Hospice Patients Research Articles

Facility- and community-level factors associated with hospice patient experience.

Mandated by the Affordable Care Act of 2010, hospices were required to provide information regarding the Hospice Quality Reporting Program, with a reduced reimbursement tied to hospices if they fail to submit data to the Centers for Medicare and Medicaid Services. The purpose of this study was to examine the association between hospice organizational and community factors and quality of hospice care as measured by patient experience through Hospice Consumer Assessment of Healthcare Providers & Systems (CAHPS®) survey. We used secondary data from Hospice Compare, Healthcare Cost Report Information System Dataset, Rural-urban commuting area codes, and the American Community Survey to examine the relationship between hospice patient/family experience and hospice organizational-level and community-level factors for the period 2017-2020. The unit of analysis was hospice-year observations. For-profit and chain-affiliated hospices were negatively associated with CAHPS® scores. Organizational longevity and Medicare payer mix were positively associated with CAHPS® scores. Hospice community factors including competition, per capita income, and the racial/ethnic minorities' percentage were negatively associated with CAHPS® scores. Hospice organizational and community factors were related to hospice quality of care. Interventions that account for organizational and community factors may be needed to improve patient/family experience of hospice care.

Use of Hospice and End-of-Life Care Quality Among Medical Centers with High Versus Lower Specialist Palliative Care Reach Among People with Heart Failure: An Observational Study.

Background: Rates of specialist palliative care (SPC) vary among Veterans Affairs Medical Centers (VAMCs) for people with advanced heart failure (aHF). We evaluated the associations between facility rates of SPC reach and the quality of end of life (EOL) care received among this population. Methods: We conducted a retrospective cohort study among 3681 people with aHF who died in 83 VAMCs from 2018 to 2020. We used multilevel logistic regression to derive SPC reach (i.e., the predicted probability or rate of SPC) for each VAMC adjusting for demographic and clinical characteristics. We examined the associations between high (top 20%) versus lower (bottom 80%) SPC reach and receipt of inpatient hospice and family-reported EOL care quality and the interactions between receiving SPC and VAMC reach on study outcomes. Results: The sample included 97.9% male, 61.6% White, and 32.2% Black adults (mean age = 72.9 ± 10.9 years). Rates of "Excellent" EOL care quality, but not inpatient hospice care, were significantly higher in VAMCs in the top 20% of reach (predicted probability: inpatient hospice = 0.56 vs. 0.51, p = 0.32; "Excellent" EOL care quality 0.69 vs. 0.60, p = 0.04). There was a significant interaction between VAMC reach, receipt of SPC, and inpatient hospice (p < 0.001) but no interaction between VAMC reach, receipt of SPC, and EOL care quality (p = 0.049). Conclusion: Families of patients with aHF who die in VAMCs with higher SPC reach report better EOL care quality regardless of whether or not they receive SPC. Research is needed to investigate factors beyond receiving SPC associated with these EOL outcomes.

Dünn in der Fläche? Regionale Disparitäten in der Hospiz- und Palliativversorgung in Deutschland

IntroductionOutpatient and inpatient hospice and palliative care services have been significantly expanded in Germany in recent decades and are increasingly being supplemented by day care services. However, the availability of these services varies greatly from region to region. The extent to which the availability of these care structures is matched by a regional need based on local population structures is as yet unknown. MethodsIn four Poisson regression models, the relationship between population indicators from the areas of demographics, employment, income, education and health and the number of offers of outpatient and inpatient hospice work and palliative care is exploratively examined. The cumulated data at district level is drawn from the INKAR database of the Federal Institute for Research on Building, Urban Affairs and Spatial Development on living conditions in Germany and from the guide of the German Association for Palliative Medicine. By means of logistic regression, factors influencing the establishment of day care services will also be identified. ResultsThe analysis included 401 districts and cities in Germany. The number of inhabitants, settlement density, and the average age of inhabitants are the strongest predictors of the number of palliative care services. In metropolitan regions, both outpatient palliative care services and palliative care units tend to be more frequently available, while the number of outpatient hospice services and inpatient hospices increases in districts with a higher number of inhabitants regardless of settlement density. The regression model was unable to demonstrate a significant influence on the emergence of semi-inpatient care facilities, neither for the population indicators nor for the existing care structures. DiscussionRegional population structures can only partially explain the geographically uneven distribution of hospice and palliative care services in districts and cities in Germany. Despite an increase in hospice and palliative care services, fewer hospice and palliative care structures are available in low population density regions that tend to have a higher share of older inhabitants. ConclusionFuture health care planning should give more consideration to other population characteristics than to population size alone in order to improve care in regions with higher care needs that are, for example, due to a higher proportion of older residents. Subsequent studies should investigate which population characteristics can best describe the actual care needs.

