The Merci Retrieval System for acute stroke: the Southeast Regional Stroke Center experience.

INTRODUCTION: The Merci Retrieval System was cleared for use in patients with stroke in August 2004. However, there are few published results of "real world experience" with the device. METHODS: We captured single-center data on 25 consecutive patients with acute ischemic stroke treated with the Merci Retrieval System according to the MERCI trial except that we treated some patients with tandem proximal carotid and intracranial lesions with carotid angioplasty and stenting and some patients were treated within the 3-hour window. RESULTS: Median patient age was 63 years and median initial National Institute of Health Stroke Scale (NIHSS) score was 18. Isolated M1 or M2 middle cerebral artery lesions occurred in 52%, "carotid T" lesions in 8%, and vertebrobasilar lesions in 8%. Tandem lesions involving proximal carotid and proximal intracranial vessel occurred in 32%, necessitating emergent multilevel treatment including carotid stenting. Median duration from symptom onset to Merci device utilization was 5.2 hours. Successful reperfusion (> or = thrombolysis in myocardial infarction [TIMI] 2 flow) in the target vessel was obtained in 56% of cases. Statistical analysis revealed a strong correlation between ability to achieve greater than or equal to TIMI 2 flow and good clinical outcome as measured by 3-month NIHSS score, modified Rankin Scale (mRS), and mortality (nine out of the 12 without successful reperfusion died compared to none of the 13 with > or =TIMI 2 flow, p < 0.001). Younger age and lower NIHSS score on presentation were also predictors of good clinical outcome at 3 months. CONCLUSION: These "real world data" demonstrate that the results of the previous MERCI trial can be "independently replicated" at a regional stroke center. Although the results of placebo-controlled trials are still pending, mechanical revascularization has become a critical component of our acute stroke protocol, particularly for severe strokes. Issues still remain regarding recalcitrant lesions and operator experience, which necessitate further clinical testing and device optimization.

Should physicians be allowed to use alcohol while on call?

Although physician alcohol use that leads to impairment has been extensively discussed, few statements address the issue of alcohol use of physicians who are on call. In this paper the authors review recent information on physicians' perceptions of alcohol use by themselves and their colleagues while on call. It is argued that conflicts in physicians' perceptions are due to the fact that the larger society has not addressed the question of whether drinking on call is public or private behaviour. The authors argue that when medicine is understood as a practice defined partly in terms of standards of excellence, the present approach of the American Medical Association to prohibit practicing medicine under the influence of alcohol requires a prohibition of drinking alcohol while on call, unless studies determine a clear threshold for drinking alcohol without placing patients at risk.

In randomized controlled trials, should subjects in both placebo and drug groups be expected to guess that they are taking drug 50% of the time?

Part of the design of some randomized controlled trials has included asking patients to guess whether they are taking placebo or active drug. Some authors have stated that in randomized, double-blind placebo-controlled clinical trials patients in each group should guess that they are taking placebo half the time. However, this pattern should occur only under a limited set of circumstances. This paper explores the factors that affect the guess and the role of the guess in understanding both the establishment and the maintenance of the blind. It suggests that more than half of those in the treatment group should guess they are taking active drug if treatment or side-effects are powerful. Though the randomized controlled trial has become the paradigmatic tool to assess treatment efficacy, studies are still needed to validate key assumptions make by investigators and the effect of violation of these assumptions on study outcomes.

Stress in caregivers of hospitalized oldest-old patients.

BACKGROUND: Stress in caregivers of elderly patients is a well-recognized health care problem. However, little has been published about the stress in caregivers of the oldest-old patients, the most rapidly growing segment of our population. METHODS: A prospective cohort study was conducted in four teaching hospitals. Questionnaires were administered to patients 80 years of age and older and their surrogates (the person who would make decisions if the patient were unable to-usually a family member) who identified themselves as the primary caregivers for the patients. Data were abstracted from medical records. RESULTS: Caregivers tended to be female and 50 years of age or older. About one in five described her own health as fair or poor; nearly half of them lived with the patient. About one quarter spent at least 8 h/d caring for the patient, and they had few persons available to help them with care. Most of the caregivers reported mild-to-moderate levels of stress. After adjustment, higher stress scores were associated with female caregivers, poorer caregiver health, more hours per day spent caring for the patient, and the presence of patient depression and hearing impairment. CONCLUSION: Stress is common in caregivers of the hospitalized oldest-old patients. Women who are in poor health and spend 8 or more hours every day caring for relatives aged 80 and over are at high risk for caregiver stress. Treatment of patient depression and hearing impairment may ameliorate caregiver stress.

