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Background: In response to the rapid aging population and increasing number of cancer patients, discussions on dignified end-of-life (EoL) decisions are active around the world. Therefore, this study aimed to identify the differences in EoL care patterns between types of hospice used for cancer patients., Methods: In this population-based cohort study, the Korean National Health Insurance Service cohort data containing all registered cancer patients who died between 2017 and 2021 were used. A total of 408,964 individuals were eligible for analysis. The variable of interest, the type of hospice used in the 6 months before death, was classified as follows: (1) Non-hospice users; (2) Hospital-based hospice single users; (3) Home-based hospice single users; (4) Combined hospice users. The outcomes were set as patterns of care, including intense care and supportive care. To identify differences in care patterns between hospice types, a generalized linear model with zero-inflated negative binomial distribution was applied., Results: Hospice enrollment was associated with less intense care and more supportive care near death. Notably, those who used combined hospice care had the lowest probability and frequency of receiving intense care (aOR: 0.18, 95% CI: 0.17-0.19, aRR: 0.47, 95% CI: 0.44-0.49), while home-based hospice single users had the highest probability and frequency of receiving supportive care (Prescription for narcotic analgesics, aOR: 2.95, 95% CI: 2.69-3.23, aRR: 1.45, 95% CI: 1.41-1.49; Mental health care, aOR: 3.40, 95% CI: 3.13-3.69, aRR: 1.35, 95% CI: 1.31-1.39)., Conclusion: Our findings suggest that although intense care for life-sustaining decreases with hospice enrollment, QoL at the EoL actually improves with appropriate supportive care. This study is meaningful in that it not only offers valuable insight into hospice care for terminally ill patients, but also provides policy implications for the introduction of patient-centered community-based hospice services., (© 2024. The Author(s).)

Objectives: With a fraction of hospices having their Consumer Assessment of Healthcare Providers and Systems (CAHPS®) scores on Hospice Compare, a significant reservoir of hospice quality data remains in online caregiver reviews. The purpose of this study was to develop a method and model of hospice quality assessment from caregiver reviews using Watson's carative model., Methods: Retrospective mixed methods of pilot qualitative thematic analysis and sentiment analysis using NLP of Google and Yelp caregiver reviews between 2013 and 2023. We employed stratified sampling, weighted according to hospice size, to emulate the daily census of enrollees across the United States. Sentiment analysis was performed ( n  = 3393) using Google NLP., Results: Two themes with the highest prevalence had moderately positive sentiments (S): Caring staff (+.47) and Care quality, comfort and cleanliness (+.41). Other positive sentiment scores with high prevalence were Gratitude and thanks (+.81), "Treating the patient with respect" (+.54) , and "Emotional, spiritual, bereavement support" (+.60). Lowest sentiment scores were " Insurance, administrative or billing" (-.37), " Lack of staffing" (-.32), and " Communication with the family" (-.01)., Significance of Results: In the developed quality model, caregivers recommended hospices with caring staff, providing quality care, responsive to requests, and offering family support, including bereavement care. All ten Watson's carative factors and all eight CAHPS measures were presented in the discovered review themes of the quality model. Close-ended CAHPS scores and open-ended online reviews have substantial conceptual overlap and complementary insights. Future hospice quality research should explore caregiver expectations and compare review themes by profit status.

Background and Objectives: Pain management is a necessary component of palliative care as most patients suffer from pain during the final phase of life. Due to the complex causation of pain in the last phase of life, it is important to utilize methods other than pharmacotherapeutic options in order to achieve adequate pain control. As little is known about treatment of pain in German hospices, a nationwide survey was conducted., Materials and Methods: All German hospices (259) were contacted by post in June 2020 and asked to participate in an anonymous cross-sectional survey., Results: A total of 148 (57%) German hospices took part in the survey. A broad variety of medication is used in the hospice setting. Metamizole is the most commonly used non-opiod analgesic , hydromorphone the most commonly used opioid, and pregabalin is the most commonly prescribed co-analgesic drug. The pain medication is usually prescribed as an oral slow-release substance. Standardized treatment schemes are rare among the responding hospices. Most of the respondents also use complementary treatment options, such as aroma (oil) therapy or music therapy, in the treatment of pain. Palliative sedation is used by nearly all responding hospices if all other treatment options fail., Conclusion: This survey provides an overview of the treatment options for pain management in German hospices. A broad variety of pain medication is used. Compared to international literature, it is debatable whether such a large variety of different types of pain medication is necessary, or whether a reduction in the type of medication available and the use of standardized treatment schemes could benefit everyone involved., (© 2023. The Author(s).)

