TY - JOUR
T1 - Rethinking fundamental assumptions
T2 - Support's implications for future reform
AU - Lynn, Joanne
AU - Arkes, Hal R.
AU - Stevens, Marguerite
AU - Cohn, Felicia
AU - Koenig, Barbara
AU - Fox, Ellen
AU - Dawson, Neal V.
AU - Phillips, Russell S.
AU - Hamel, Mary Beth
AU - Tsevat, Joel
N1 - Publisher Copyright:
© 2000 The American Geriatrics Society.
PY - 2000/5/1
Y1 - 2000/5/1
N2 - BACKGROUND: The intervention in SUPPORT, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, was ineffective in changing communication, decision-making, and treatment patterns despite evidence that counseling and information were delivered as planned. The previous paper in this volume shows that modest alterations in the intervention design probably did not explain the lack of substantial effects. OBJECTIVE: To explore the possibility that improved individual, patient-level decision-making is not the most effective strategy for improving end-of-life care and that improving routine practices may be more effective. DESIGN: This paper reflects our efforts to synthesize findings from SUPPORT and other sources in order to explore our conceptual models, their consistency with the data, and their leverage for change. RESULTS: Many of the assumptions underlying the model of improved decision-making are problematic. Furthermore, the results of SUPPORT suggest that implementing an effective intervention based on a normative model of shared decision-making can be quite difficult. Practice patterns and social expectations may be strong influences in shaping patients' courses of care. Innovations in system function, such as quality improvement or changing the financing incentives, may offer more powerful avenues for reform. CONCLUSIONS: SUPPORT's intervention may have failed to have an impact because strong psychological and social forces underlie present practices. System-level innovation and quality improvement in routine care may offer more powerful opportunities for improvement.
AB - BACKGROUND: The intervention in SUPPORT, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, was ineffective in changing communication, decision-making, and treatment patterns despite evidence that counseling and information were delivered as planned. The previous paper in this volume shows that modest alterations in the intervention design probably did not explain the lack of substantial effects. OBJECTIVE: To explore the possibility that improved individual, patient-level decision-making is not the most effective strategy for improving end-of-life care and that improving routine practices may be more effective. DESIGN: This paper reflects our efforts to synthesize findings from SUPPORT and other sources in order to explore our conceptual models, their consistency with the data, and their leverage for change. RESULTS: Many of the assumptions underlying the model of improved decision-making are problematic. Furthermore, the results of SUPPORT suggest that implementing an effective intervention based on a normative model of shared decision-making can be quite difficult. Practice patterns and social expectations may be strong influences in shaping patients' courses of care. Innovations in system function, such as quality improvement or changing the financing incentives, may offer more powerful avenues for reform. CONCLUSIONS: SUPPORT's intervention may have failed to have an impact because strong psychological and social forces underlie present practices. System-level innovation and quality improvement in routine care may offer more powerful opportunities for improvement.
KW - decision-maker
KW - end-of-life care
KW - quality improvement
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U2 - 10.1111/j.1532-5415.2000.tb03135.x
DO - 10.1111/j.1532-5415.2000.tb03135.x
M3 - Article
C2 - 10809478
AN - SCOPUS:0034020038
SN - 0002-8614
VL - 48
SP - S214-S221
JO - Journal of the American Geriatrics Society
JF - Journal of the American Geriatrics Society
IS - S1
ER -