What SUPPORT really means. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.
Explore the source record for details and available documents.
Advance Directives↗
Biomedical subjects
L J Markson
Publications and source records attributed to L J Markson.
Implementing advance directives in the primary care setting.
BACKGROUND: Despite the potential benefits of advance directives, few patients complete them. This study examined whether barriers to advance decision making can be overcome via a combined educational and administrative intervention targeted at physicians. METHOD: The subjects consisted of all the internists (n = 6) at a primary care physician home care (HC) service and all the internists (n = 4) at a primary care nursing home (NH) service. Physicians were given a 5-week course on the law relating to advance directives. Administrative consent was obtained to permit physicians to spend additional time with patients to discuss advance directives. Physicians were asked to discuss advance directives with newly enrolled patients and to assist interested patients to complete directives. During the first 2 months of the trial, physicians did not approach any patients. Therefore, the study design was changed to include all active patients, and physicians received additional training that involved observing and leading discussions with their own patients. RESULTS: Physicians approached 74 of 356 competent HC patients, of whom 48 (65%) completed directives. All 42 competent NH patients were approached, and 38 (90%) completed directives. Most patients who completed a directive chose relatives as proxies. Most directed that life-sustaining treatment be withheld in the event they were permanently unconscious (HC, 81%; NH, 92%). Other common choices were to decline long-term mechanical ventilation (HC, 58%; NH, 79%), long-term artificial nutrition (HC, 44%; NH, 79%), and cardiopulmonary resuscitation (HC, 27%; NH, 66%). CONCLUSIONS: Physicians can overcome initial reluctance to integrate advance decision making into primary care provided to elderly patients. Teaching physicians about the law is not sufficient to change behavior; physicians also need practical experience discussing directives with patients. Our high patient response suggests that a physician-directed intervention is sufficient to achieve high rates of completing directives without additional, concomitant patient-directed intervention.
Advance Directives↗
Physician assessment of patient competence.
OBJECTIVE: To determine if physicians know and can apply the legal standard for determining competence; to determine if physician assessment of competence varies by physician age or specialty. DESIGN: Mail survey with specific questions about a patient scenario and general questions about the law. PARTICIPANTS: 2100 randomly selected Massachusetts internists, surgeons, and psychiatrists. MEASUREMENTS: In Part I, the survey presented a scenario adapted from a court case that involved an elderly woman's refusing lifesaving surgery. The scenario was divided into three sections: the medical history, the patient's rationale, and a psychiatrist's opinion that the patient was incompetent. Respondents were not told that an appellate court later decided the psychiatrist applied the wrong standard of competence and the patient was indeed competent. Respondents were asked whether the patient was competent, whom they would consult, and how they would respond. Part II posed a series of theoretical questions about competence. Group differences were tested by chi-square. MAIN RESULTS: Surveys were returned by 823 (41%) of the sample. In Part I, before the psychiatrist's opinion, 58% thought the patient was competent, 92% would consult a psychiatrist to help assess competence, and only 17% would to go to court. After the psychiatrist's opinion, only 30% thought she was competent and 55% would go to court. In Part II, 89% knew the correct standard for competence; however, most incorrectly responded that conditions such as dementia and psychosis establish incompetence. Psychiatrists performed significantly better on theoretical, but frequently worse on scenario, questions. CONCLUSIONS: Physicians in general, and psychiatrists in particular, know the standard for competence but may apply it incorrectly. This suggests that the common clinical practice of relying on expert medical opinion may introduce bias and produce inaccurate results that undermine patient autonomy.
Age Factors↗
Pneumococcal vaccination: perceptions of primary care physicians.
BACKGROUND: Little is known about barriers to pneumococcal vaccination in the primary care setting. METHODS: Mail survey to 405 randomly selected Massachusetts primary care physicians (response rate 68%). RESULTS: Seventy-nine percent considered themselves knowledgeable about current vaccination guidelines, and 75% said vaccination is an important clinical priority. Respondents answered a mean of five of six knowledge questions about vaccination "correctly," that is, consistent with current scientific evidence or expert opinion. Physicians reported high immunization rates: 51% thought over half their eligible patients were vaccinated; however, only 27% thought their colleagues immunized a similar number of patients. Physician attitude was the strongest independent predictor of high reported immunization rates (odds ratio of 4.7, P = 0.0001). Twenty-four percent of respondents thought physician oversight due to the need to attend to other active medical problems greatly reduces the number of patients they immunize. None of eight other financial, administrative, and clinical barriers were felt to be important by more than 7% of physicians. Sixty-six percent of physicians favored a standing order policy to immunize their eligible patients. CONCLUSIONS: Oversight and overestimation of immunization rates appear to be important barriers to pneumococcal vaccination. The literature suggests that reminder and performance feedback systems directed toward eliminating these barriers have had some success; interventions such as standing order policies may yield further improvements and appear to be acceptable to most physicians.
Adult↗