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Dyspnea, pain, agitation, and burdensome interventions are common in the last months of life in individuals with dementia.1–3 Hospice is associated with improvements in end-of-life care for these individuals, including better symptom management, fewer hospitalizations, and greater caregiver satisfaction.4–10 Although hospice enrollment in individuals with dementia is increasing, these individuals are still referred to hospice at lower rates than those with some other life-limiting illnesses.11–14 For example, in a study of Medicare beneficiaries, 41% of those who died of dementia used hospice, compared with 65% of those who died of cancer, which is the single most common admission diagnosis of hospice enrollees.11,14 Hospice providers commonly cite difficulty with prognostication due to variability in disease progression as a barrier to hospice referral for individuals with dementia.15–17 National Hospice and Palliative Care Organization (NHPCO) Guidelines for determining prognosis in dementia are based on the Functional Assessment Staging (FAST), a seven-step staging system that identifies progressive cognitive and functional decline. These guidelines suggest that an appropriate cutoff for enrolling persons with dementia in hospice is stage 7C (completely dependent in all activities of daily living, nonambulatory, limited or no speech) along with the presence of one or more dementia-related comorbidities (e.g., aspiration pneumonia, urinary tract infection, impaired nutritional status).18,19 A number of studies suggest that these criteria do not accurately predict 6-month mortality, which is a requirement for certification under the Medicare Hospice Benefit.19–23 These criteria also do not include other factors associated with poorer survival in individuals with dementia, including older age, male sex, and comorbidities such as diabetes mellitus and heart disease.19,23,24 In the absence of accurate tools for prognostication, not surprisingly, individuals with dementia enrolled in hospice have longer lengths of stay than individuals with cancer, who tend to have a more-predictable trajectory of decline in the last months of life.25–27 In 2005, the median length of stay for Medicare beneficiaries with dementia who enrolled in hospice was 27 versus 20 days for those with cancer, and one-quarter of those with dementia had lengths of stay exceeding 180 days, compared with fewer than 10% of individuals with cancer.28 In addition to longer lengths of stay, hospice enrollees with dementia are also more likely than those with cancer to be discharged from hospice alive because their condition stabilizes or improves and they no longer meet eligibility criteria.29,30 In 2008, Medicare beneficiaries with dementia or other neurological conditions who were discharged alive made up 18% to 41% of all hospice discharges, whereas those with cancer who were discharged alive made up only 10% to 24% of hospice discharges.13 Although longer lengths of stay, female sex, better functional status, and having a noncancer diagnosis have been associated with being discharged alive from hospice,30 little is known about which individuals with dementia are likely to be discharged because they stabilize and no longer meet prognostic eligibility criteria or about what happens to them after they are discharged. This information would be valuable in the current regulatory environment with greater scrutiny of hospice providers to identify fraud and misuse of the Medicare Hospice Benefit related to enrollment of individuals who have prognoses exceeding 6 months.13,31,32 Given the longer lengths of stay of enrollees with dementia than for those with other diagnoses, utilization review and fraud investigators may tend to focus on the charts of these individuals and on hospice providers whose enrollees include a significant proportion diagnosed with dementia. Because of concerns about allegations of fraud and difficulties with accurate prognostication, hospice providers may be cautious about admitting or retaining individuals with dementia.31,32 Using data from a large national hospice provider, the purpose of this study was to compare the characteristics of individuals with dementia who died while receiving hospice with the characteristics of those who were discharged alive because their condition stabilized or improved and to identify factors associated with death in the year after discharge from hospice in individuals who were discharged alive. Understanding which individuals with dementia are likely to be discharged alive from hospice and, of those, which are likely to die in the year after discharge may improve prognostication in hospice enrollees with dementia and inform the development of other services that may contribute to quality of life for those who are no longer eligible for hospice care.

