Hospice Patients Research Articles

The issue of patient-oriented organization of palliative and hospice care in Ukraine

The quality of the provision of palliative and hospice care (PHC) depends on regulatory, legal and logistical support, the practice of implementing laws, and the support of society. The need for PHC is growing both worldwide and in Ukraine, which is associated with the aging of the population and global medical advances, thanks to which people live to a greater age and continue to live even with serious diseases and severe disabilities. Patients with incurable diseases most often need analgesia, which in low- and middle-income countries the population either does not receive at all, or has limited access to narcotic analgesics. The task of the PHC organization corresponds to the European integration obligations of Ukraine at a high level, and is in the sphere of responsibility of the Ministry of Health. The insufficient level of development of the national PHC system depends on imperfect legislation, non-implementation of adopted laws, lack of public results of calculating the need for PHC among adults and children. The system of training medical workers to work in hospices and palliative care departments, which concerns both doctors and nurses, also needs improvement. The routes of movement of palliative patients during the provision of assistance to them in the institutions of the health care system require public discussion. Instructions regarding the movement of these patients should be understandable to a doctor of any specialty, and contain step-by-step algorithms of actions. The practice of euthanasia, which is not allowed in Ukraine, is important for palliative patients. The PHC system should become one of the key components of the health care system, provided at the place of residence of patients (in hospices and palliative departments of hospitals) in the area where they live, or in "hospices at home". The development of the national PHC system, in which all known shortcomings will be taken into account and corrected, will be able to reduce the level of suffering of terminally ill patients and their relatives, and ensure their standard of living at the average European level. Keywords: PHC, need for medical assistance, health care financing.

Evaluation of Antibiotic Initiation Tools in End-of-Life Care.

Hospice patients are frequently confronted with potentially infectious complications necessitating antibiotic consideration. Information regarding the appropriate use of antibiotics and their impact on symptom management in hospice patients are unknown. This study aimed to evaluate and describe the use of an antibiotic initiation tool in patients admitted to outpatient hospice services. The primary outcome assessed the percentage of antibiotics that were appropriately initiated based on Loeb's Minimum Criteria (LMC) for Antibiotic Initiation Tool. Secondary outcomes included the number of patients with documented symptom resolution following antibiotic completion, the number of antibiotic courses that were successfully completed, and treatment-related adverse events. This was a retrospective, multisite, descriptive analysis of hospice patients treated with antibiotics between April 2019 and September 2020. Two hundred and thirty patients were assessed for inclusion, with 172 meeting eligibility criteria and receiving a total of 201 antibiotic courses. Based on LMC, 84 of the 201 (42%) antibiotics ordered were appropriate, with 60% of these LMC-approved courses resulting in symptom resolution. Out of 201 total courses, 99 (49%) resulted in symptom resolution. Overall, 160 (80%) antibiotic courses were successfully completed. In this study, antibiotic initiation in hospice patients frequently did not meet LMC. Less than half of the antibiotics prescribed led to symptom resolution despite antibiotic course completion in most patients. There is no consensus or guidelines directing appropriate antibiotic decision-making in hospice patients. The appropriate use of antibiotics in terminally ill patients warrants additional research.

Healthcare Reimbursement and Service Utilization for One Year of Post-Allogeneic Hematopoietic Cell Transplantation (alloHCT) Care for Medicare Beneficiaries Ages 65 and Older with Acute Myeloid Leukemia

