The Legacy of SUPPORT

• Hospitalization
• Outcome assessment (health care)
• Health resources
• Age factors
• Severity of illness index

Few clinical research projects have generated as much public interest or as many published articles as SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). The first publication of the study's overall results in 1995 (1) generated front-page coverage in many major newspapers as well as multiple television news stories. At last count, data from SUPPORT have formed the basis for more than 62 published articles, including 9 in Annals of Internal Medicine—the latest of which, by Hamel and colleagues (2), appears in this issue. A forthcoming special supplement of the Journal of the American Geriatrics Society will contain an additional 30 articles based on the SUPPORT data. Innumerable other articles reference the findings of SUPPORT.

What accounts for SUPPORT's impact? In my view, there are four key explanations. First is the study's salience. By attempting to understand and then correct the problems identified among severely ill, hospitalized patients, SUPPORT explored a fundamental human concern. The study consisted of two phases, each conducted at five academic medical centers. Phase I, a descriptive, observational study, involved 4301 patients hospitalized with life-threatening medical conditions so severe that half of the patients were expected to die within 6 months. It produced sobering findings: Physicians didn't seem to know what kind of care their patients wanted, severe pain was unacceptably common, and too many patients died in intensive care units hooked up to machines.

Confronted with these disappointing findings, the investigators resolved to improve them. At that time, the expert consensus was that uncertainty over determining patients' prognoses and inadequate understanding of patients' wishes were the key barriers to improving end-of-life care. Convinced by the expert consensus that targeted interventions would work, the SUPPORT research team designed a second research phase aimed at fixing these problems. Unfortunately, they, …