OBJECTIVES: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) project was a study of 9105 seriously ill patients, 4274 of whom died within 6 months. HELP, the Hospitalized Elderly Longitudinal Project, was an ancillary study, in four of the five SUPPORT hospitals, of 1286 persons aged 80 years and older, 321 of whom died within 6 months. This paper reviews the SUPPORT and HELP literature to bring together insights concerning the time near death of seriously ill patients. METHODS: We reviewed published reports from SUPPORT and HELP, specifically, demographics of dying; characteristics of a prognostic model to estimate survival; patient symptoms near death; patient preferences and decision‐making near death; ineffectiveness of the SUPPORT intervention; costs of dying while seriously ill; and the impact of serious illness on the family. We also compared and contrasted the experience of patients with different conditions. RESULTS: Patients in SUPPORT who died were typically younger than age 75. Most SUPPORT patients who died were male and most had an income of less than $11,000, although the older patients in HELP were even more likely to have had such low incomes. Patients with cirrhosis were much younger than most decedents, and patients with cancer were less often poor. Most had serious symptoms close to death. The place of death was more closely related to hospital bed supply than to decisions made by healthcare providers or individual patient preferences or characteristics. Prognosis near death was quite uncertain, especially in patients with heart and lung failure. CONCLUSIONS: Although SUPPORT aimed to describe and compare decision‐making affecting seriously ill patients, it also illuminated many other aspects of their course near death.

Objective: Previous studies have shown social support to be inversely associated with cardiovascular disease (CVD) in men, whereas fewer studies have assessed the relationship in women. The purpose of this study was to evaluate the relationship between perceived social support and cardiovascular outcomes among postmenopausal women enrolled in the Women's Health Initiative Observational Study.Methods: We examined the relationships between perceived social support and (1) incident coronary heart disease (CHD), (2) total CVD, and (3) all-cause mortality. Participants were Women's Health Initiative Observational Study women, ages 50 to 79 years, enrolled between 1993 and 1998 and followed for up to 10.8 years. Social support was ascertained at baseline via nine questions measuring the following functional support components: emotional/informational, tangible, positive social interaction, and affectionate support.Results: Among women with prior CVD (n ¼ 17,351) and no prior CVD (n ¼ 73,421), unadjusted hazard ratios ranged from 0.83 to 0.93 per standard deviation increment of social support. Adjustment for potential confounders, such as smoking and physical activity levels, eliminated the statistical significance of the associations with CHD and CVD. However, for all-cause mortality and among women free of baseline CVD, the association was modest but remained statistically significant after this adjustment (hazard ratio ¼ 0.95 [95% confidence interval, 0.91-0.98]). No statistically significant association was observed among women with a history of CVD.Conclusions: After controlling for potential confounding variables, higher perceived social support is not associated with incident CHD or CVD. However, among women free of CVD at baseline, perceived social support is associated with a slightly lower risk of all-cause mortality.

Qualitative claims analysis illuminated many problems in the care of chronically ill older people at the end of life and suggested that traditional vital statistics assignation of a single cause of death may distort policy priorities. This novel approach to claims review is feasible and deserves further study.

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