Background: Spiritual uncertainty is a new construct for end-of-life care that focuses on the questions, worries and doubts people have with end-of-life spirituality. Spiritual uncertainty can contribute to spiritual distress for patients and families dealing with the end of life, as well as lead healthcare providers to avoid spiritual care methods., Aims: This article reports on the item construction of a new survey design to measure the spiritual uncertainty of healthcare providers., Methods: Items were constructed from qualitative data gathered from five focus groups (with a total of 23 interdisciplinary hospice and palliative care providers being surveyed). Data were developed through three rounds of item construction, selection/refinement and assessment., Findings: A final pool of 42 items was constructed to measure the spiritual uncertainty of healthcare providers. Expert validity was obtained by 16 interdisciplinary hospice and palliative care providers., Conclusion: This survey is the first to measure spiritual uncertainty of healthcare providers. Additional research is needed to assess the psychometric properties of survey items.

Introduction: Dementia is a terminal illness and in an advanced stage it is suitable for palliative care., Objectives: To examine the results of a pilot program of home hospice for the elder patients with advanced dementia., Methods: Patients aged 65 years and over who met the criteria for advanced dementia and palliative care were treated as part of the geriatric team-based home hospice program. The program included home visits by a multidisciplinary team that was available 24/7. During the program, special questionnaires are used to assess the patients' condition, the caregivers' burden and the caregivers' satisfaction with the treatment., Results: Between August 2017 and July 2020, 44 patients were treated in hospice, the mean age was 86.1 ± 6.2 years and 26 (59%) of the patients were women. The average length of stay in the hospice was 129.4 ± 155.5 days (median 68 days) and most patients (36) died at home. The home hospice program leads to statistically significant improvement in the intensity of the behavioral and psychological effects of dementia, the severity of the pain and the intensity of the patients' suffering. In addition, there was a statistically significant decrease in the level of distress and the intensity of anxiety and depression of the family members. Almost all family members noted high satisfaction with end-of-life care., Conclusions: A home hospice program for patients with advanced dementia, based on a multidisciplinary geriatric team and the use of dedicated tools to evaluate the effectiveness of the intervention makes it possible to prevent the suffering of patients and their families and enable them to die in their preferred place., Discussion: Home hospice is a worthy treatment alternative for terminally ill patients with advanced dementia who want to end their lives at home The home hospice care alleviates the patient's suffering, allows him/her to die in his/her preferred place and alleviates the distress of the family members, who express satisfaction from the treatment.

Ecuador, located in South America, has a population of 16 million people. According to the National Institution of Statistics in Ecuador, every year 8 out of a 1000 individuals die due to various causes. Palliative care and hospice are relatively new concepts for the Ecuadorian society. In Ecuador people usually die at home, in hospitals, or in nursing homes. In 2012, the first Ecuadorian hospice was created. According to symbolic interactionism theory, research needs to study participants' world in order to understand the dynamic nature of human behavior. Symbolic interactionism proposes that human beings cannot be understood without the context of their interactions. Through an ethnomethodological approach, the following research aims to understand the way that individuals understand and describe death while in the local hospice in Ecuador. Results emerge from the introspection of real stories, field notes, participant observation, and informal conversations at the hospice. Based on a thematic analysis, the following study presents major themes that emphasize the dynamic process of creating meaning of death.

Purpose: Although rates of hospice use have increased over time, insurance plan- and racial/ethnic-based disparities in rates have been reported in the USA. We hypothesized that increased rates of hospice use would reduce or eliminate insurance plan-based disparities and that racial/ethnic disparities would be eliminated in managed care (MC) insurance plans., Methods: We studied the use of hospice care in the final 30 days of life among 40,184 elderly Texas Medicare beneficiaries who died from primary breast, colorectal, lung, pancreas, or prostate cancer between January 1, 2007 and December 31, 2013, using statewide Medicare claims linked to cancer registry data. Rates of hospice use were computed by race/ethnicity and insurance plan (MC or fee-for-service (FFS)). We used logistic regression to account for the impact of confounding factors., Results: Rates of hospice use increased significantly over time, from 68.9% in 2007 to 76.1% in 2013. By 2013, differences in hospice use rates between MC and FFS plans had been reduced from 10% to < 5%. However, after accounting for insurance plan and confounding factors, racial/ethnic minority beneficiaries' hospice use was significantly lower than non-Hispanic white beneficiaries' (p < 0.0001). This disparity was observed among both FFS and MC beneficiaries., Conclusions: Hospice use in the final 30 days of life has increased among elderly cancer patients in Texas, virtually eliminating the difference between FFS and MC insurance plans. Despite these positive trends, racial/ethnic-based disparities persist. These disparities are not explained by confounding factors. Future research should address social and behavioral influences on end-of-life decisions.

