Showing papers on "End-of-life care published in 2006"

Factors influencing death at home in terminally ill patients with cancer: systematic review.

Abstract: Objectives To determine the relative influence of different factors on place of death in patients with cancer. Data sources Four electronic databases—Medline (1966-2004), PsycINFO (1972-2004), CINAHL (1982-2004), and ASSIA (1987-2004); previous contacts with key experts; hand search of six relevant journals. Review methods We generated a conceptual model, against which studies were analysed. Included studies had original data on risk factors for place of death among patients, > 80% of whom had cancer. Strength of evidence was assigned according to the quantity and quality of studies and consistency of findings. Odds ratios for home death were plotted for factors with high strength evidence. Results 58 studies were included, with over 1.5 million patients from 13 countries. There was high strength evidence for the effect of 17 factors on place of death, of which six were strongly associated with home death: patients' low functional status (odds ratios range 2.29-11.1), their preferences (2.19-8.38), home care (1.37-5.1) and its intensity (1.06-8.65), living with relatives (1.78-7.85), and extended family support (2.28-5.47). The risk factors covered all groups of the model: related to illness, the individual, and the environment (healthcare input and social support), the latter found to be the most important. Conclusions The ne of factors that influence where patients with cancer die is complicated. Future policies and clinical practice should focus on ways of empowering families and public education, as well as intensifying home care, risk assessment, and training practitioners in end of life care.

What matters most in end-of-life care: perceptions of seriously ill patients and their family members

Abstract: Background: Initiatives to improve end-of-life care are hampered by our nascent understanding of what quality care means to patients and their families. The primary purpose of this study was to describe what seriously ill patients in hospital and their family members consider to be the key elements of quality end-of-life care. Methods: After deriving a list of 28 elements related to quality end-of-life care from existing literature, focus groups with experts and interviews with patients, we administered a face-to-face questionnaire to older patients with advanced cancer and chronic end-stage medical disease and their family members in 5 hospitals across Canada to assess their perspectives on the importance. We compared differences in ratings across various subgroups of patients and family members. Results: Of 569 eligible patients and 176 family members, 440 patients (77%) and 160 relations (91%) agreed to participate. The elements rated as „extremely important” most frequently by the patients were „To have trust and confidence in the doctors looking after you” (55.8% of respondents), „Not to be kept alive on life support when there is little hope for a meaningful recovery” (55.7%), „That information about your disease be communicated to you by your doctor in an honest manner” (44.1%) and „To complete things and prepare for life9s end — life review, resolving conflicts, saying goodbye” (43.9%). Significant differences in ratings of importance between patient groups and between patients and their family members were found for many elements of care. Interpretation: Seriously ill patients and family members have defined the importance of various elements related to quality end-of-life care. The most important elements related to trust in the treating physician, avoidance of unwanted life support, effective communication, continuity of care and life completion. Variation in the perception of what matters the most indicates the need for customized or individualized approaches to providing end-of-life care.

Improving the Quality of End-of-Life Care in the Pediatric Intensive Care Unit: Parents' Priorities and Recommendations

Abstract: OBJECTIVE Despite recognition that dying children and their families have unique palliative care needs, there has been little empirical inquiry of parent perspectives to improve the quality of end-of-life care and communication The purpose of this study was to identify and describe the priorities and recommendations for end-of-life care and communication from the parents9 perspective METHODS This was a qualitative study based on parental responses to open-ended questions on anonymous, self-administered questionnaires, conducted at 3 pediatric ICUs in Boston, Massachusetts Fifty-six parents whose children had died in PICUs after withdrawal of life support participated in this study We measured parent-identified priorities for end-of-life care and communication RESULTS Parents identified 6 priorities for pediatric end-of-life care including honest and complete information, ready access to staff, communication and care coordination, emotional expression and support by staff, preservation of the integrity of the parent-child relationship, and faith CONCLUSIONS Parental priorities and recommendations offer simple yet compelling guidance to improve pediatric end-of-life clinical practice and research

Dying, dignity, and new horizons in palliative end-of-life care.