Objective: Acute myeloid leukemia (AML) is the most common indication for alloHCT in the United States (US) for Medicare beneficiaries. An increasing number of older patients are now able to undergo alloHCT; however, there is a significant gap in knowledge about their healthcare costs. The primary objective of this study was to assess healthcare reimbursement, service utilization, and overall survival for designated time points up to 1-year post-alloHCT for Medicare beneficiaries ages 65 and older in the US with an AML diagnosis.Methods: Medicare claims data from 2010 - 2012 were merged with Center for International Blood & Marrow Transplant Research (CIBMTR) clinical outcomes data. Patients were excluded who underwent alloHCT before 3/1/10 or after 12/31/11 (to allow for 2 months prior and 1-year follow-up), had a prior autologous or alloHCT, or were not enrolled in both Parts A and B 60 days prior to and on date of HCT. The total amount of reimbursement for 1-year post-transplant included the Medicare payment, secondary payer payments, and coinsurance and out-of-pocket payments made by beneficiaries. Cumulative reimbursement for Part A facility inpatient services, outpatient services, home health and hospice services and Part B physician services were inflation-adjusted to 2017 dollars using Centers for Medicare and Medicaid Services (CMS) Market Baskets. Weighted generalized linear models were used to identify key drivers of total reimbursement adjusting for age, gender, transplant center region, year of transplant, Karnofsky score, disease status, donor type, graft type, Sorror comorbidity score, cytomegalovirus (CMV) serostatus, conditioning intensity, graft-versus-host disease (GVHD) prophylaxis, anti-thymocyte globulin (ATG)/Alemtuzumab (Campath) use, and 2-month total reimbursement prior to the index HCT hospitalization or outpatient HCT date. Service utilization was measured by counts of reported claims and total service days. The Kaplan-Meier method was used to estimate the probability of overall survival (OS) stratified by disease status and conditioning intensity.Results: A total of 250 patients met inclusion criteria. Mean age at HCT was 68.7 yrs. The total cumulative reimbursement for the entire cohort were $166,032 (95% confidence interval (CI): $153,931, $178,133) at 100-days and $230,815 (95% CI: $214,381, $247,249) at 1-year post-alloHCT with inpatient reimbursement accounting for more than 80% of the total at each designated time point (Figure 1). The cumulative total reimbursements were $148,684 (95% CI: $137,994, $159,375) for patients surviving 100 days and $186,254 (95% CI: $166,765, $205,744) for patients surviving 1-year post-alloHCT. Counts of claims and total service days by service component and time point post transplant are shown (Tables 1 and 2). In multivariate analysis, patients who received cord blood compared to peripheral blood stem cell had significantly higher adjusted reimbursement (p=0.006). Similarly, myeloablative (MA) conditioning was associated with significantly higher reimbursement compared to non-myeloablative (NMA) (P < 0.0001). The Northeast (p=0.0275) and West (p=0.0323) regions had significantly higher reimbursement compared to the Midwest region. OS at 1-year post-alloHCT was 52% (95% CI: 46%-59%). Patients undergoing alloHCT in CR1/CR2 had better survival (p=0.0030) as did those who received NMA conditioning (P=0.0067).Conclusions: This unique dataset facilitated an analysis of key drivers of Medicare reimbursement for AML by patient and HCT related variables and outcomes. It was not surprising that a cord blood graft was a driver of reimbursement, likely due to acquisition costs, prolonged time to engraftment and subsequent hospitalization. The variation in reimbursement by region may be partly due to geographic adjustment of Medicare payments or transplant center billing practices. Interestingly, NMA conditioning not only led to lower 1-year reimbursement but also improved survival and may inform clinical practice. Future research will stratify each component of post-transplant reimbursement into specific cost categories to evaluate Medicare reimbursement and effects of practice patterns. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Preferences for end-of-life care settings among the healthy population in Israel-Related socio-demographic variables.