Short- and long-term survival after cardiopulmonary resuscitation.

BACKGROUND: The objective was to evaluate the effect of patient characteristics and other factors on cardiopulmonary resuscitation (CPR) survival, hospital discharge survival and function, and long-term survival. METHODS: All patients 18 years and older experiencing in-hospital CPR from December 1983 through November 1991 at Marshfield Medical Center (Marshfield Clinic and adjoining St Joseph's Hospital), Marshfield, Wis, were selected. We performed a retrospective medical record review and augmented these data with updated vital status information. MAIN OUTCOME MEASURES: Cardiopulmonary resuscitation survival, hospital discharge survival and function, and long-term survival. RESULTS: Of 948 admissions during which CPR was performed, 61.2% of patients survived the arrest and 32.2% survived to hospital discharge. Mechanism of arrest was the most important variable associated with hospital discharge. Patients with pulseless electrical activity had the worst chance of hospital discharge, followed by those with asystole and bradycardia. Follow-up information was available for 298 patients who survived to discharge. One year after hospital discharge, 24.5% of patients, regardless of age, had died. Survival was 18.5% at 7 years in those 70 years or older, compared with 45.4% in those aged 18 to 69 years. Heart rhythm at the time of arrest strongly influenced long-term survival. Bradyarrhythmias produced a nearly 2-fold increased mortality risk compared with normal sinus rhythm. CONCLUSIONS: Survival until hospital discharge after CPR at our institution during an 8-year period was higher than previously reported for other institutions. Long-term survival after discharge was equal to or higher than reported estimates from other institutions. Hospital admission practices and selection of patients receiving CPR may account for these findings.

How well do surrogates assess the pain of seriously ill patients?

OBJECTIVE: To compare pain assessments made by seriously ill hospitalized patients and their surrogates and to understand factors that might lead to reporting differences. DESIGN: Cross-sectional study. SETTING: Five U.S. teaching hospitals. PATIENTS: Patients were 2,645 of 9,105 patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments for whom there were both patient and surrogate interviews about pain. The majority of patients had acute respiratory failure, multiple organ system failure with sepsis, exacerbation of chronic obstructive pulmonary disease, and congestive heart failure. INTERVENTIONS: None. MEASUREMENTS: We queried patients and surrogates by using Likert-type scale questions about the frequency and severity of patients' pain. MAIN RESULTS: Overall, surrogates correctly estimated presence or absence of patients' pain 73.5% of the time (kappa = 0.47, 95% confidence interval [CI], 0.44, 0.50), overestimating 16.8% of the time and underestimating 9.7% of the time. Exact estimation of the presence and level of pain was considerably poorer, with only 53.0% of surrogates correctly assessing exact level of pain (kappa = 0.31; 95% CI, 0.28, 0.33; weighted kappa = 0.43; 95% CI, 0.41, 0.46). Patients' reported level of pain, days in hospital before study admission, time interval between patient and surrogate assessment, and study hospital were associated with inaccuracy in surrogates' estimation of patients' pain. CONCLUSIONS: Family members correctly assess the level of pain of hospitalized patients with moderate success. Further studies are needed to assess the accuracy of assessment of pain by family members compared with that of health professionals, and to determine whether surrogates' accuracy in estimating patients' pain can be improved.

Prediction of survival for older hospitalized patients: the HELP survival model. Hospitalized Elderly Longitudinal Project.