Abstract: Palliative care practitioners are now better able than ever before to ameliorate end-of-life symptom distress What remains less developed, however, is the knowledgebase and skill set necessary to recognize, assess, and compassionately address the psychosocial, existential, and spiritual aspects of the patient's dying experience This review provides an overview of these areas, focusing primarily on empirical data that has examined these issues A brief overview of psychiatric challenges in end-of-life care is complemented with a list of resources for readers wishing to explore this area more extensively The experience of spiritual or existential suffering toward the end of life is explored, with an examination of the conceptual correlates of suffering These correlates include: hopelessness, burden to others, loss of sense of dignity, and desire for death or loss of will to live An empirically-derived model of dignity is described in some detail, with practical examples of diagnostic questions and therapeutic interventions to preserve dignity Other interventions to reduce existential or spiritual suffering are described and evidence of their efficacy is presented The author concludes that palliative care must continue to develop compassionate, individually tailored, and effective responses to the mounting vulnerability and increasingly difficult physical, psychosocial, and spiritual challenges facing persons nearing the end of life

Providing a “Good Death”: Critical Care Nurses’ Suggestions for Improving End-of-Life Care

Abstract: • BACKGROUND Providing appropriate end-of-life care has become a primary concern of nurses and the public. The highly technological critical care environment may not facilitate such care. • OBJECTIVE To collect suggestions from critical care nurses for improving end-of-life care in intensive care units. • METHODS A geographically dispersed, random sample of 1409 members of the American Association of Critical-Care Nurses was sent a 72-item survey on perceptions of end-of life care. The survey included a request for suggestions on ways to improve end-of life care. • RESULTS Of the 861 critical care nurses who responded to the survey, 485 offered 530 suggestions for improving end-of-life care. Providing a “good death” was the major theme; specific suggestions included ways to help ensure death with dignity and peace. Barriers to providing good deaths included nursing time constraints, staffing patterns, communication challenges, and treatment decisions that were based on physicians’ rather than patients’ needs. Suggestions for providing a good death included facilitating dying with dignity; not allowing patients to be alone while dying; managing patients’ pain and discomfort; knowing, and then following, patients’ wishes for end-of-life care; promoting earlier cessation of treatment or not initiating aggressive treatment at all; and communicating effectively as a healthcare team. Educational initiatives for professionals and the public were also suggested. • CONCLUSIONS Implementation of specific suggestions provided by experienced critical care nurses might increase the quality of end-of-life care, facilitating a good death for intensive care patients. (American Journal of Critical Care. 2006;15:38-46)

End-of-life care for the critically ill: A national intensive care unit survey.

Abstract: Objective:One in five Americans dies following treatment in an intensive care unit (ICU), and evidence indicates the need to improve end-of-life care for ICU patients. We conducted this study to elicit the views and experiences of ICU directors regarding barriers to optimal end-of-life care and to i

Clinician statements and family satisfaction with family conferences in the intensive care unit

Abstract: Objectives:The quality of family-clinician communication in the intensive care unit is often inadequate, but little is known about specific clinician communication behaviors that might improve family satisfaction. In this exploratory analysis, we hypothesized that clinicians’ communication behaviors

Communication between physicians and nurses as a target for improving end-of-life care in the intensive care unit: challenges and opportunities for moving forward.

Abstract: Our objective was to discuss obstacles and barriers to effective communication and collaboration regarding end-of-life issues between intensive care unit nurses and physicians. To evaluate practical interventions for improving communication and collaboration, we undertook a systematic literature review. An increase in shared decision making can result from a better understanding and respect for the perspectives and burdens felt by other caregivers. Intensive care unit nurses value their contributions to end-of-life decision making and want to have a more active role. Increased collaboration and communication can result in more appropriate care and increased physician/nurse, patient, and family satisfaction. Recommendations for improvement in communication between intensive care unit physicians and nurses include use of joint grand rounds, patient care seminars, and interprofessional dialogues. Communication interventions such as use of daily rounds forms, communication training, and a collaborative practice model have shown positive results. When communication is clear and constructive and practice is truly collaborative, the end-of-life care provided to intensive care unit patients and families by satisfied and engaged professionals will improve markedly.

Proposed quality measures for palliative care in the critically ill: a consensus from the Robert Wood Johnson Foundation Critical Care Workgroup.