Preferences for end-of-life (EoL) care settings is of considerable interest for developing public health policy and EoL care strategies. Culture, the cause of illness, and background characteristics may impact preferences. The present study aimed to explore preferences for EoL care settings: homes, hospitals, and inpatient hospice units among the general healthy population in Israel. Possible associations between the setting preferences and socio-demographic characteristics were also examined. A cross-sectional survey was conducted among 311 healthy adults who were recruited through a representative internet panel of the Israeli population using the Israeli census sampling method. The sex ratio was almost 1:1 with 158 women (50.8%) and 153 men (49.2%). All participants completed self-report measures using an online survey system. The questionnaires assessed sociodemographics and preferences for EoL care settings. This survey revealed that 52.1% of the participants expressed preference for being cared for at home rather than in an inpatient hospice unit, 40.8% expressed being cared for at home rather than in a hospital, while 36.7% had no preference regarding being cared for in hospital or in a hospice unit. Among the socio-demographic variables, only age and gender were found to be significantly associated with preferences for EoL care settings. The present study highlights the need to be cautious when regarding home as the preferred EoL care setting, as some individuals declared that they would prefer EoL hospice/hospital care. Age and gender should be considered when discussing and tailoring strategies regarding EoL preferences.

ÜRİNER İNKONTİNANSIN HUZUREVİ VE EVİNDE YAŞAYAN YAŞLILARDA YAŞAM KALİTESİNE ETKİSİ

Aim: The aim of the study was to analyze the effect of urinary incontinence on the quality of life of elderly people living at home and those living in a hospice by focusing on the different demographic and incontinence related factors. Method: The study was designed as a cross-sectional descriptive study and was conducted between December 2015 and June 2016. Fifty participants aged ≥ 65 years who met the inclusion criteria were incruited in the study. Twenty-five of them were admitted by random sampling method from patients applying to faculty’s geriatric outpatient clinic with the complaint of incontinence. The other 25 were selected according to the study criteria out of elderly people living in the Darulaceze Institute. The International Consultation on Incontinence Questionnaire-ShortForm (ICIQ-SF), Incontinence Quality of Life (I-QOL) scale, and Katz Activities of Daily Living scale were used with all the individuals. Other variables were assessed using a demographic data form. Results: There was no difference between the quality of life (QOL) scores between the hospice and home groups (p=0.836, p=0.865, p=0.841, p=0.883). Social life was the most affected subdomain for both groups. Urinary incontinence (UI) affected psychologic effect (PE) and behavioral restriction (BR) aspects of QOL in individuals between the ages of 65 and 75 years more than those &amp;gt;75 years of age in the hospice (p=0.024, p=0.019). A higher UI output lowered BR scores only in hospice patients (p=0.016). For both groups, frequent incontinence episodes indicated a significantly lower QOL in terms of PE than rare episodes (p=0.032-home, p=0.022-hospice) and lower QOL in BR in home care (p=0.037). Mixed type incontinence affected QOL in terms of BR more than other types of incontinence in both groups (p=0.019-hospice, p=0.007-home). There was a significant correlation between I-QOL and ICIQ-SF visual analogue scale scores that measured quality of life (r=-0.64, p&amp;lt;0.001). Conclusions: Frequency of incontinence episodes is the major factor affecting QOL in both groups. Incontinence output has a significant role in QOL for hospice patients. The ICIQ-SF visual scale may be sufficient to evaluate the quality of life. I-QOL can be used for further evaluation of different aspects. Studies on incontinence and QOL in the institutionalized and home-care elderly population should be encouraged to improve conditions.

Reducing Hospital Visit Rates in Hospice Patients Using Telemedicine.

The purpose of this project was to examine the impact of accessibility to a provider via telemedicine on emergency department visit rates in adults, 35 years and older, on home hospice and palliative care. Utilizing a quasi-experimental design, 44 adults 35 years and older were educated on Doxy.me telemedicine usage as an intervention. Measures included gender, diagnosis, age, the reason for contact, and outcome (intervention group only); the number of emergency department visits, the number of 911 calls, and the number of discharges/transfers (control and intervention) in the 8 weeks after the evidence-based telemedicine intervention. Statistical analyses were performed to examine the number of emergency department visits and 911 calls preintervention and postintervention among all participants. A total of eight teletechnology calls were documented from a patient or patient caregiver. Among the intervention group, the number of emergency department visits and the number of 911 calls decreased from 12 (54.5%) to one (4.5%) postintervention. Paired-samples t tests show there were statistically significant differences in the number of emergency department visits and 911 calls between the two points in time. In conclusion, a telemedicine hospice care application may benefit a palliative and hospice organization by enhancing patient clinical outcomes and decreasing emergency department visit rates.