Hypothalamic Hyperphagia in the Hospice Patient: Case Report and Discussion

We present a case of insatiable appetite and harmful overeating in a hospice patient that showcases the burden of hypothalamic hyperphagia, a rare complication of brain cancer. While confounders exist such as progression of disease and prior tapering of dexamethasone, in this case the initiation of metformin was associated with substantial appetite reduction and resolution of our patient's debilitating food-seeking behaviors.We will explore metformin as a potential cost-effective option for palliation in a hospice setting and explore some of the physiologic mechanisms involved.

Features and Differences in Core Symptom Clusters in Home-Based Hospice Patients With Advanced Cancer: A Network Analysis.

Patients with terminal-stage cancer frequently experience multiple symptoms simultaneously. Little is known about how core symptom clusters differ in advanced-cancer patients with different survival expectancies receiving hospice care. To identify the core symptom clusters of hospice-care cancer patients with different survival expectancies and compare the features of their symptom networks. In this retrospective study, secondary data analysis was conducted. Records of 6946 patients with advanced cancer who received home-based hospice care service in a hospice center from April 2001 to December 2020 were collected and analyzed using network analysis. This analysis included 6946 patients with advanced cancer receiving hospice care. In patients with survival expectancies of 0-6 months, loss of appetite was identified as the core symptom (rs = 4.03, rb = 5.21, rc = 2.63), and five symptom clusters were identified. Malnutrition was the core symptom in patients with survival expectancies of 6-12 months (rs = 2.83, rb = 2.43, rc = 0.93), and nine symptom clusters were identified. Wasting syndrome was the core symptom cluster in two groups. The network density of symptoms in patients with < 6 months of survival expectancy (91.99) was higher than in patients with 6-12 months (28.39). Nutrition impact symptoms are the core symptoms for home-hospice care cancer patients with a survival period of 1 year or below. Moreover, hospice cancer patients with short survival expectancies have greater inter-symptom impact.

Sights and Sounds of Respiratory Changes During Hospice Death Vigils: Hospice Caregivers Experience

ContextResearch has documented common respiratory changes at the end of life for hospice patients. Some studies have noted these symptoms as distressing and challenging for families, and as a potential reason for emergency room visits and hospice benefit revocation. However, the experiences and emotions of family members regarding these respiratory changes in the final days, particularly when they are alone in a home setting, are not well documented. A recent study found 51% caregivers identified abnormal breathing as a challenge during their vigil experience. ObjectivesThe study aimed to answer three research questions: 1) How do family members describe the sights and sounds of the respiratory changes experienced during the final days of life? 2) What are the emotions caregivers experience as a result of witnessing the sights and sounds of respiratory changes? 3) What interventions are caregivers using to manage respiratory changes? MethodsA secondary analysis of 22 hospice caregiver interviews from a larger study of family interviews focused analyzing in depth narratives related to respiratory changes during the vigil period. Results Caregiver narrativesDistressful sights and sounds related to respiratory symptoms during the final days were described by 27% and 77% of family narratives, respectively. Negative emotional reactions were reported by more than a third of those interviewed. Caregivers expressed frustration at not understanding the reasons behind respiratory changes, with 27% noting they wished for more information on what to expect and how to intervene. There were inconsistencies in the interventions provided by hospice teams in managing respiratory symptoms. ConclusionsOpportunities exist for hospice agencies to better address the caregiver distress caused by witnessing noisy breathing (death rattle), Cheyne-Stokes breathing, and agonal breathing. Further research is needed to identify standard definitions for these respiratory changes, their prevalence in the home hospice setting, and to develop practice standards and effective interventions to relieve caregiver distress.

"Who You Are and Where You Live Matters": Hospice Care in New York City During COVID-19 Perspectives on Hospice and Social Determinants: A Rapid Qualitative Analysis.