Objectives: The current study sought to understand the differences hospice nurses perceived in caring for older adult patients who utilize hospice for longer and shorter periods, older adult patients' experience of hospice services, and if length of hospice stays influenced the patients' end-of-life experience., Methods: Interpretative Phenomenological Analysis was used to extract themes and subthemes from 10 interviews conducted with hospice nursing staff., Results: Four major themes were identified pertaining to nurses perspective on older adults' views of hospice and how length of hospice use impacts end-of-life care., Conclusion: These themes suggest hospice nursing staff believe longer hospice stays are more positive and that older adults identify more positive aspects of hospice when using it for longer periods of time. Results suggest that nurses believe length of use directly impacts patient care and the experience of hospice services., Clinical Implications: Participating nurses reported that older adults have a lack of information on hospice services. It was suggested that more information is needed and that providing such education may lead to longer hospice stays.

Context: Residential hospices may be an optimal compromise between home and hospital settings for end-of-life care, but there has been little systematic research regarding the quality of dying and death in such locations., Objectives: The objective of this study was to assess the quality of dying and death of patients who received end-of-life care in a residential hospice and its relationship to hospice length of stay (LOS) and prior receipt of palliative care., Methods: A total of 100 caregivers of patients who died in a residential hospice in downtown Toronto, Canada, were recruited four to six months after patient's death. The quality of dying and death was measured, based on interviews with bereaved caregivers, using the Quality of Dying and Death (QODD) questionnaire., Results: The overall mean QODD score was 68.85 ± 11.62, which is in the intermediate ("neither good nor bad") range (30-70) of the scale. The lowest QODD subscale score was on the Transcendence subscale, which evaluates death-related concerns; this was 59.48 ± 25.37, with ratings in 14.6% of the sample in the "terrible to poor" (0-29) range. QODD scores were higher for patients with hospice LOS of more than one week (72.21 ± 9.64) than for those with a shorter LOS (60.38 ± 11.92) (P < 0.001)., Conclusion: Overall quality of dying and death was perceived as average to above average, in an urban residential hospice, although death-related distress was present in a substantial minority of patients. The association of better QODD with hospice LOS of more than one week may be due to better clinical status on admission and/or longer duration of time that is needed to achieve optimal outcomes., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Introduction: Advanced imaging can inform prognosis and may be a mechanism to de-escalate unnecessary end-of-life care in patients with cancer. Associations between greater use of advanced imaging and less-aggressive end-of-life care in real-world practice has not been examined., Methods: We conducted a retrospective analysis of SEER-Medicare data on patients who died from breast, lung, colorectal, or prostate cancer between 2002 and 2007. Hospital referral region (HRR)-level use of computerized tomography (CT), magnetic resonance imaging, and positron emission tomography was categorized by tertile of imaging use and correlated with hospice enrollment overall and late hospice enrollment using multivariable logistic regression., Results: A total of 55,058 patients met study criteria. Hospice use ranged from 50.8% (colorectal cancer) to 62.1% (prostate cancer). In multivariable analyses, hospital referral regions (HRRs) with high rates of CT imaging were associated with lower odds of hospice enrollment (odds ratio, 0.80; 95% CI, 0.70-0.90) and late enrollment among those who did enroll (odds ratio, 1.49; 95% CI, 1.26-1.76). HRRs with the highest rates of CT use were predominantly located in the Midwest and Northeast and associated with higher percentage population of black patients (14.5 vs 5.6%), greater comorbidity (28.4 vs 23.7%), metropolitan residence (93.9 vs 78.5%), and less than high school education (26.4 vs 19.3%)., Conclusion: In this population-based retrospective study, we did not observe evidence that overall and timely hospice are associated with higher rates of imaging near the end of life. An observed association between higher rates of imaging, particularly CT, may be explained in part by HRR-level differences in practice patterns and patient demographic characteristics. Further research is warranted to explore the ability of oncologic imaging to appropriately de-escalate care.