Perceptions That Influence Acupuncture Use in Hospice Settings: Results of a State-Wide Survey Study.

Background: Acupuncture is an effective and low-risk therapy for a wide spectrum of medical conditions. In the hospice setting, where comfort is the top priority, acupuncture could play a vital role in reducing symptom burden at the end of life. Objective: This state-wide survey study explored perceived barriers to acupuncture use in the hospice setting from acupuncturist and hospice staff perspectives. Specific barriers addressed included insurance coverage/funding for acupuncture, lack of knowledge of acupuncture as a therapeutic modality, and perceived insufficient evidence base for acupuncture. Materials and Methods: Acupuncturists and hospice staff in Oregon were recruited by e-mail and/or telephone to complete their survey. Results: Among acupuncturists, a response rate of 50% was obtained. The response rate of hospice staff could not be obtained. There were a total of 270 providers and hospice staff (102 acupuncturists, 16 hospice doctors, 14 hospice directors, 93 hospice nurses, 30 hospice social workers, and 15 hospice chaplains). The majority of acupuncturists (76% and 89%, respectively) and hospice staff (59% and 82%, respectively) strongly agreed or somewhat agreed that insurance coverage/funding for acupuncture and lack of knowledge of acupuncture as a therapeutic modality are important barriers. With respect to the perceived evidence base for acupuncture, the majority of acupuncturists (91%) and hospice staff (69%) strongly agreed or somewhat agreed that acupuncture can help provide a higher quality of life for hospice patients, although knowledge of specific conditions amenable to acupuncture among acupuncturists and hospice staff varied. Conclusions: From the acupuncturist and hospice staff perspectives, insurance coverage/funding for acupuncture, lack of knowledge of acupuncture as a therapeutic modality, and perceived insufficient evidence base for acupuncture are primary barriers to the use of acupuncture in hospice care. Increased awareness/education about acupuncture in the hospice setting, as well as improved funding structures, is critical.

Nurse roles in the advance directive system in Korea.

In 2016, the Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care was implemented in Korea, providing a broad framework for end-of-life decision-making for the first time and making advance directives legally recognized documents. This Act can correct long-standing under-recognition of patients as valid decision makers for their own treatment choices. However, limited recognition of patient self-determination, rigid legal forms for documenting patient wishes, and the roles of family under the Act may pose challenges both to patients and nurses. This paper critiques whether this newly introduced system of advance directives can truly guarantee protection of the patient's interests and respect for patient autonomy in real life​, and discusses ethical and legal issues regarding the Act. We reviewed the current system of advance directives by raising three questions: (1) Do advance directives reflect a competent person's voluntary and informed choice?, (2) Are advance directives applicable in diverse clinical situations?, and (3) Does the Korean advance directive system ensure that such directives are honored in reality? Although the Act is an important first step in respecting patient autonomy in end-of-life decision-making, it remains inadequate as it fails to provide thorough guidance in terms of the quality of writing process, applicability, and the guaranteed effects of advance directives. As nurses are best situated for addressing these limitations due to their roles and competencies in clinical practice, expanding the roles of nurses in every stage of advance directive practice could help achieve the original purpose of advance directives. This calls for a policy that promotes an expanded role of nurses to improve the quality of advance directive practice.

General Inpatient Hospice Care #415.

General Inpatient Hospice Care #415.

Development and validation of a patient-reported measure of compassion in healthcare: the Sinclair Compassion Questionnaire (SCQ)

ObjectivesCompassion is a key indicator of quality care that is reportedly eroding from patients’ care experience. While the need to assess compassion is recognised, valid and reliable measures are lacking....

Socio-Economic Deprivation and Symptom Burden in UK Hospice Patients with Advanced Cancer-Findings from a Longitudinal Study.