Geriatrician and nongeriatrician faculty need instruction as teachers to provide quality training for a broader community of physicians who can care for the expanding population of older adults. Educators at Duke University designed a program to equip geriatrician and nongeriatrician faculty to develop quality educational programs and teach medical learners about geriatrics. Eighty-three faculty representing 52 institutions from across the United States participated in mini-fellowship programs (2005–09) consisting of workshops and 1-year follow-up mentoring by Duke faculty. Participants attended 1-week on-campus sessions on curriculum development and teaching skills and designed and implemented a curriculum in their home institution. Participant specialties included general medicine (nearly 50%), family medicine, surgery, psychiatry, rehabilitation medicine, and emergency medicine. Pre- and postprogram self-efficacy surveys, program evaluation surveys, and 6- and 12-month progress reports on scholars' educational projects were used to assess the effect of the Duke mini-fellowship programs on participants' educational practices. Forty-four scholars (56%) completed the end-of-year self-efficacy survey and end-of-program evaluation. Self-efficacy results indicated significant gains (P < .001) in 12 items assessed at 1 week and 1 year. Scholars reported the largest average gains at 1 year in applying adult learning principles in the design of educational programs (1.72), writing measurable learning objectives (1.51), and identifying optimal instructional methods to deliver learning objectives (1.50). Participants described improved knowledge and skills in designing curricula, implemented new and revised geriatrics curricula, and demonstrated commitment to faculty development and improving learning experiences for medical learners. This faculty development program improved participants' self-efficacy in curriculum design and teaching and enhanced geriatrics education in their home institutions.

Despite disparities in health care access and quality, African Americans are underrepresented in many areas of clinical investigation, including research in end-of-life care. Because of the importance of surrogate reports in assessing the quality of end-of-life care, this study examined racial differences in next-of-kin participation in an ongoing study of satisfaction with end-of-life care. The parent study includes after-death interviews with next-of-kin of elderly African Americans and Caucasians who died at Duke Hospital. This analysis included next-of-kin of elders who died at Duke Hospital from December 1, 2003 to December 31, 2004. During this period, there were 471 decedents whose next-of-kin were eligible for participation. Of these, 133 (28%) were African American and 338 (72%) were Caucasian. There were no racial differences in completion, contact, or overall response rates. Of those contacted, 39.8% of African Americans and 37.8% of Caucasians completed the study. In multivariate analysis, only the relationship of the next-of-kin to the decedent was an independent predictor of study completion. Children of decedents were significantly more likely to participate than spouses (odds ratio [OR] 2.1 [1.14, 3.86]). In this analysis, next-of-kin of African American and Caucasian decedents were equally likely to participate in an after-death interview assessing satisfaction with end-of-life care. The use of racially concordant interviewers, subject identification with the institution, and the absence of socioeconomic constraints may partly explain these findings. Given the growing diversity of the U.S. population, researchers in end-of-life care must use strategies aimed at recruiting racially and ethnically diverse samples.

Spirituality is an important part of African-American culture and is often cited as an explanation for the more-aggressive treatment preferences of some African Americans at the end of life. This paper reviews the literature on spiritual beliefs that may influence the treatment decisions of African Americans. Medline 1966 to February 2003, Psych Info 1872 to February 2003, and CINAHL 1982 to February 2003 were searched for studies exploring spiritual beliefs that may influence the treatment preferences of African Americans. All candidate papers were examined for quality, and data were extracted on study population, design, analysis, and results to identify recurrent themes. Forty studies met inclusion criteria. Recurrent themes describing spiritual beliefs that may influence the treatment preferences of African Americans throughout the course of illness include the following: spiritual beliefs and practices are a source of comfort, coping, and support and are the most effective way to influence healing; God is responsible for physical and spiritual health; and the doctor is God's instrument. Spiritual beliefs specifically addressing treatment preferences at the end of life include: only God has power to decide life and death, there are religious prohibitions against physician-assisted death or advance directives limiting life-sustaining treatments, and divine intervention and miracles occur. For some African Americans, spiritual beliefs are important in understanding and coping with illness and may provide a framework within which treatment decisions are made. Given the growing ethnic diversity of the United States, some understanding of the complexities of culture and spirituality is essential for healthcare providers.