OBJECTIVE: To develop and validate a model estimating the survival time of hospitalized persons aged 80 years and older. DESIGN: A prospective cohort study with mortality follow-up using the National Death Index. SETTING: Four teaching hospitals in the US. PARTICIPANTS: Hospitalized patients enrolled between January 1993 and November 1994 in the Hospitalized Elderly Longitudinal Project (HELP). Patients were excluded if their length of hospital stay was 48 hours or less or if admitted electively for planned surgery. MEASUREMENTS: A log-normal model of survival time up to 711 days was developed with the following variables: patient demographics, disease category, nursing home residence, severity of physiologic imbalance, chart documentation of weight loss, current quality of life, exercise capacity, and functional status. We assessed whether model accuracy could be improved by including symptoms of depression or history of recent fall, serum albumin, physician's subjective estimate of prognosis, and physician and patient preferences for general approach to care. RESULTS: A total of 1266 patients were enrolled over a 10-month period, (median age 84.9, 61% female, 68% with one or more dependency), and 505 (40%) died during an average follow-up of more than 2 years. Important prognostic factors included the Acute Physiology Score of APACHE III collected on the third hospital day, modified Glasgow coma score, major diagnosis (ICU categories together, congestive heart failure, cancer, orthopedic, and all other), age, activities of daily living, exercise capacity, chart documentation of weight loss, and global quality of life. The Somers' Dxy for a model including these factors was 0.48 (equivalent to a receiver-operator curve (ROC) area of 0.74, suggesting good discrimination). Bootstrap estimation indicated good model validation (corrected Dxy of 0.46, ROC of 0.73). A nomogram based on this log-normal model is presented to facilitate calculation of median survival time and 10th and 90th percentile of survival time. A count of geriatric syndromes or comorbidities did not add explanatory power to the model, nor did the hospital of patient recruitment, depression, or the patient preferences for general approach to care. The physician's perception of the patient's preferences and the physician's subjective estimate of the patient's prognosis improved the estimate of survival time significantly. CONCLUSIONS: Accurate estimation of length of life for older hospitalized persons may be calculated using a limited amount of clinical information available from the medical chart plus a brief interview with the patient or surrogate. The accuracy of this model can be improved by including measures of the physician's perception of the patient's preferences for care and the physician's subjective estimate of prognosis.

The effect of nutritional supplementation on survival in seriously ill hospitalized adults: an evaluation of the SUPPORT data. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

BACKGROUND: Enteral tube and parenteral hyperalimentation are widely used nutritional support systems. Few studies examine the relation between nutritional support and patient outcomes in seriously ill hospitalized adults. OBJECTIVE: To explore the association between nutritional support and survival in seriously ill patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). DESIGN: A prospective study of preferences, decision-making, and outcomes. SETTING: Five teaching hospitals PARTICIPANTS: 6298 patients aged 18 or older meeting diagnostic and illness severity criteria. MEASUREMENT: Demographic characteristics, diagnoses, comorbid conditions, acute physiology score, nutritional support, and functional status before hospitalization. RESULTS: A total of 2149 patients received nutritional support. In patients who received artificial nutrition on hospital days 1 or 3 (Cohort 1), enteral feeding was associated with improved survival in coma (hazard: 0.53; 95%CI, 0.42-0.66), and reduced survival in COPD (hazard: 1.57; 95%CI, 1.18-2.08). In patients who were hospitalized on Day 7 and received artificial nutrition on days 1, 3, or 7 (Cohort 2), enteral tube feeding (hazard: 0.35; 95%CI, 0.27-0.46) or hyperalimentation (hazard: 0.58; 95%CI, 0.38-0.90) was associated with improved survival in coma. Tube feeding was associated with decreased survival in acute respiratory failure (ARF) or multiorgan system failure (MOSF) with sepsis (hazard: 1.21; 95%CI, 10.4-1.41), cirrhosis (hazard: 2.15; 95%CI, 1.35-3.42), and COPD (hazard: 1.37; 95%CI, 1.04-1.80). Hyperalimentation was associated with decreased survival in ARF or MOSF with sepsis (hazard: 1.34; 95%CI, 1.12-1.59). CONCLUSIONS: Nutritional support was associated with improved survival in coma. Enteral feeding and hyperalimentation was associated with decreased survival in ARF or MOSF with sepsis. Tube feeding was associated with decreased survival in cirrhosis and COPD. Except for patients in coma, artificial nutrition was not associated with a survival advantage.

A prospective study of patient-physician communication about resuscitation.

OBJECTIVE: To evaluate prospectively seriously ill patients' characteristics, perceptions, and preferences associated with discussing resuscitation (CPR) with their physicians. DESIGN: Prospective cohort. SETTING: Five academic medical centers. PARTICIPANTS: Patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments who had not communicated with their physicians about CPR at admission to a hospital for life-threatening illness (n = 1288). MEASUREMENTS: Baseline surveys of patients' characteristics, health status, desires for participation in medical decision making, and cardiopulmonary resuscitation. Two month follow-up surveys of patients' communication of resuscitation preference. Chart reviews for clinical indicators. RESULTS: Thirty percent of patients communicated their resuscitation preference to their physician during a 2 month-period following hospital admission. Patients whose preference was to forego CPR (odds ratio (OR) 2.9;(95% CI, 1.9-4.2)) and whose preference had changed from desiring to foregoing CPR (OR 1.6; (95% CI, 1.1-2.4)) were more likely to communicate their preference than patients who continued to prefer to receive CPR. However, only 50% of patients who maintained a preference to forego CPR communicated this over a 2-month period. Having an advance directive and remaining in the hospital at 2-month follow-up were also independently associated with communication, whereas patients' preference for participation in decision-making, health status, and prognostic estimate were not. CONCLUSIONS: Communication about resuscitation preferences occurred infrequently after hospital admission for a serious illness, even among patients wishing to forego resuscitation. Factors such as declining quality of life, which were expected to be associated with communication, were not. An invitation to communicate about CPR preference is important after hospital admission for a serious illness. Novel approaches are needed to promote physician-patient discussions about resuscitation.