Context: Social determinants of health (SDOH) impacted the quality of home hospice care provided during the COVID-19 pandemic. Perspectives from professionals who provided care identify challenges and lessons learned from their experience. Objective: To examine hospice professionals' perspectives of how SDOH affected the delivery of high-quality home hospice care in New York City (NYC) during the COVID-19 pandemic. Methods: We conducted semistructured interviews with 30 hospice professionals who delivered care to home hospice patients during the COVID-19 pandemic in NYC using a qualitative descriptive design. Purposive sampling was used to recruit professionals from a range of disciplines including physicians, advanced practice providers, nurses, social workers, chaplains, and hospice administration and management. Participants worked for one of two large NYC metro hospices and one outpatient palliative care practice serving the five boroughs of NYC and the surrounding suburbs. Rapid qualitative analysis was used to identify themes. Results: Thirty hospice professionals were interviewed, spanning a variety of clinical and administrative roles. Most (21 out of 30) reported that social determinants affected access and/or delivery of equitable hospice care. Two key themes emerged from interviews: (1) SDOH exist and affect the delivery of high-quality care and (2) disparities were exacerbated during the COVID-19 pandemic resulting in barriers to care. Subthemes outline barriers described by hospice professionals: decreased hospice enrollment, telehealth challenges, resulting in deficient patient/family education, shortages of nursing assistants in some neighborhoods, and diminished overall quality of hospice care for some patients. SDOH created barriers to hospice care through neighborhood factors, resource barriers, and system challenges. Conclusion: SDOH provide a context to understand disparity in the provision of hospice care. COVID-19 exacerbated these conditions. Addressing multidimensional barriers created by SDOH is key in creating high-quality and equitable hospice care, particularly during a crisis.

Family caregiver narratives of hospice death vigils

BackgroundOften, family members and friends gather around a dying hospice patient to say goodbye in what is known as a death vigil. The purpose of this study is to explore...

Comprehensive geriatric assessment and palliative care.

The geriatric vision of palliative care is based on a multidisciplinary, patient-centered approach, looking for a balance between human dignity and medical treatments with a particular focus on the social and ethical aspects. In order to develop the best care models, there is a rising need for a tighter collaboration of all the involved players (i.e., doctors, nurses, social workers). Indeed, the idea of a fragmented system without considering the patient or his/her family is not at all applicable to older patients with chronic disease. The causes of death, the phase of death changes, and the extend of last period of life could be a long phase characterized by complicated treatment decisions, difficult management of symptoms, multiple psychosocial problems, and complex spiritual distress. Recently, Italian guidelines on Comprehensive Geriatric Assessment (CGA) have been published. However, none of the identified studies on patients in hospice and other palliative care facilities met the criteria for inclusion. These findings underscore the need for further research to determine the potential benefits of a multidimensional approach for patients in hospice and other palliative care settings. Our reflections and suggestions on the CGA use for older persons in palliative care may be a starting point for an open and continuous dialogue with all the operators concerned.

Understanding Intensive Care Unit Family Caregivers' Vulnerability to Post-Traumatic Stress Disorder: The Impact of Neurotic Personality Traits, Emotional Suppression, and Perceptions of Unexpected Death.

Rationale: Family members of patients who die in an intensive care unit (ICU) are at heightened risk of post-traumatic stress disorder (PTSD) symptoms. Not all surrogates develop these symptoms and heterogeneity exists in PTSD symptom clusters. Objectives: The study tested a personality model of PTSD symptoms in bereaved family caregivers of ICU patients. It was hypothesized that family members endorsing higher levels of neurotic personality traits would report higher levels of PTSD symptom clusters and that these associations would be explained by tendencies to view the patient's death as unexpected and to cope by suppressing their emotions. Methods: Participants were family members of ICU patients at an urban, academic medical center who either died or were discharged to an inpatient hospice unit. Participants were contacted for participation at least six months after the patient's death. Participants completed measures of personality, emotion regulation, and PTSD symptoms. Data were analyzed using path analysis. Results: Approximately one-third (35%) of the sample of 162 caregivers endorsed at-risk levels of PTSD. Individuals reporting higher levels of neurotic personality traits reported more PTSD symptoms (r = 0.53, p < 0.001). Perceptions that the patient death was unexpected partially explained the association of neuroticism with the intrusive re-experiencing PTSD symptoms (B = 0.45, p = 0.031). In contrast, emotional suppression partially explained the association of neuroticism with avoidance (B = 0.70, p = 0.010) and hyperarousal symptom clusters (B = 0.37, p = 0.041). Conclusions: Family vulnerability to PTSD after an ICU death can be conceptualized based on neurotic personality traits. Tendencies to view the patient's death as unexpected may contribute to intrusive thoughts and memories of the ICU experience. Individuals may avoid reminders and remain at heightened levels of arousal when they suppress their emotional experiences. Key Message: Family members who experience the death of a loved one following ICU treatment are vulnerable to PTSD symptoms. These reactions to ICU-related losses may be shaped by family members' personalities, expectations, and emotion regulation styles. Understanding these characteristics could inform family screening and intervention efforts in the ICU.