Simple SummaryWe know that socio-economic factors influence delay in presentation and diagnosis of cancer and that patients living in areas of greater socio-economic deprivation are less likely to be referred to palliative care services including hospice. However, very little is known regarding the impact of socio-economic deprivation on symptom burden in advanced cancer patients. Our study found that patients experiencing greater socio-economic deprivation were more likely to report depression and pain and greater global symptom burden than patients from less socio-economically deprived areas. We also found that reporting a lack of information at time of diagnosis was significantly associated with socio-economic deprivation. Although more than one-third of patients recruited into this study were diagnosed with cancer within the preceding 12 months, this was not associated with socio-economic factors and socio-economic factors did not appear to influence survival in our study. The impact of socio-economic factors on symptom burden and information needs should be acknowledged within palliative care settings.Socio-economic deprivation is known to impact on cancer diagnosis, treatment and access to services, but little is known of the impact of socio-economic deprivation on symptom burden in patients with advanced cancer. Patients with advanced cancer attending hospice day services were recruited into a 24 week longitudinal study. An area-based index of social deprivation was collected along with depression and symptom burden at baseline, 8, 16 and 24 weeks. Of the 595 patients included, with an age range of 33–89 years and a mean age of 68 years, 67% were female, and 37% were diagnosed with cancer in the last 12 months. Twenty nine percent lived in one of the most deprived 20% of neighbourhoods. Patients living in the most socio-economically deprived areas were significantly likely to report receiving insufficient information regarding their cancer at diagnosis (p = 0.007), greater pain (p = 0.02), moderate to severe depression (p = 0.04) and higher global symptom burden (p = 0.04). This study is the first to report that patients with advanced cancer attending hospice services, living in the most deprived neighbourhoods experience significantly greater symptom burden, notably depression and pain. We recommend using patient outcome measures in order to provide targeted support and thereby reduce the increased symptom burden that socio-economically disadvantaged patients experience at the end of life.

Inequity in location and quality of death of advanced cancer patients by immigrant status.

12036 Background: Most cancer patients prefer to die at home, a location associated with better quality of death (QoD) and caregiver outcomes. A number of studies demonstrate disparities in end-of-life (EoL) care among immigrant vs non-immigrant populations in the U.S. This study aims to evaluate how immigrant status affects location and QoD among patients with advanced cancer in the U.S. Methods: Data were derived from Coping with Cancer, a federally funded multi-site prospective study of advanced cancer patients and caregivers. The analytic sample of patients who died during the study observation period was weighted (Nw=308) to reduce statistically significant sociodemographic differences between immigrant (Nw=49) and non-immigrant (Nw=259) groups. Immigrant status was determined by patient self-report. Primary outcomes were location of death (intensive care unit, hospital, nursing home, inpatient hospice, home), death at preferred location (yes/no, as per caregiver report in post-mortem interview), and poor QoD (composite score of post-mortem caregiver ratings for patient psychological distress, physical distress, and quality of life in the last week of life). Results: As compared to non-immigrants, immigrants were more likely to die in a hospital as opposed to home [AOR 3.33; 95% CI (1.65-6.71); p=0.001] and less likely to die where they preferred [AOR 0.42, 95% CI (0.20-0.90); p=0.026]. As shown in Table, values-inconsistent aggressive EoL care mediated the effect of immigrant status on death at the patient s preferred location. Further, immigrants were more likely to have poor QoD [AOR 5.47; 95% CI (2.70-11.08); p&lt;0.001]. In particular, among patients who preferred symptom-directed, comfort EoL care, immigrants as opposed to non-immigrants were more likely to have poor QoD [AOR 9.53, 95%CI (4.05-22.40); p&lt;0.001]. Conclusions: Immigrants, as compared to non-immigrants, are more likely to die in hospital settings, less likely to die at their preferred location, and more likely to have poor QoD. These findings are consistent with previously described inequities in EoL care of immigrants and highlight the importance of determining the potential causes and solutions to ensure immigrants receive values-congruent care.[Table: see text]