Family satisfaction with end-of-life care in seriously ill hospitalized adults.

OBJECTIVE: To examine factors associated with family satisfaction with end-of-life care in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). DESIGN: A prospective cohort study with patients randomized to either usual care or an intervention that included clinical nurse specialists to assist in symptom control and facilitation of communication and decision-making. SETTING: Five teaching hospitals in the United States. PARTICIPANTS: Family members and other surrogate respondents for 767 seriously ill hospitalized adults who died. MEASUREMENTS: Eight questionnaire items regarding satisfaction with the patient's medical care expressed as two scores, one measuring satisfaction with patient comfort and the other measuring satisfaction with communication and decision-making. RESULTS: Sixteen percent of respondents reported dissatisfaction with patient comfort and 30% reported dissatisfaction with communication and decision-making. Factors found to be significantly associated with satisfaction with communication and decision-making were hospital site, whether death occurred during the index hospitalization (adjusted odds ratio (AOR) 2.2, 95% CI, 1.3-3.9), and for patients who died following discharge, whether the patient received the SUPPORT intervention (AOR 2.0, 1.2-3.2). For satisfaction with comfort, male surrogates reported less satisfaction (0.6, 0.4-1.0), surrogates who reported patients' preferences were followed moderately to not at all had less satisfaction (0.2, 0.1-0.4), and surrogates who reported the patient's illness had greater effect on family finances had less satisfaction (0.4, 0.2-0.8). CONCLUSIONS: Satisfaction scores suggest the need for improvement in end-of-life care, especially in communication and decision making. Further research is needed to understand how factors affect satisfaction with end-of-life care. An intervention like that used in SUPPORT may help family members.

Withholding versus withdrawing life-sustaining treatment: patient factors and documentation associated with dialysis decisions.

OBJECTIVE: We evaluated prospectively the use of acute hemodialysis among hospitalized patients to identify demographic and clinical predictors of and chart documentation concerning dialysis withheld and withdrawn. DESIGN: Prospective cohort study. SETTING: Five teaching hospitals. PATIENTS: Five hundred sixty-five seriously ill hospitalized patients who had not previously undergone dialysis who developed renal failure. MAIN OUTCOME MEASURES: Patient demographics, clinical characteristics, preferences, and prognostic estimates associated with having dialysis withheld rather than initiated and withdrawn rather than continued. Differences in chart documentation concerning decision-making for dialysis withheld, withdrawn, and continued. RESULTS: Older patient age, cancer diagnosis, and male gender were associated with dialysis withheld rather than withdrawn. Age and gender differences persisted after adjustment for patients' aggressiveness of care preference. Worse 2-month prognosis was associated with both withholding and withdrawing dialysis. Chart documentation of decision-making was lacking more often for patients with dialysis withheld than for dialysis withdrawn. CONCLUSIONS: Measuring the equity of life-sustaining treatment use will require evaluation of care withheld, not just care withdrawn. Older patients and men, after accounting for prognosis and function, are more likely to have dialysis withheld than withdrawn after a trial. Further exploration is needed into this disparity and the inadequate chart documentation for patients with dialysis withheld.

Living and dying with chronic obstructive pulmonary disease.