Context: The rate of live discharge from hospice and the proportion of hospices exceeding their aggregate caps have both increased for the last 15 years, becoming a source of federal scrutiny. The cap restricts aggregate payments hospices receive from Medicare during a 12-month period. The risk of repayment and the manner in which the cap is calculated may incentivize hospices coming close to their cap ceilings to discharge existing patients before the end of the cap year., Objective: The objective of this work was to explore annual cap-risk trends and live discharge patterns. We hypothesized that as a hospice comes closer to exceeding its cap, a patient's likelihood of being discharged alive increases., Methods: We analyzed monthly hospice outcomes using 2012-2013 Medicare claims., Results: Adjusted analyses showed a positive and statistically significant relationship between cap risk and live discharges., Conclusion: Policymakers ought to consider the unintended consequences the aggregate cap may be having on patient outcomes of care., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose Patients with advanced cancer experience potentially burdensome transitions of care after hospitalizations. We examined predictors of discharge location and assessed the relationship between discharge location and survival in this population. Methods We conducted a prospective study of 932 patients with advanced cancer who experienced an unplanned hospitalization between September 2014 and March 2016. Upon admission, we assessed patients' physical symptoms (Edmonton Symptom Assessment System) and psychological distress (Patient Health Questionnaire-4). The primary outcome was discharge location (home without hospice, postacute care [PAC], or hospice [any setting]). The secondary outcome was survival. Results Of 932 patients, 726 (77.9%) were discharged home without hospice, 118 (12.7%) were discharged to PAC, and 88 (9.4%) to hospice. Those discharged to PAC and hospice reported high rates of severe symptoms, including dyspnea, constipation, low appetite, fatigue, depression, and anxiety. Using logistic regression, patients discharged to PAC or hospice versus home without hospice were more likely to be older (odds ratio [OR], 1.03; 95% CI, 1.02 to 1.05; P < .001), live alone (OR, 1.95; 95% CI, 1.25 to 3.02; P < .003), have impaired mobility (OR, 5.08; 95% CI, 3.46 to 7.45; P < .001), longer hospital stays (OR, 1.15; 95% CI, 1.11 to 1.20; P < .001), higher Edmonton Symptom Assessment System physical symptoms (OR, 1.02; 95% CI, 1.003 to 1.032; P < .017), and higher Patient Health Questionnaire-4 depression symptoms (OR, 1.13; 95% CI, 1.01 to 1.25; P < .027). Patients discharged to hospice rather than PAC were more likely to receive palliative care consultation (OR, 4.44; 95% CI, 2.12 to 9.29; P < .001) and have shorter hospital stays (OR, 0.84; 95% CI, 0.77 to 0.91; P < .001). Patients discharged to PAC versus home had lower survival (hazard ratio, 1.53; 95% CI, 1.22 to 1.93; P < .001). Conclusion Patients with advanced cancer who were discharged to PAC facilities and hospice had substantial physical and psychological symptom burden, impaired physical function, and inferior survival compared with those discharged to home. These patients may benefit from interventions to enhance their quality of life and care.

Objective: Pediatric hospice has been the adoption of several service provision models in highly developed countries such as UK, Germany, Australia or Canada for a few decades, yet it has seldom been the case in the Asian Continent. This study aimed to evaluate the newest challenge for the children with Life-threatening illness (LTI) and described the characteristic of pediatric palliative care at the first pediatric hospice in Japan., Methods: A retrospective review of all patients at our pediatric hospice in these three years was conducted. Of the 294 cases reviewed, 269 cases were eligible for analysis., Results: We reviewed 269 patients admitted during the first three years. Most patients required intensive medical intervention. Patients were hospitalized in our pediatric hospice not only for end-of-life care (EOL), but also for respite care. Only 7% of the patients were with cancer. To support children and family to make the most of their time together, we provided a range of medical and recreational care. It is expected that the pediatric hospice will extend and establish cooperation with other hospitals or community services., Conclusion: Three years' experience of pediatric palliative care at the first pediatric hospice in the Asian Continent is encouraging. Further experience and improved communication with other pediatric service providers as well as their education in palliative care will enhance the recognition of the capacity of our hospice and support the needs of more children. Furthermore, we would like to introduce the idea of pediatric hospice and spread it throughout the Asian Continent in the future., (Copyright © 2017 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.)