Differential impact of inpatient and outpatient palliative care on end-of-life outcomes in hospitalized patients with cancer.

e24069 Background: Palliative care (PC) improves outcomes for patients with advanced cancer, and current ASCO guidelines recommend early outpatient referral. However, recent data show that PC teams at many cancer centers see more inpatient consults than outpatient visits; the comparative impact of inpatient versus outpatient PC is not well-described. For this reason, we conducted a retrospective cohort study of hospitalized cancer patients to quantify exposure to inpatient/outpatient PC, and to describe associations between PC exposure and end-of-life (EOL) quality measures including hospice utilization, advance care planning (ACP), and intensity of care. Methods: We identified all patients admitted to one cancer center’s inpatient oncology unit during a fiscal year (10/1/2017 - 9/30/2018). Demographics, admission statistics, inpatient/outpatient PC visits, and EOL outcomes were abstracted from the electronic medical record. Deceased patients were identified through chart review and public obituaries. Results were summarized by descriptive statistics, and standard statistical tests were used to evaluate associations between PC exposure and EOL outcomes. Results: 842 patients were hospitalized in one year. 522 patients died by the study end-date of 10/1/2020 and were included in analysis. 50% of deceased patients had any PC exposure prior to death, but only 21% had an outpatient PC visit. Patients seen by PC were younger at time of death (median: 67 vs 72 years; p &lt; .001) and more likely to be female (52% vs 42%; p = .03). Compared to patients never seen by PC, patients with any PC exposure were significantly more likely to enroll in hospice (78% vs 44%; p &lt; .0001), have do-not-resuscitate status (87% vs 55%; p &lt; .0001), have scanned ACP documents (53% vs 31%; p &lt; .0001), and die at home or inpatient hospice instead of in the hospital (67% vs 40%; p &lt; .01). PC exposure was not associated with differences in 30-day re-admissions, systemic cancer therapy in the last 14 days of life, or intensive care (ICU) utilization in the last 30 days of life. Notably, PC exposure was associated with longer hospital length-of-stay (LOS) (8.4 vs 7.0 days), but this association was reversed for patients seen by outpatient PC versus all others (6.3 vs 8.3 days; p &lt; .01). Patients seen by outpatient PC also had longer hospice LOS (46.5 vs 27.1 days; p &lt; .01) and less EOL ICU use (6% vs 15%; p &lt; .05) compared to all others. Conclusions: In this large retrospective study of hospitalized cancer patients, PC exposure was associated with significant improvements in multiple EOL quality measures. The subset of patients seen by outpatient PC experienced additional benefits, including shorter hospital LOS, longer hospice LOS, and less EOL ICU utilization. These findings point to differential effects between inpatient and outpatient PC, underscoring the importance of early, longitudinal PC involvement.

Cannabis and End-of-Life Care: A Snapshot of Hospice Planning and Experiences Among Illinois Medical Cannabis Patients With A Terminal Diagnosis.

Between 2013 and 2019, Illinois limited cannabis access to certified patients enrolled in the Illinois Medical Cannabis Program (IMCP). In 2016, the state instituted a fast-track pathway for terminal patients. The benefits of medicinal cannabis (MC) have clear implications for patients near end-of-life (EOL). However, little is known about how terminal patients engage medical cannabis relative to supportive care. Anonymous cross-sectional survey data were collected from 342 terminal patients who were already enrolled in (n = 19) or planning to enroll (n = 323) in hospice for EOL care. Logistic regression models compare patients in the sample on hospice planning vs. hospice enrollment, use of palliative care vs. hospice care, and use standard care vs non-hospice palliative care. In our sample, cancer patients (OR = 0.21 (0.11), p < .01), and those who used the fast-track application into the IMCP (OR = 0.11 (0.06), p < .001) were less likely to be enrolled in hospice. Compared to patients in palliative care, hospice patients were less likely to report cancer as their qualifying condition (OR = 0.16 (0.11), p < .01), or entered the IMCP via the fast-track (OR = 0.23 (0.15), p < .05). Given low hospice enrollment in a fairly large EOL sample, cannabis use may operate as an alternative to supportive forms of care like hospice and palliation. Clinicians should initiate conversations about cannabis use with their patients while also engaging EOL Care planning discussions as an essential part of the general care plan.