Abstract: For critically ill patients and their loved ones, high-quality health care includes the provision of excellent palliative care. To achieve this goal, the healthcare system needs to identify, measure, and report specific targets for quality palliative care for critically ill or injured patients. Our objective was to use a consensus process to develop a preliminary set of quality measures to assess palliative care in the critically ill. We built on earlier and ongoing efforts of the Robert Wood Johnson Foundation Critical Care End-of-Life Peer Workgroup to propose specific measures of the structure and process of palliative care. We used an informal iterative consensus process to identify and refine a set of candidate quality measures. These candidate measures were developed by reviewing previous literature reviews, supplementing the evidence base with recently published systematic reviews and consensus statements, identifying existing indicators and measures, and adapting indicators from related fields for our objective. Among our primary sources, we identified existing measures from the Voluntary Hospital Association's Transformation of the ICU program and a government-sponsored systematic review performed by RAND Health to identify palliative care quality measures for cancer care. Our consensus group proposes 18 quality measures to assess the quality of palliative care for the critically ill and injured. A total of 14 of the proposed measures assess processes of care at the patient level, and four measures explore structural aspects of critical care delivery. Future research is needed to assess the relationship of these measures to desired health outcomes. Subsequent measure sets should also attempt to include outcome measures, such as patient or surrogate satisfaction, as the field develops the means to rigorously measure such outcomes. The proposed measures are intended to stimulate further discussion, testing, and refinement for quality of care measurement and enhancement.

Satisfaction with End‐of‐Life Care for Nursing Home Residents with Advanced Dementia

Abstract: OBJECTIVES To identify factors associated with satisfaction with care for healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia.

Toward interventions to improve end-of-life care in the pediatric intensive care unit

Abstract: Although children account for only about 3% of all deaths that occur in the United States each year, these patients and their families have needs that are uniquely different from those of adult patients. To date, however, no research on interventions to improve end-of-life care in the pediatric intensive care unit (PICU) has been performed. This review seeks to facilitate and inform future interventional studies by summarizing existing descriptive data about end-of-life care in this setting. These data are organized around six domains that have been identified as critical to high-quality, family-centered care: 1) support of the family unit; 2) communication with the child and family about treatment goals and plans; 3) ethics and shared decision making; 4) relief of pain and other symptoms; 5) continuity of care; and 6) grief and bereavement support. These data are integrated and used to develop evidence-based suggestions for a variety of interventions that could be implemented and then evaluated for their potential contribution to improving the care of children dying in the PICU.

Peaceful awareness in patients with advanced cancer.

Abstract: Background: Previous studies have shown that prognostic awareness may be harmful to mental health yet beneficial for end of life care planning. The effects of prognostic awareness coupled with a sense of inner peace are unknown. Methods: In the multisite, longitudinal Coping with Cancer Study, 280 patients with advanced cancer were interviewed at baseline. Patients defining themselves as "terminally ill" and/or "at peace" most days were paired with others on sociodemographic, mental health and advance care planning. Primary caregivers of deceased patients were interviewed 6 months postloss and compared on their physical and mental health and their perceptions of patients' end-of-life care and death. Results: Overall, 17.5% of patients reported being both peaceful and aware. Peacefully aware patients had lower rates of psychological distress and higher rates of advance care planning (e.g., completing do-not-resuscitate [DNR] orders, advance care planning discussions with physicians) than those who were not...