Context: In the U.S., palliative care programs improve access to hospice through enhanced communication and efficiencies in hospice eligibility review and enrollment. For community-based programs, this task may begin with telephone contact., Objectives: To evaluate the incidence and predictors of hospice enrollment following telephonic outreach by a nurse after referral to a community-based, specialist palliative care program., Methods: During 2012-2014, 299 consecutive patients who were referred to a palliative care program and subsequently enrolled in hospice provided electronic health record data for a retrospective cohort study. Those who elected hospice after telephonic outreach and before the first palliative care home visit, were compared with those who enrolled in hospice after palliative care visits began, using both bivariate and multivariate analyses., Results: Mean (SD) age was 74.1 (18.7) years; 60.2% were women, 44.4% were White, 22.5% were Hispanic, 20.9% were Black, and 9.6% were Asian. In total, 177 patients (59.2%) elected hospice following telephonic outreach and 122 (40.8%) enrolled after home visits began. The former group received a mean of 4.5 calls (median = 3.0) before hospice election. In multivariate analysis, hospice enrollment following telephonic outreach alone was associated with hospital or nursing home referral, not married status, and poor performance status (all P < 0.05)., Conclusion: More than half of patients electing hospice after referral to a palliative care program did so following telephonic outreach alone. Both sociodemographic and clinical characteristics predicted this outcome. Palliative care programs can improve hospice access through initial telephonic outreach by trained professionals., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Context: The proportion of patients disenrolling from hospice before death has increased over the decade with significant variations across hospice types and regions. Such trends have raised concerns about live disenrollment's effect on care quality. Live disenrollment may be driven by factors other than patient preference and may create discontinuities in care, disrupting ongoing patient-provider relationships. Researchers have not explored when and how providers make this decision with patients., Objective: The objective of this study was to ascertain provider perspectives on key drivers of live discharge from the Medicare hospice program., Methods: We conducted semistructured telephone interviews with 18 individuals representing 14 hospice providers across the country. Transcriptions were coded and analyzed using a template analysis approach., Results: Analysis generated four themes: 1) difficulty estimating patient prognosis, 2) fear of Centers for Medicare & Medicaid Services audits, 3) rising market competition, and 4) challenges with inpatient contracting. Participants emphasized challenges underlying each decision to discharge patients alive, stressing that there often exists a gray line between appropriate and inappropriate discharges. Discussions also focused on scenarios in which financial motivations drive enrollment and disenrollment practices., Conclusion: This study provides significant contributions to existing knowledge about hospice enrollment and disenrollment patterns. Results suggest that live discharge patterns are often susceptible to market and regulatory forces, which may have contributed to the rising national rate., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe the prevalence of screening for complicated grief (CG) and depression in hospice and access to bereavement therapy and to examine whether screening and access to therapy varied according to hospice organizational characteristics or staff training and involvement., Design: Cross-sectional national survey conducted from 2008 to 2009., Setting: United States., Participants: Hospices (N = 591)., Measurements: Whether hospices screened for depression or CG at the time of death or provided access to bereavement therapy (individual or group). Organizational characteristics included region, chain status, ownership, and patient volume. Staffing-related variables included training length and meeting attendance requirements., Results: Fifty-five percent of hospices provided screening for CG and depression and access to bereavement therapy, 13% provided screening but not access to bereavement therapy, 24% provided access to bereavement therapy but not screening, and 8% neither screened nor provided access to bereavement therapy. Hospices with 100 patients per day or more were significantly more likely to provide screening and access to bereavement therapy., Conclusion: Hospices appear to have high capacity to provide screening for CG and depression and to deliver group and individual therapy, but data are needed on whether screeners are evidence based and whether therapy addresses CG or depression specifically. Future work could build upon existing infrastructure to ensure use of well-validated screeners and evidence-based therapies., (© 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.)

Context: Little is known about how hospice live discharges vary by hospice providers' tax status and chain affiliation., Objectives: To characterize hospices with high rates of problematic patterns of live discharges., Methods: Three hospice-level patterns of live discharges were defined as problematic when the facility rate was at the 90th percentile or higher. A hospice with a high rate of patients discharged, hospitalized, and readmitted to hospice was considered to have a problematic live discharge pattern, which we have referred to as burdensome transition. The two other problematic live discharge patterns examined were live discharge in the first seven days of a hospice stay and live discharge after 180 days in hospice. A multivariate logistic model examined variation in the hospice-level rate of each discharge pattern by the hospice's chain affiliation and profit status. This model also adjusted for facility rates of medical diagnoses, nonwhite patients, average age, and the state in which the hospice program is located., Results: In 2010, 3028 hospice programs had 996,208 discharges, with 18.0% being alive. Each proposed problematic pattern of live discharge varied by chain affiliation. For-profit providers without a chain affiliation had a higher rate of burdensome transitions than did for-profit providers in national chains (18.2% vs. 12.1%, P < 0.001), whereas not-for-profit providers had the lowest rate of burdensome transitions (1.4%). About one in three (33.8%) for-profit providers exhibited one or more of these discharge patterns compared with 9.0% of not-for-profit providers., Conclusion: Problematic patterns of live discharges are higher among for-profit providers, especially those not affiliated with a hospice chain., (Copyright © 2015 American Academy of Hospice and Palliative Medicine. All rights reserved.)

