Can Clinical Interventions Change Care at the End of Life?

PURPOSE: To review clinical interventions designed to change care at the end of life. DATA SOURCES: Published results of clinical trials identified by MEDLINE searches, review of abstracts from meetings, and selected bibliographies. STUDY SELECTION: Studies were included if data were presented on a clinical intervention designed to change medical care at the end of life. Studies done in nonclinical settings or outside the United States were excluded. DATA EXTRACTION: Interventions were classified as targeting patients, physicians, or both and were analyzed by their effect on four common clinical goals: increasing use of patient preferences, decreasing pain and suffering, reducing use of life-sustaining treatments, and reducing costs. Positive and negative trial results were compared for differences in intervention, target group, and strength of study methods. DATA SYNTHESIS: Educational interventions usually increased expression of patient treatment preferences. Success rates were higher when more severely ill patients were targeted and when written materials were combined with repeated discussions in clinical encounters. Educational interventions with physicians led to increased use of patient preferences, but sophisticated educational techniques were needed to motivate physicians to change their behavior. Three studies provided limited evidence that physician education reduced the use of life-sustaining treatments. No clinical intervention had an effect on pain, suffering, or cost of medical care. CONCLUSION: To change care at the end of life, intensive educational interventions for physicians and broad institutional programs seem more promising than advance directives. Future innovations should seek to change physician practices, reduce costs, and improve patient-centered outcomes, such as pain control and satisfaction.