Risk Factors and Antipsychotic Usage Patterns Associated With Terminal Delirium in a Veteran Long-Term Care Hospice Population

The development of delirium is very common in terminally ill patients. However, risk factors for terminal delirium in the veteran population are poorly identified. The purpose of this study was to (1) Identify risk factors for terminal delirium in a US Department of Veterans Affairs inpatient hospice population; (2) Assess usage patterns of antipsychotics for treatment of terminal delirium; and (3) Describe nursing assessment, nonpharmacologic interventions, and documentation of terminal delirium.This was a retrospective case-control study of veterans who expired while admitted into hospice care at a long-term care hospice unit during the period of October 1, 2013 to September 30, 2015. Veterans' medical records were reviewed for the 2 weeks prior to the recorded death.Of 307 veterans admitted for hospice care, 67.4% required antipsychotics in the last 2 weeks of life for the treatment of terminal delirium. The average number of antipsychotic doses given was 14.9 doses per patient. The risk factors that were identified included the use of steroids, opioids, or anticholinergics; Vietnam-era veterans with liver disease; veterans with cancer and a comorbid mental health disorder; and veterans with a history of drug and/or alcohol abuse.More than half of veterans admitted for hospice care experienced terminal delirium requiring treatment with antipsychotics. The identification of veterans most likely to develop terminal delirium will allow for early nonpharmacologic interventions and potentially decrease the need for treatment with antipsychotic medications.

Academic-community partnerships to promote end-of-life care competencies through interprofessional teamwork

This curricular resource describes an interprofessional educational program and curricular structure for teaching a rare but critical skill: how to care for someone when there is no cure, and to do so in a home environment when death is expected and supported as a natural process. Through academic-community partnerships and a blended-experiential model, students learn from hospice patients, their family members, other community volunteer caregivers, and hospice staff while simultaneously engaging in curricular activities that include online training modules, reflective writing exercises, and weekly discussion sessions with peers, faculty, and providers, all key components identified for professional identity formation (Simmonds et al., 2020; Wald et al., 2015). 1,2 The program was developed with the Learn, See, Practice, Prove, Do model, an evidence-based educational framework that helps students gain competence in their procedural skills and transition from the role of observer to that of a skilled care provider (Sawyer et al., 2015). Students were given pretest and posttest surveys, reflective journaling assignments, and a posttest questionnaire. Triangulation of data sources indicates that learning objectives and desired outcomes were consistently achieved. In addition, students reported high levels of satisfaction with the program, significant improvements in both empathy and self-efficacy to provide end-of-life care, and program impacts on both their personal perspectives and career goals/professional identities.

Pain, symptom distress, and pain barriers by age among patients with cancer receiving hospice care: Comparison of baseline data

