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results (SUPPORT Principal Investigators, 1995). Elsewhere, the study investigators have reported that some physician behaviors were associated with specially status (e.g., cardiologists being less likely to write DNRs than pulmonologists or intensive care specialists) (Hakim et al., 1996). More generally, many believe that the dominant medical culture makes it difficult for physicians to accept patient wishes to forego treatment, at least when clinicians see some chance for successful treatment (see, e.g., Katz, 1984; Schneiderman et al., 1993; Nuland, 1994; Annas, 1995; and Chapter 8 of this report).
characteristics of educational and decisionmaking processes. Inadequate processes for patient and family advance care planning and lack of clinical information about patient prognosis and preferences have been identified as problems. Efforts to improve information, decisionmaking, and outcomes have sometimes proved disappointing. Most notably, one stimulus to the consideration of new strategies is the disappointing results of a major intervention to improve discussions and knowledge of hospital patients' preferences through information and counseling (SUPPORT Principal Investigators, 1995). The patients assigned to the intervention (or their surrogates) were not more likely to report a discussion with a physician about resuscitation or prognosis, to have their preferences known to their physician, to have DNR orders documented, to have them documented earlier, to spend fewer days in the intensive care unit, or to have different levels of resource use. Almost half the DNR orders were documented during the last two days before death, and barely half of patients who preferred not to be resuscitated had DNRs written (Hakim et al., 1996). The percentage of patients with some kind of advance directive was essentially unchanged at about one in five, but those in the intervention group who had such directives were more likely to have them documented in the medical record (Teno, Lynn, Wenger, et al., 1997).
organizational structures and processes. Increasingly, organizational systems are viewed as major determinants of practice patterns including practices related to care at the end of life (Pritchard et al., 1994; Reilly et al., 1994; Berwick, 1995; Blumenthal and Scheck, 1995; Solomon, 1995). The focus then becomes identifying and remedying faulty processes rather trying to identify, change, or punish faulty individuals. The SUPPORT investigators discovered considerable differences among the five medical centers they studied, and factors associated with these differences are still being studied. In general, it might be expected that values and practices might differ from general community hospitals to highly specialized academic medical centers. Likewise, an organization with strong computer-based patient records and information systems should be better able to document patient directives, make information readily available to clinicians, and provide data allowing outcomes to be assessed and problems