Purpose: The purpose of this study was to describe the unique characteristics of informal hospice cancer caregiving., Methods: Researchers conducted a secondary analysis of data drawn from a randomized clinical trial of an informal hospice caregiving intervention (N = 348). Demographic characteristics and measures of the informal caregiving experience of hospice patients and their informal caregivers were compared based on the patient's diagnosis using chi-square tests for association of categorical variables and t tests for continuous variables., Results: Informal caregivers of cancer patients differed from their non-cancer counterparts in a number of respects including patient age, caregiver age, patient residence, relationship between patient and caregiver, amount and duration of care provided, likelihood to incur out-of-pocket expenses related to patient care, caregiver problem-solving style, and impact on caregiver daily schedule. There were no statistically significant differences between cancer and non-cancer caregivers in terms of gender, race, employment status, anxiety, and quality of life., Conclusions: While cancer and non-cancer caregivers are similar in many respects, a number of unique features characterize the informal hospice cancer caregiving experience. Attention to these unique features will allow hospice providers to tailor supportive care interventions to better address cancer caregivers' needs.

Context: Complementary and alternative medicine (CAM) provides clinical benefits to hospice patients, including decreased pain and improved quality of life. Yet little is known about the extent to which U.S. hospices employ CAM therapists., Objectives: To report the most recent national data regarding the inclusion of art, massage, and music therapists on hospice interdisciplinary teams and how CAM therapist staffing varies by hospice characteristics., Methods: A national cross-sectional survey of a random sample of hospices (n = 591; 84% response rate) from September 2008 to November 2009., Results: Twenty-nine percent of hospices (169 of 591) reported employing an art, massage, or music therapist. Of those hospices, 74% employed a massage therapist, 53% a music therapist, and 22% an art therapist, and 42% expected the therapist to attend interdisciplinary staff meetings, indicating a significant role for these therapists on the patient's care team. In adjusted analyses, larger hospices compared with smaller hospices had significantly higher odds of employing a CAM therapist (adjusted odds ratio 6.38; 95% CI 3.40, 11.99) and for-profit hospices had lower odds of employing a CAM therapist compared with nonprofit hospices (adjusted odds ratio 0.52; 95% CI 0.32, 0.85). Forty-four percent of hospices in the Mountain/Pacific region reported employing a CAM therapist vs. 17% in the South Central region., Conclusion: Less than one-third of U.S. hospices employ art, massage, or music therapists despite the benefits these services may provide to patients and families. A higher proportion of large hospices, nonprofit hospices, and hospices in the Mountain/Pacific region employ CAM therapists, indicating differential access to these important services., (Published by Elsevier Inc.)

The legalization of physician-assisted death in states such as Washington and Oregon has presented defining ethical issues for hospice programs because up to 90% of terminally ill patients who use the state-regulated procedure to end their lives are enrolled in hospice care. The authors recently partnered with the Washington State Hospice and Palliative Care Organization to examine the policies developed by individual hospice programs on program and staff participation in the Washington Death with Dignity Act. This article sets a national and local context for the discussion of hospice involvement in physician-assisted death, summarizes the content of hospice policies in Washington State, and presents an analysis of these findings. The study reveals meaningful differences among hospice programs about the integrity and identity of hospice and hospice care, leading to different policies, values, understandings of the medical procedure, and caregiving practices. In particular, the authors found differences 1) in the language used by hospices to refer to the Washington statute that reflect differences among national organizations, 2) the values that hospice programs draw on to support their policies, 3) dilemmas created by requests by patients for hospice staff to be present at a patient's death, and 4) five primary levels of noninvolvement and participation by hospice programs in requests from patients for physician-assisted death. This analysis concludes with a framework of questions for developing a comprehensive hospice policy on involvement in physician-assisted death and to assist national, state, local, and personal reflection., (Copyright © 2014 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Objectives: There is limited evidence of the impact of advance care planning (ACP) on outcomes. We conducted a retrospective cohort study on deaths of all patients known to a hospice in a 2.5-year period to see if use of ACP affected actual place of death, hospital use and cost of hospital care in the last year., Results: 969 patients were included. 550 (57%) people completed ACP. 414 (75%) achieved their choice of place of death. For those who chose home, 34 (11.3%) died in hospital; a care home 2 (1.7%) died in hospital; a hospice 14 (11.2%) died in hospital and 6 (86%) who chose to die in hospital did so. 112 (26.5%) of people without ACP died in hospital. Mean number of days in hospital in the last year of life was 18.1 in the ACP group and 26.5 in the non-ACP group(p<0.001). Mean cost of hospital treatment during the last year of life for those who died in hospital was £11,299, those dying outside of hospital £7,730 (p<0.001). Mean number of emergency admissions for those who died in hospital was 2.2 and who died elsewhere was 1.7 (p<0.001)., Conclusions: ACP can be used routinely in a hospice setting. Those who used ACP spent less time in hospital in their last year. ACP is associated with a reduction in the number of days in hospital in the last year of life with less hospital costs, supporting the assumptions made in the End of Life Care Strategy 2008.