OBJECTIVE: To characterize chronic obstructive pulmonary disease (COPD) over patients' last 6 months of life. STUDY DESIGN: A retrospective analysis of a prospective cohort from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). SETTING: Hospitalization for exacerbation of COPD at five US teaching hospitals. PARTICIPANTS: COPD patients who died within 1 year (n = 416) among 1016 enrolled. METHODS: Interview and medical record data were organized into time windows beginning with death and ending 6 months earlier. OUTCOME MEASURES: Days in hospital, prognosis, illness severity, function, symptoms, patients' preferences, and impacts on families. RESULTS: One-year survival was 59%, 39% had > or = 3 comorbidities, and 15 to 25% of the patients' last 6 months were in hospitals. Exacerbation etiologies included respiratory infection (47%) and cardiac problems (30%). Better quality of life predicted longer survival (ARR: 0.36; 95% CI, 0.19-0.87) as did heart failure etiology of exacerbation (ARR: 0.57; CI, 0.40, 0.82). Estimates of survival by physicians and by prognostic model were well calibrated, although patients with the worst prognoses survived longer than predicted. Patients' estimates of prognosis were poorly calibrated. One-quarter of patients had serious pain throughout, and two-thirds had serious dyspnea. Patients' illnesses had a major impact on more than 25% of families. Patients' preferences for Do-Not-Resuscitate orders increased from 40% at 3 to 6 months before death to 77% within 1 month of death; their decisions not to use mechanical ventilation increased from 12 to 31%, and their preferences for resuscitation decreased from 52 to 23%. CONCLUSIONS: Patients with advanced COPD often die within 1 year and have substantial comorbidities and symptoms. Adequate description anchors improved care.

Dying with acute respiratory failure or multiple organ system failure with sepsis.

BACKGROUND: The dying experience of patients with acute respiratory failure (ARF) or multiple organ system failure with sepsis (MOSF) has not been described. OBJECTIVES: To describe patients dying from ARF or MOSF, including demographic characteristics, baseline function and quality of life, symptoms, preferences, use of life-sustaining treatments, satisfaction with care, and family burden. DESIGN: A multicenter prospective study. SETTING: Five US teaching hospitals, in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). PARTICIPANTS: A total of 1295 adults who died during hospitalization for ARF or MOSF. MEASUREMENTS: Chart reviews and interviews with patients and surrogates. RESULTS: SUPPORT enrolled 2956 patients with ARF or MOSF, and 44% died during enrollment hospitalization. Quality of life before hospitalization was reported as fair by 87% of patients. The mean number of impairments in their baseline activities of daily living was 1.6. At the time of death, 79% had a DNR order and 31% had an order to withhold ventilator support. The average time from the DNR order to death was 2 days. Dying patients spent an average of 9 days on a ventilator. Surrogates indicated that one out of four patients died with severe pain and one out of three with severe confusion. Families of 42% of the patients who died reported one or more substantial burden. CONCLUSIONS: Patients in this study reported substantial functional impairments and reduced quality of life. Limitations to aggressive treatments were usually implemented only when death was imminent. Family impact and physical and emotional suffering were substantial.

Dying with lung cancer or chronic obstructive pulmonary disease: insights from SUPPORT. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

CONTEXT: Many are calling for patients with advanced chronic obstructive pulmonary disease (COPD) to receive hospice care, but the traditional hospice model may be insufficient. OBJECTIVE: To compare the course of illness and patterns of care for patients with non-small cell lung cancer and severe COPD. DESIGN: Prospective cohort study of seriously ill, hospitalized adults. SETTING: Five teaching hospitals in the United States. PATIENTS: Patients with Stage III or IV non-small cell lung cancer (n = 939) or acute exacerbation of severe COPD (n = 1008). MAIN OUTCOME MEASURES: Patients' preferences for pattern of care and for ventilator use; symptoms; life-sustaining interventions; and survival prognoses. RESULTS: Sixty percent in each group wanted comfort-focused care; 81% with lung cancer and 78% with COPD were extremely unwilling to have mechanical ventilation indefinitely. Severe dyspnea occurred in 32% of patients with lung cancer and 56% of patients with COPD and severe pain in 28 % of patients with lung cancer and 21% of patients with COPD. Patients with COPD who died during index hospitalization were more likely than patients with lung cancer to receive mechanical ventilation (70.4% vs 19.8%), tube feeding (38.7% vs 18.5%), and cardiopulmonary resuscitation (25.2% vs 7.8%). Mechanical ventilation had greater short term effectiveness in patients with COPD, based on survival to hospital discharge (76% vs 38%). Patients with COPD maintained higher median 2-month and 6-month survival prognoses, even days before death. CONCLUSIONS: Hospitalized patients with lung cancer or COPD preferred comfort-focused care, yet dyspnea and pain were problematic in both groups. Patients with COPD were more often treated with life-sustaining interventions, and short-term effectiveness was comparatively better than in patients with lung cancer. In caring for patients with severe COPD, consideration should be given to implementing palliative treatments more aggressively, even while remaining open to provision of life-sustaining interventions.

Age-related differences in care preferences, treatment decisions, and clinical outcomes of seriously ill hospitalized adults: lessons from SUPPORT.