Should an Acute Palliative Care Unit be Mandatory for Cancer Centers and Tertiary Care Hospitals?

Acute palliative care units have been developing in the last years and their clinical activity and characteristics have been described, despite large differences in different countries. One controversial topic is whether such units should be mandatory as standard in comprehensive cancer centers or even in tertiary hospitals.In this “Controversies in Palliative Care” article, three expert clinicians independently answer this question. Specifically, each group provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. Interestingly, all three experts arrived at similar conclusions. They underscored the importance of an acute palliative care unit, which provides a different pattern of activities in comparison with typical inpatient hospices, generally caring for patients who have a limited expected survival

Impact of a Teenage Musical Volunteer on End-of-Life Care: Effects on Hospice Patients and the Volunteer

This report documents the case of a middle school student who served as a musical volunteer in a hospice ward in southern Taiwan. It analyzes the impact of this volunteer experience on both terminally ill patients and the volunteer himself. The contributions they can make to end-of-life care.

Top Ten Tips Palliative Care Clinicians Should Know About Hospice Live Discharge.

Hospice care is designed to support the medical and psychosocial needs of individuals with serious illness and their caregivers through the dying process. Some individuals, though, leave hospice prior to death, generally referred to as disenrollment or a "live discharge." Live discharge from hospice is a common and often distressing issue for hospice patients, their caregivers, and also for hospice professionals and agencies. This paper discusses common issues surrounding live discharge that clinicians and other healthcare professionals should consider when dealing with live discharge in their own clinical practices. Where applicable, we provide practical steps for hospice and palliative care clinicians to better support patients and families through this critical care transition. Further, we offer strategic directions interprofessional clinicians can take to affect systemic change to improve live discharge experiences.

Optimizing Hospice Care: A Scoping Review of Staffing Strategies to Enhance Practice

Background Investigating hospice staffing models is vital for ensuring patient-centered care by aligning workforce capabilities with evolving patient needs. With the opening of the Hospice Residence at Providence Care Hospital, effective staffing can enhance operational efficiency, staff well-being, retention, and elevate the quality of end-of-life care. Objective: The primary objective is to investigate models of hospice care, staffing characteristics across disciplines, staff qualifications, training and operational metrics. Methods A comprehensive search of academic literature was conducted using MEDLINE, CINAHL, and Embase, following the PRISMA-ScR framework. The review focused on hospice care for adults, covering staffing and care models. Studies on general palliative care, pediatric/NICU care, non-full-text studies, and those published before 2013 were excluded. A grey literature search was also performed. Results Out of 1,579 imported studies, 1,082 were screened, 260 full texts reviewed, and 51 met inclusion criteria. Published between 2013 and 2024, the studies were conducted in North America, Europe, and Asia, covering various designs including randomized control trials, observational, qualitative, and mixed-methods. Patient populations included terminally ill individuals with diagnoses such as cancer, COPD, and heart failure. The majority of studies examined inpatient hospices. Facility sizes ranged from 6 to 33 beds (median = 16). Key topics included staffing models, staff-to-patient ratios, training, volunteer roles, care delivery, and patient satisfaction, with common ratios being 5.5:1 to 6.5:1 for physicians and 1.5:1 to 2.7:1 for nurses. Hospice staff included physicians, nurses, aides, social workers, spiritual care providers, and volunteers, with training ranging from specialized education to minimal instruction. Conclusion Understanding staffing strategies is crucial for hospices to meet growing demand and patient complexity. This review emphasizes optimal staff-to-patient ratios, diverse care models, and the vital role of volunteers. Further research is needed to establish best practices for sustainable, high-quality hospice care. Contributors: Patel, V.; Aghakhani Barfeh, K.; McDonald, H.; Kang, J.; Pranajaya, P.; Toon, D.; Wong, M.; Goldie, C.L.