Since the Association of American Medical Colleges geriatric competencies were released, educators are striving to incorporate them into medical student curricula. The purpose of this study is to examine medical students' reflections after an interdisciplinary, hospice staff-precepted clinical experience, and whether these reflections relate to the geriatric competencies which focus on palliative care. From July 2010 to June 2011, 155 2nd- and 3rd-year medical students participated in a required, half-day hospice experience, with 120 (77%) submitting narrative reflections for analysis. The narratives were analyzed using the constant comparative method associated with grounded theory, followed by consensus-building in an iterative process, to identify themes. Six themes were identified from the analysis of student narratives: demonstrating a new or expanded knowledge of hospice care (79%, 95/120), developing new insights about self and others (74%, 89/120), changing attitudes toward hospice care (63%, 76/120), linking patient needs with appropriate team members (43%, 52/120), understanding patient goals of care (43%, 51/120), and discussing palliative care as a treatment option (27%, 32/120). The authors conclude that a brief, interdisciplinary, hospice staff-precepted clinical experience is an effective model to inspire medical students to reflect on geriatric palliative care. Students clearly reflected on the geriatric palliative care competencies of symptom assessment and management, and gained insight into the role of the hospice team members and how hospice care can be a positive treatment option. Future educators should think about building on this type of high impact learning experience, and developing items to measure application of knowledge gained.

Objectives: Hospices are increasingly involved in medical student teaching, which the patients generally enjoy. No studies have specifically investigated how hospice patients view the prospect of physical examination by students. Previous evidence involves patients who have already seen students, while the views of other patients are unknown. This study aimed to provide an initial understanding of the views of a diverse group of hospice inpatients on the acceptability and perceived importance of students physically examining them., Methods: 42 hospice inpatients completed a short questionnaire focusing on their views of medical students examining them. Patients chose to do this alone or via a short interview. All inpatients at Exeter Hospice were considered eligible, including patients who were asked and those who may not have been asked to see students; all 42 patients completed the study., Results: In accordance with existing evidence, patients generally held positive views about seeing students. However, many patients expressed concerns about being physically examined by students, specifically including that it might be painful, tiring or embarrassing. Most importantly, several patients who did not wish to be examined by medical students said they would feel obliged to accept it, or would find it difficult to decline., Conclusions: Hospice inpatients generally wish to be involved in medical student teaching, but many are concerned about being physically examined, and some feel a sense of obligation to participate. There are implications for hospices that teach students. Further research is necessary to investigate the frequency and severity of these concerns.

Background: Informal hospice caregivers may experience compromised well-being as a result of significant stress. Although quite limited, problem-solving interventions with this population have garnered empirical support for improved caregiver well-being., Aim: Researchers sought to answer the following question: which specific intervention processes impacted informal hospice caregivers who participated in a problem-solving intervention?, Design: Researchers conducted a thematic analysis of open-ended exit interviews with informal hospice caregivers who had participated in a structured problem-solving intervention., Setting/participants: Participants were friends and family members who provided unpaid care for a home hospice patient receiving services from one of two hospice agencies located in the Pacific Northwest region of the United States., Results: During their participation in the problem-solving intervention, caregivers actively reflected on caregiving, structured problem-solving efforts, partnered with interventionists, resolved problems, and gained confidence and control., Conclusions: The study findings provide much needed depth to the field's understanding of problem-solving interventions for informal hospice caregivers and can be used to enhance existing support services.