Looking Back From Death: The Value of Retrospective Studies of End-of-Life Care

Abstract: Cancer is projected to cause more than 570,000 deaths in the United States in 2005. As patients with cancer approach death, the issues they face are often similar regardless of the original site of disease. Important practice variation has been documented near the end of life, with inadequate treatment of pain and other symptoms, increasing use of overly aggressive anticancer treatments, and disparities in access to hospice services. As a result, the quality of end-of-life care delivered to patients who die as a result of cancer is a major public health concern. Two approaches have commonly been used to study the quality of end-of-life care. Many studies have retrospectively assessed the care received by patients in the time frame leading up to death, whereas others have identified patients entering the terminal phase of disease and prospectively observed their care forward in time. Each of these approaches has its theoretical and practical advantages and disadvantages, yet it has been suggested recently that retrospective designs are particularly biased and thus should be “laid to rest.” This sweeping recommendation, however, risks the loss of important opportunities to understand and improve end-of-life care in large representative cohorts of patients with cancer. In a perfect world, the optimal way to study end-of-life care, assuming unlimited resources, cooperation, and time, would be to assemble a cohort of all patients with incident disease, regardless of initial stage or severity, and collect data on their care until all of them have died. This study design provides an unbiased look at care before death among those who died, and also allows study cohorts to be defined by sentinel events among those who went on to die as a result of their disease and those who did not. However, obtaining information from a representative sample is particularly challenging. If one is able to identify patients who are entering the terminal phase and approach them quickly enough, they are often by definition very ill and unable to provide information. Although such studies have been conducted successfully, they are expensive and laborious, making alternative study designs attractive. There are two alternatives: less-than-optimal prospective approaches to define study cohorts and retrospective approaches to this task. In retrospective studies of end-of-life care, the cohort consists of decedents. These participants can be either patients who died as a result of a particular disease (as determined by death certificate, for example) or patients with a particular disease who died as a result of any cause. Investigators then look back over the time leading up to death to observe preterminal care. Retrospective designs have several advantages over prospective designs. First, they allow for easy identification of cohorts of relevant patients. In contrast, prospectively identifying patients who are approaching the end of life is often not feasible— especially from administrative data sources. Second, a retrospective approach allows all patients who come to the end of life to be studied, not just a nonrandom subset defined by a disease characteristic or event that identifies them as dying. For example, assembling a prospective cohort based on hospice enrollment will only capture those patients whose physicians recognized that they were approaching the end of life, whose physicians were able to raise this difficult issue with them, and who themselves philosophically accepted hospice care. In another example, it has been suggested that analysis of end-of-life care be restricted to patients presenting with metastatic breast cancer, rather than looking at all patients who die of breast cancer. Less than 20% of the patients who die as a result of breast cancer initially present with clearly terminal disease, however, and these patients have been shown to have different characteristics from those who initially present with earlier stage cancer and then later relapse. Unfortunately, relapse of cancer is not accurately or completely captured by most tumor registries. A prospective cohort study of patients with metastatic breast cancer at diagnosis would yield no information about the majority of patients who die as a result of breast cancer. In addition, there is great variability in the natural history and effectiveness of therapies among patients with metastatic cancer, such that some patients with incurable metastatic breast cancer may be “terminally ill” for several years. In those situations, their initial care will not be focused on end-of-life issues. Without research using retrospective designs, the end-of-life experiences of patients not easily defined as dying will often be overlooked. Lastly, by only assessing the end-of-life care of patients who actually die, efficient retrospective designs facilitate the development of performance measures that can be used with readily available data to monitor end-of-life care across providers, geographic areas, demographic groups, and time periods. Such performance measures may become key elements of new national systems to monitor and improve the quality of cancer care. JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 24 NUMBER 6 FEBRUARY 2

Practice of Expert Critical Care Nurses in Situations of Prognostic Conflict at the End of Life

Abstract: • BACKGROUND Prolonging the living-dying process with inappropriate treatment is a profoundly disturbing ethical issue for nurses in many practice areas, including the intensive care unit. Despite the frequent occurrence of such distressing events, research suggests that critical care nurses assume a limited role in end-of-life decision making and care planning. • OBJECTIVES To explore the practice of expert critical care nurses in end-of-life conflicts and to describe actions taken when the nurses thought continued aggressive medical interventions were not warranted. • METHODS A qualitative design was used with narrative analysis of interview data that had a temporal ordering of events. Interviews were conducted with 21 critical care nurses from 7 facilities in the southwestern United States who were nominated as experts by their colleagues. • RESULTS Three recurrent narrative plots were derived: protecting or speaking for the patient, presenting a realistic picture, and experiencing frustration and resignation. Narratives of protecting or speaking for the patient concerned preventing further technological intrusion and thus permitting a dignified death. Presenting a realistic picture involved helping patients’ family members reframe the members’ sense of the potential for recovery. Inability to affect a patient’s situation was expressed in narratives of frustration and resignation. • CONCLUSIONS The transition from curative to end-of-life care in the intensive care unit is often fraught with ambiguity and anguish. The expert nurses demonstrated the ability and willingness to actively protect and advocate for their vulnerable patients even in situations in which the nurses’ actions did not influence the outcomes. (American Journal of Critical Care. 2006;15:480-491)

The Validity and Reliability of Scales for the Evaluation of End-of- Life Care in Advanced Dementia