Upper gastrointestinal cancers: Trends and determinants of location of death

BackgroundPatients diagnosed with upper gastrointestinal cancers often require extensive end-of-life care. We sought to investigate social determinants of health associated with disparities in the location of death among patients who died of upper gastrointestinal cancers. MethodsPatients who died between 2003 and 2020 from esophageal cancer, gastric cancer, hepatobiliary cancer, and pancreatic cancer were identified using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Social determinants of health were assessed using the Social Vulnerability Index. Patients were categorized on the basis of location of death: inpatient hospital, home, nursing home, hospice, and outpatient medical facility/emergency department. Multivariable regression and mediation analyses defined the association of patient race as well as social determinants of health with location of death. ResultsAmong 815,780 decedents (esophageal cancer: 15.3%; gastric cancer: 3.6%; hepatobiliary cancer: 36.6%; pancreatic cancer: 54.5%), most were male (60.8%), aged 55–74 years (52.3%), and White (89.1%). Most decedents died at home (55.7%), followed by inpatient hospital (24.8%), hospice (9.0%), nursing home (8.1%), and outpatient medical facility/emergency department (2.5%). During the study period, location of death shifted notably from inpatient hospital (36.8% to 21.3%) to home (45.8% to 56.3%). Residents of high Social Vulnerability Index areas were more likely to die at inpatient hospital compared with home (31.8% vs 24.3%) (P < .001). Black race (reference: White; odds ratio; 0.41, 95% confidence interval, 0.40–0.42) and social vulnerability (reference: low Social Vulnerability Index; odds ratio, 0.64, 95% confidence interval, 0.63–0.65) remained independently associated with lower odds of dying at home compared with an inpatient hospital. Notably, 65% of the overall race-based association with death at inpatient hospital was driven indirectly through social determinants of health. ConclusionSocial determinants are important drivers of end-of-life care and impact the potential ability of patients with cancer to die at home.

The multinomial mixed-effect regression model for predicting PCOC phases in hospice patients

PurposeThe Palliative Care Outcomes Collaboration (PCOC) aims to enhance patient outcomes systematically. However, identifying crucial items and accurately determining PCOC phases remain challenging. This study aims to identify essential PCOC data items and construct a prediction model to accurately classify PCOC phases in terminal patients.MethodsA retrospective cohort study assessed PCOC data items across four PCOC phases: stable, unstable, deteriorating, and terminal. From July 2020 to March 2023, terminal patients were enrolled. A multinomial mixed-effect regression model was used for the analysis of multivariate PCOC repeated measurement data.ResultsThe dataset comprised 1933 terminally ill patients from 4 different hospice service settings. A total of 13,219 phases of care were analyzed. There were significant differences in the symptom assessment scale, palliative care problem severity score, Australia-modified Karnofsky performance status, and resource utilization groups-activities of daily living among the four PCOC phases of care. Clinical needs, including pain and other symptoms, declined from unstable to terminal phases, while psychological/spiritual and functional status for bed mobility, eating, and transfers increased. A robust prediction model achieved areas under the curves (AUCs) of 0.94, 0.94, 0.920, and 0.96 for stable, unstable, deteriorating, and terminal phases, respectively.ConclusionsCritical PCOC items distinguishing between PCOC phases were identified, enabling the development of an accurate prediction model. This model enhances hospice care quality by facilitating timely interventions and adjustments based on patients' PCOC phases.

Arvo Pärt, Death, and Affective Practice

Abstract: Recent scholarship suggests that the modern West offers few spiritual resources to prepare people for death. This essay contends that Arvo Pärt's music can act as a contemporary affective practice that consoles listeners facing death and compares this use of music with the medieval spiritual practices associated with ars moriendi . This essay attends to the first-person accounts of hospice patients listening to Pärt's music as a compelling case study of contemporary affective practice and develops a new framework for understanding the affective capacities of music by engaging emerging scholarship on spirituality and affect theory.

Utilization of Antibiotics for the Treatment of Urinary Tract Infections in End-of-Life Patients.