ObjectivesAge group differences have been reported for pain and symptom presentations in outpatient and inpatient oncology settings, but it is unknown if these differences occur in hospice. We examined whether there were differences in pain, symptom distress, pain barriers, and comorbidities among three age groups (20–64 years, 65–84 years, and 85+) of hospice patients with cancer. Materials and MethodsParticipants were recruited from two hospices. Half were women; 49% White and 34% Black. 42% were 20–64 y, 43% 65–84 y, and 15% 85+ y. We analyzed baseline data for 230 hospice patients with cancer (enrolled 2014–2016, mean age 68.2 ± 14.0, 20–100 years) from a stepped-wedge randomized controlled trial. Measures were the Average pain intensity (API, 0–10: current, least and worst pain intensity during the past 24 h), Symptom Distress Scale (SDS, 13–65), Barriers Questionnaire-13 (BQ-13, 0–5), and comorbid conditions. Descriptive, bivariate association, and multiple regression analyses were performed. ResultsMean API scores differed (p < .001) among the three age groups (5.6 ± 2.0 [20–64 years], 4.7 ± 2.0 [65–84 years], and 4.4 ± 1.8 [85+], as did the mean SDS scores (36.1 ± 7.3, 33.5 ± 8.1, and 31.6 ± 6.6, p = .004). BQ-13 mean scores (2.6 ± 0.9, 2.7 ± 0.8, and 2.5 ± 0.7) and comorbidities were not significantly different across age groups. In multiple regression analyses, age-related differences in API and SDS remained significant after adjusting for gender, race, cancer, palliative performance score, and comorbidities. Comorbidities were positively associated with SDS (p = .046) but not with API (p = .64) in the regression model. ConclusionOlder hospice patients with cancer reported less pain and symptoms than younger patients, but all groups reported similar barriers to pain management. These findings suggest the need for age- and race-sensitive interventions to reduce pain and symptom distress levels at life's end.

Changes in the palliative performance scale may be as important as the initial palliative performance scale for predicting survival in terminal cancer patients.

The accurate estimation of expected survival in terminal cancer patients is important. The palliative performance scale (PPS) is an important factor in predicting survival of hospice patients. The purpose of this study was to examine how initial status of PPS and changes in PPS affect the survival of hospice patients in Korea. We retrospectively examined 315 patients who were admitted to our hospice unit between January 2017 and December 2018. The patients were divided based on the PPS of ≥50% (group A) and ≤40% (group B). We performed survival analysis for factors associated with the length of survival (LOS) in group A. Based on the hospice team's weekly evaluation of PPS, we examined the effect of initial levels and changes in group A on the prognosis of patients who survived for 2 weeks or more. At the time of admission to hospice, 265 (84.1%) patients were PPS ≥50%, and 50 (15.9%) were PPS ≤40%. The median LOS of PPS ≥50% and PPS ≤40% were 15 (2-158 days) and 9 (2-43 days), respectively. Male, gastrointestinal cancer, and lower initial PPS all predicted poor prognosis in group A. Male, gastrointestinal cancer, and a PPS change of 10% or greater, compared with initial status 1 week and 2 weeks of hospitalization, were all predictors of poor prognosis in group A patients who survived for 2 weeks or longer. Our research demonstrates the significance of PPS change at 1 week and 2 weeks, suggesting the importance of evaluating not only initial PPS but also change in PPS.

Study recruitment factors in advanced cancer: the Prognosis in Palliative care Study II (PiPS2) - a multicentre, prospective, observational cohort project

ObjectivesThe Prognosis in Palliative care Study II (PiPS2) was a large multicentre observational study validating prognostic tools in patients with advanced cancer. Many palliative care studies fail to reach their...

Changing Institutional Culture Around Hospice Using LEAN Tools to Improve Hospice Utilization in a Veteran Population

BackgroundLonger hospice length of stay improves the palliation of symptoms, quality of life, and the dying process for patients and their caregivers. We used a Lean designed Rapid Improvement Event (RIE) to facilitate earlier entry into hospice. MeasuresOur primary outcome was hospice length of stay. Secondary outcomes were avoiding unwanted inpatient utilization and hospice location. InterventionsWe conducted a five-day RIE utilizing Lean tools targeting the inpatient medicine wards. OutcomesHospice length of stay increased from a median (interquartile range [IQR]) of 11 (7,27) days prior to 37 (7,73) days following the RIE. Home hospice and outside Skilled Nursing Home (SNF) hospice use increased while use of the onsite VA hospice decreased. Conclusions/Lessons LearnedLEAN tools can be used successfully to improve end of life outcomes in an inpatient VA setting. The 90-day sustainment period following the RIE uncovers barriers to implementation and allows for adjustments to implementation.