Abstract: The lack of valid and reliable instruments designed to measure the experiences of older persons with advanced dementia and those of their health care proxies has limited palliative care research for this condition. This study evaluated the reliability and validity of 3 End-of-Life in Dementia (EOLD) scales that measure the following outcomes: (1) satisfaction with the terminal care (SWC-EOLD), (2) symptom management (SM-EOLD), and (3) comfort during the last 7 days of life (CAD-EOLD). Data were derived from interviews with the health care proxies (SWC-EOLD) and primary care nurses (SM-EOLD, CAD-EOLD) for 189 nursing home residents with advanced dementia living in 15 Boston-area facilities. The scales demonstrated satisfactory to good reliability: SM-EOLD (α = 0.68), SWC-EOLD (α = 0.83), and CAD-EOLD (α = 0.82). The convergent validity of these scales, as measured against other established instruments assessing similar constructs, was good (correlation coefficients ranged from 0.50 to 0.81). The results of this study demonstrate that the 3 EOLD scales demonstrate “internal consistency” reliability and demonstrate convergent validity, and further establish their utility in palliative care dementia research.

A survey of end-of-life care in care homes: Issues of definition and practice.

Abstract: Care homes throughout the UK provide long-term care for frail older people. Whilst care homes are a home for life, many of the older people living in this setting also die there. There is increased interest in improving the care that older people receive in care homes towards the end of life. One way to achieve this has been through links with specialist palliative care services. The knowledge held in care homes by staff, residents and their family carers has yet to be fully integrated into this work. Consequently, a postal survey of care home managers in one English county was undertaken to examine the characteristics of end-of-life care for older people in these care homes. We sought to establish the managers’ understanding of end-of-life care; the extent to which dying and death is present in this setting; the attributes of the resident population living in these care homes; and the availability of resources to support the provision of end-of-life care in this setting. The survey identified that managers held diverse understandings regarding the meaning of end-of-life care. The features of the residents’ conditions and the dying that they experience requires a different way to conceptualise end-of-life care. A longer-term perspective is offered here that encompasses the whole period of a person's residence in a care home.

Barriers to implementing an integrated care pathway for the last days of life in nursing homes

Abstract: Aim: This paper explores the barriers that needed to be overcome during the process of implementing an integrated care pathway for the last days of life as a way of developing quality end-of-life care in nursing homes. Methods: An action research methodology underpinned the study. Qualitative and quantitative data were collected in eight nursing homes before, during and after the implementation of the care pathway. Findings: Six main barriers were identified: a lack of knowledge of palliative care drugs and control of symptoms at the end of life; lack of preparation for approaching death; not knowing when someone is dying or understanding the dying process; lack of multidisciplinary team working in nursing homes; lack of confidence in communicating about dying; some nursing homes are not ready or able to change. These findings highlight a functional ‘rehabilitative’ culture that may not be so appropriate in the current context of nursing home care, and one that makes implementing an integrated care pathwa...

Nurses' perceptions of quality end-of-life care on an acute medical ward.

Abstract: Journal of AdvancedNursing 53(2), 169–177Nurses’ perceptions of quality end-of-life care on an acute medical wardAim. This paper reports the findings of a study that generated a conceptualmodel of the nursing behaviours and social processes inherent in the provision ofquality end-of-life care from the perspective of nurses working in an acute caresetting.Background. The majority of research examining the issue of quality end-of-lifecare has focused on the perspectives of patients, family members and physicians.The perspective of nurses has generally received minimal research attention, withthe exception of those working within palliative or critical care. The vastmajority of hospitalized patients, however, continue to be cared for and die onmedical units. To date, little research has been conducted examining definitionsand determinants of quality end-of-life care from the perspective of nursesworking in acute adult medical settings.Method. Grounded theory method was used in this study of 10 nurses workingon acute medical units at two tertiary university-affiliated hospitals in centralCanada. Data were collected during 2002 by interview and participant obser-vation.Findings. The basic social problem uncovered in the data was that of nursesstriving to provide high quality end-of-life care on an acute medical unit whilebeing pulled in all directions. The unifying theme of ‘Creating a haven for safepassage’ integrated the major sub-processes into the key analytic model in thisstudy. ‘Creating a haven for safe passage’ represents a continuum of behavioursand strategies, and includes the sub-processes of ‘facilitating and maintain a lanechange’; ‘getting what’s needed’; ‘being there’; and ‘manipulating the care envi-ronment’.Conclusion. The ability of nurses to provide quality end-of-life care on an acutemedical unit is a complex process involving many factors related to the patient,family, healthcare providers and the context in which the provision of end-of-lifecare takes place.Keywords: end-of-life care, grounded theory, medical nursing, nurses, qualitynursing care