OBJECTIVES: To review previously published findings about how patient age influenced patterns of care for seriously ill patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). DESIGN: An observational prospective study. SETTING: Five acute care hospitals. PARTICIPANTS: A total of 9105 seriously ill patients enrolled in SUPPORT. MEASUREMENTS: The outcomes examined included patients' preferences for aggressive care, decision making regarding cardiopulmonary resuscitation and use of other life-sustaining treatments, hospital costs, intensity of resource use, and survival. RESULTS: Although older patients preferred less aggressive care than younger patients, many older patients wanted cardiopulmonary resuscitation and care focused on life extension. Patients' families and healthcare providers underestimated older patients' desire for aggressive care. After adjustment for illness severity, comorbidity, baseline function, and patients' preferences for aggressive care, older age was associated with lower hospital costs and resource intensity and higher rates of decisions to withhold life-sustaining treatments. In adjusted analyses, older age was associated with a slight survival disadvantage. This survival disadvantage persisted, even after adjustment for aggressiveness of care, suggesting that the relation between age and survival is not accounted for by less aggressive treatment of older patients. CONCLUSIONS: Even after adjustment for patients' prognoses and care preferences, seriously ill hospitalized older patients were treated less aggressively than younger patients. SUPPORT cannot fully identify whether the relationship between older age and less aggressive treatment is better explained by the withholding of potentially beneficial treatments from older patients, or by the excessive provision of ineffective treatment to younger patients. However, the latter explanation is favored by the SUPPORT finding that less aggressive treatment for older patients does not contribute to the modest survival disadvantage associated with older age.

Pain and suffering in seriously ill hospitalized patients.

BACKGROUND: Previous studies had suggested a high prevalence of pain in hospitalized patients but had not specifically evaluated pain and other symptoms in seriously ill and older hospitalized patients. OBJECTIVE: The SUPPORT and HELP studies were designed to (1) assess the frequency and severity of pain and other symptoms during hospitalization 2 and 6 months later, and before death; (2) identify factors associated with pain and other symptoms; and (3) test an intervention to improve pain. DESIGN: An observational cohort and randomized controlled trial. SETTING: Five major teaching hospitals in the US. PATIENTS: Hospitalized patients aged 80 years and older or with one of nine serious illnesses. INTERVENTION: Education of patients and family members about pain control, monitoring of patients' pain, and feedback about pain with treatment suggestions to nurses and physicians. MEASUREMENTS: Data from the medical record and interview-based information about pain and other symptoms and preferences for care and symptom control from patients and family members. RESULTS: Pain and other symptoms were frequent and often severe in seriously ill and older patients during hospitalization, at follow-up, and before death, even in those with diseases not traditionally associated with pain. There was wide variation in symptom experience across hospitals. Patients' preference for pain control was not associated with symptom experience. The intervention did not improve pain control. CONCLUSIONS: Control of pain and other symptoms remains an important medical and ethical issue. Routine monitoring of pain and other symptoms should be linked to treatment strategies aimed at combinations of symptoms and tested to assuage concerns about side effects.

Insights about dying from the SUPPORT project. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

OBJECTIVES: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) project was a study of 9105 seriously ill patients, 4274 of whom died within 6 months. HELP, the Hospitalized Elderly Longitudinal Project, was an ancillary study, in four of the five SUPPORT hospitals, of 1286 persons aged 80 years and older, 321 of whom died within 6 months. This paper reviews the SUPPORT and HELP literature to bring together insights concerning the time near death of seriously ill patients. METHODS: We reviewed published reports from SUPPORT and HELP, specifically, demographics of dying; characteristics of a prognostic model to estimate survival; patient symptoms near death; patient preferences and decision-making near death; ineffectiveness of the SUPPORT intervention; costs of dying while seriously ill; and the impact of serious illness on the family. We also compared and contrasted the experience of patients with different conditions. RESULTS: Patients in SUPPORT who died were typically younger than age 75. Most SUPPORT patients who died were male and most had an income of less than $11,000, although the older patients in HELP were even more likely to have had such low incomes. Patients with cirrhosis were much younger than most decedents, and patients with cancer were less often poor. Most had serious symptoms close to death. The place of death was more closely related to hospital bed supply than to decisions made by healthcare providers or individual patient preferences or characteristics. Prognosis near death was quite uncertain, especially in patients with heart and lung failure. CONCLUSIONS: Although SUPPORT aimed to describe and compare decision-making affecting seriously ill patients, it also illuminated many other aspects of their course near death.