The use of antibiotics for end-of-life patients is controversial; currently there is limited guidance on the use of antibiotics in hospice patients. The threat of antibiotic resistance, risk of adverse events, variable efficacy, and time to benefit in hospice patients makes their use divisive. Patients' potential care needs are estimated using the palliative performance scale (PPS) with lower scores indicating more care is required. The purpose of this project is to examine the utilization of antibiotics for urinary tract infections (UTIs) in hospice patients. This multi-center retrospective observational cohort study evaluated the prescribing of antibiotics in symptomatic vs asymptomatic hospice patients being treated for UTIs and assessed antibiotic initiation based on PPS of ≥30% or <30%. Patients included in this study were adults initiated on oral antibiotics for UTI. Exclusion criteria included antibiotics initiated prior to admission, prophylactic antibiotics, non-oral antibiotics, or if the patient revoked election of hospice. A total of 56 patients were prescribed antibiotics for UTIs during the 1-year study period. Half of the antibiotics were prescribed appropriately based on documented symptoms when starting the antibiotics. There was not a statistically significant difference between appropriate utilization based on PPS ≥30% or <30% using the Mann-Whitney U test (P = 0.255). The prescribing of antibiotics in end-of-life patients is not always appropriate regardless of the PPS. This may indicate that antibiotics are initiated in asymptomatic hospice patients, and the utilization of unnecessary medications presents the risk of adverse effects.

Virtual Reality Videos for Symptom Management in Hospice and Palliative Care

ObjectiveTo learn more about the effect of virtual reality videos on patients’ symptoms near the end of life, including which are most effective, how long the effect lasts, and which patients benefit the most. Patients and MethodsWe conducted a prospective study of 30 patients in a regional hospice and palliative care program from March 11, 2022, through July 14, 2023. Using a head-mounted display virtual reality, all participants viewed a 15-minute video of serene nature scenes with ambient sounds. Fifteen patients also participated in a second session of viewing bucket-list video clips they selected. Symptoms were measured with the revised Edmonton Symptom Assessment Scale before, immediately after, and 2 days after each experience. Participants rated their bucket-list selections by level of previous experience, strength of connection, and overall video quality. Functional status was also recorded. ResultsNature scenes significantly improved total symptom scores (30% decrease, P<.001), as well as scores for drowsiness, tiredness, depression, anxiety, well-being, and dyspnea. The improved scores were not sustained 2 days later. Overall, bucket-list videos did not significantly improve symptoms. Neither previous experience with an activity nor a strong connection correlated with significant improvement; however, when patients rated video quality as outstanding, scores improved (31% decrease, P=.03). Patients with lower functional status tended to have more symptoms beforehand and improve the most. ConclusionSerene nature head-mounted display virtual reality scenes safely reduce symptoms at the end of life. Bucket-list experiences may be effective if they are high-quality. More infirm patients may benefit the most.

Roles of Chaplains and Clergy in Spiritual Care for African Americans in Hospice: A Pilot Study.

Spiritual care is recognition of patient and caregiver spiritual/religious needs and attention to those needs. Caregivers of African American hospice patients are more likely to report worse emotional/religious support. Yet, spiritual care delivery and roles of community clergy and chaplains for African American hospice patients are not well understood. Examine who provides spiritual care to African American hospice patients and caregivers. Partnering with large, urban/suburban community hospice, we interviewed caregivers of deceased African American hospice patients (n = 12), their clergy (n = 3) and chaplains (n = 5). Using a phenomenological qualitative study design, we coded transcripts and deceased patient chart data and conducted thematic analysis to identify themes. Community clergy and chaplains tend to not interact and provide different aspects of emotional, religious and spiritual support to hospice patients and families. Clergy and chaplains agreed that rapport and openness of the patient were main factors in meeting spiritual care needs. Clergy provided interaction with a trusted person and connection to church, congregational support, religious beliefs/theology, and practices. Chaplains focused on present needs and issues of death and dying. Clergy and chaplains have distinct, complementary roles in providing spiritual care to African American hospice patients and families. Both are needed to provide desired spiritual care for African American hospice patients and their caregivers. Robust spiritual care programs need to ensure chaplains have sufficient time to spend with patients and families and incorporate collaboration, handoffs and integrated processes for clergy and chaplains. Research is needed on effectively including clergy in hospice spiritual care delivery.