Good end-of-life care according to patients and their GPs

Abstract: Background Most patients prefer to die at home, where a GP provides end-of-life care. A few previous studies have been directed at the GPs9 values on good end-of-life care, yet no study combined values of patients and their own GP. Aim To explore the aspects valued by both patients and GPs in end-of-life care at home, and to reflect upon the results in the context of future developments in primary care. Design of study Interviews with patients and their own GP. Setting Primary care in the Netherlands. Method Qualitative, semi-structured interviews with 20 GPs and 30 of their patients with a life expectancy of less than 6 months, and cancer, heart failure or chronic obstructive pulmonary disease as underlying disease. Results Patients and GPs had comparable perceptions of good end-of-life care. Patients and GPs identified four core items that they valued in end-of-life care: availability of the GP for home visits and after office-hours, medical competence and cooperation with other professionals, attention and continuity of care. Conclusions Future developments in the organisation of primary care such as the restriction of time for home visits, more part-time jobs and GP cooperatives responsible for care after office hours, may threaten valued aspects in end-of-life care.

A Cross-Cultural Study of Physician Treatment Decisions for Demented Nursing Home Patients Who Develop Pneumonia

Abstract: PURPOSE We wanted to explore factors that influence Dutch and US physician treatment decisions when nursing home patients with dementia become acutely ill with pneumonia. METHODS Using a qualitative semistructured interview study design, we collected data from 12 physicians in the Netherlands and 12 physicians in North Carolina who care for nursing home patients. Our main outcome measures were perceptions of influential factors that determine physician treatment decisions regarding care of demented patients who develop pneumonia. RESULTS Several themes emerged from the study. First, physicians viewed their patient care roles differently. Dutch physicians assumed active, primary responsibility for treatment decisions, whereas US physicians were more passive and deferential to family preferences, even in cases when they considered families’ wishes for care as inappropriate. These family wishes were a second theme. US physicians reported a perceived sense of threat from families as influencing the decision to treat more aggressively, whereas Dutch physicians revealed a predisposition to treat based on what they perceived was in the best interest of the patient. The third theme was the process of decision making whereby Dutch physicians based decisions on an intimate knowledge of the patient, and American physicians reported limited knowledge of their nursing home patients as a result of lack of contact time. CONCLUSION Physician-perceived care roles regarding treatment decisions are influenced by contextual differences in physician training and health care delivery in the United States and the Netherlands. These results are relevant to the debate about optimal care for patients with poor quality of life who lack decision-making capacity.

Promoting Excellence in End-of-Life Care: A Report on Innovative Models of Palliative Care

Abstract: Background: Promoting Excellence in End-of Life Care, a national program of The Robert Wood Johnson Foundation, funded 22 demonstration projects representing a wide range of health care settings and patient populations to develop innovative models for delivering palliative care that addressed documented deficiencies in the care of patients and families facing the final stage of life. Objective: To determine the practicality (feasibility of development and operation as well as acceptance by stakeholders) of new models of care and to determine the impact of the models on access to, quality of and financing for palliative care. Design: The program cannot report scientifically rigorous outcomes, but the grant-funded projects used a variety of methods and measures to assess acceptance of new models and their impact from the perspectives of various stakeholders, including patients and their families, clinicians, administrators and payers. While it is not possible to aggregate data across projects, the data repo...

Challenges to end of life care in the acute hospital setting

Abstract: Background: Research exploring patients' care and treatment preferences at the end of life (EOL) suggests they prefer comfort more than life-extension, wish to participate in decision-making, and w...

Shelter-based palliative care for the homeless terminally ill:

Abstract: Background: The homeless have high rates of mortality, but live in environments not conducive to terminal care. Traditional palliative care hospitals may be reluctant to accept such patients, due t...

The state of advance care planning: one decade after SUPPORT.

Abstract: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) was a landmark study regarding end-of-life decision making and advance care planning. Phase I of the study looked at the state of end of life in various hospitals, and phase II implemented a nurse-facilitated intervention designed to improve advance care planning, patient-physician communication, and the dying process. The observational phase found poor quality of care at the end of life and the intervention failed to improve the targeted outcomes. The negative findings brought public attention to the need to improve care for the dying and spawned a wealth of additional research on decision-making at the end of life. In the decade since SUPPORT, researchers have defined the attributes of a "good death," addressed the role of advance directives in advance care planning, and studied the use of surrogate decision-making at the end of life. This rekindled the discussion on advance care planning and challenged health care providers to design more flexible approaches to end of life care.