With increased regulation and scrutiny of outcomes, hospice programs are being challenged to consider the implementation of evidence-based practices (EBPs). This study reports findings from hospice director interviews and staff focus groups, which occurred following the completion of a multifaceted translating research into practice (TRIP) intervention designed to promote evidence-based pain management practices. The purpose of this article is to provide background on the use of EBPs, to report facilitators and barriers to overall implementation of pain management EBPs in hospice, and to provide recommendations for hospices interested in increasing the use of EBPs. Three areas for evaluation prior to implementing an EBP initiative in hospices were identified: community, agency, and staff cultures. Recommendations for implementation of EBPs in hospices are provided.

Background: Clinicians' discussions about hospice with patients and families are important as a means of communicating end-of-life options., Objective: To identify determinants of clinicians' hospice discussions and the impact of such discussions on hospice use., Design: We interviewed 215 patients age > or = 60 years with advanced cancer, chronic obstructive pulmonary disease (COPD), or heart failure (HF) at least every 4 months for up to 2 years. Participants provided information about their health status and treatment preferences. Clinicians completed a questionnaire every 6 months about their estimates of patient life expectancy and their communication with the patient and family about hospice., Results: In their final survey, clinicians reported discussing hospice with 46% of patients with cancer, compared to 10% with COPD and 7% with HF. Apart from diagnosis of cancer, the factors most strongly associated with hospice discussion were clinicians' estimate of and certainty about patient life expectancy (P < 0.001). However, clinicians were unable to anticipate the deaths of a considerable portion of patients (40%). Although patient unwillingness to undergo minor medical interventions was associated with hospice discussion (P < 0.05), a sizeable portion of clinicians (40%) whose patients reported this characteristic did not have the discussion. Clinicians' discussion of hospice independently increased the likelihood of hospice use (OR = 5.3, 95% CI = 2.3-13)., Conclusions: Clinicians' discussion of hospice for patients with advanced illness, and, ultimately, patients' use of hospice, relies largely on clinician estimates of patient life expectancy and the predictability of disease course. Many clinicians whose patients might benefit from learning about hospice are not having these discussions.

The Palliative Care Service at Montefiore Medical Center (MMC) established a pilot project in the emergency department (ED) to identify chronically ill older adults in need of palliative care, homecare, and hospice services and to link such patients with these services. Two advance practice nurses conducted consultations on elderly patients who were found to have one or more "palliative care triggers" on initial screening. A standardized medical record abstraction form was developed. Service utilization and survival were evaluated using the Clinical Information Systems of MMC. Activity of daily living items were developed from the Outcome and Assessment Information Set and the Palliative Care Performance Scale (PPS). Risk factors for hospitalization and use of the ED were taken from the SIGNET model risk screening tool. Physical and emotional symptoms were evaluated using the 28-item Memorial Symptom Assessment Scale short form. Preliminary outcomes and characteristics are presented for 291 patients who completed the intake needs assessment questionnaire. Almost one third (30.9%) of the study cohort died during the project period. Most of the deaths occurred beyond the medical center (7.7% died in the medical center and 23.3% outside the medical center). Thirty percent of patients who died were enrolled on a hospice. Survival time was predicted by the presence of dyspnea, clinician prediction of death on the current hospitalization, psychosocial distress, and PPS scores. Chronically ill patients visiting an urban community ED had complex medical and psychosocial problems with limited support systems and homecare services. Significant proportions of such patients can be expected to have limited likelihood of survival. The presence of palliative homecare and hospice outreach services in the ED in urban community hospitals may provide an effective strategy for linkage of elderly patients at the end of life with otherwise underutilized services.

At the present time, there is a widening search for spirituality as distinct from organized religion, particularly as it relates to well-being, wholeness, and healing. In both professional and lay contexts, spirituality has come to the forefront of public consciousness. The place of spirituality within the hospice movement is not unaffected by this shift in popular priorities. Once the prerogative of chaplains and clergy, the nurturing of spiritual journeys is now becoming a common concern. Experiencing sensory spirituality can provide both caregivers and those for whom they care a blessed respite for bodies, minds, and spirits.

There are a myriad of physical symptoms which can complicate the care of patients with advanced disease. Without knowledge of and attention to these distressing symptoms, the rest of the work of the interdisciplinary hospice team is greatly hampered. In this article, we review the management of ten prevalent symptoms in hospice care and to identify areas of clinical investigation underway and point of future areas ripe for investigation.