Hospice Patients Research Articles

Kidney supportive care for advanced chronic and end-stage kidney disease: a retrospective cohort study.

Kidney supportive care is an interdisciplinary model of person-centred medicine, suitable for patients with advanced Chronic Kidney Disease (CKD) and with End-Stage Kidney Disease (ESKD). There is little information on routine care, and palliative careremains poorly integrated into standard nephrology care. The aim of this study was to describe our experience in integrating a palliative care approach into the nephrology care of advanced chronic and end-stage kidney disease. A retrospective cohort study was conducted from 1 June, 2017 until 31 December, 2020 on 67 advanced CKD and ESKD patients admitted to a palliative care service. The patients' median age was 83.6years, 62.7% were male, 16.4% had CKD stage 4 and 83.6% stage 5. Almost half (47.8%) of the patients were on kidney replacement therapy, and 52.2% were on conservative therapy. The majority (77.6%) received home-based palliative care, 17.9% hospice care and 4.5% day-hospice care. The median number of nephrologists' visits per patient was 3.5. Access to palliative care specialists was set at 100% and the median number of palliative clinicians' visits was 8. Eighty-five percent of patients did not require hospitalisation and 94% did not access to theemergency room; 86.2% of the patients died in hospice or at home. This study reports onthe first stepstaken to change practice in nephrology, by applying the Italian guideline for an integrated pathway of palliative carein nephrology. Nephrologists' and the palliative careteam created a multi- and inter-disciplinary team, sharing their professional skills to support patients in hospice or at home.

Prevalence and characteristics of patients prescribed opioids and central nervous system depression agents on discharge to hospice care.

Hospice patients with end-stage liver disease (ESLD) have an increased risk of adverse drug events due to physiological changes and changes in pharmacokinetic and pharmacodynamic properties of medications; however, the use of opioid and central nervous system (CNS) depressant prescribing among patients with ESLD is prevalent. This study quantified the frequency and distribution of opioid and concomitant respiratory and CNS depressant prescribing among hospice patients with ESLD compared to other common hospice diagnoses of cancer, chronic obstructive pulmonary disorder (COPD), heart failure, and end-stage renal disease. This was a cross-sectional study of adult (age 18 years or older) decedents of a large hospice chain. Patients included had a primary diagnosis of liver, cancer, cardiovascular, or respiratory disease. Among 119,424 hospice decedents, mean age of 77.9 years (standard deviation =13.5 years), 54.6% were female, and 58.9% were of a non-Hispanic white race. There was a similar frequency of prescribing a "scheduled" and "as needed [pro re nata (PRN)]" opioid or benzodiazepine in patients with ESLD compared to other common hospice diagnoses. In addition, there was a high prevalence of concurrent opioid and benzodiazepine prescriptions among patients with ESLD compared to cardiovascular and respiratory disease at admission (65.4% vs. 63.9% and 64.9%). Opioid requirements, oral morphine equivalent (OME) median [interquartile range (IQR)] at discharge were similar between cancer, liver, and respiratory disease, 120 OME [60-300], 120 OME [50-240], and 120 OME [50-240], respectively. We observed a high frequency of opioid and CNS depressant prescribing in a hospice patient population with ESLD which was similar to other common admitting hospice diagnoses.

Place of death in Parkinson's disease and related disorders in England and Wales: post-pandemic trends and implications for care planning.

With growing emphasis on palliative care for neurodegenerative conditions, understanding trends in place of death helps improve quality of end-of-life care for people with Parkinson's disease and related disorders (PDRDs), focusing allocation of resources and training and identifying inequalities. Review national and regional place of death trends for people with PDRD including pre- and post-pandemic trends. Mortality data for England and Wales (March 2018 and July 2022) were analysed with summary statistics and interrupted time series, exploring place of death for those who died with PDRD, with and without coexisting dementia, with reference to all deaths in England and Wales. Of 2,415,566 adult deaths, 56,790 included mention of PDRD. Hospital deaths were most common in people with PDRD (39.17%), followed by care homes (38.84%). People with PDRD were half as likely to die in hospice compared with the general population (2.03 vs 4.94%). Proportion of care home deaths fell significantly after March 2020 (40.6-37%, P= 0.035). Regionally, London was an outlier with a lower proportion of deaths occurring in care homes with a higher proportion of hospital deaths. Place of death for people with PDRD is changing, with more hospice and home deaths. People with PDRD, particularly those with co-existent dementia, are less likely to access inpatient hospice care than the general population. Since the COVID-19 pandemic, the proportion of care home deaths has reduced significantly with an increase in home deaths, with implications for service and resource allocation.

Mental Health Service Integration in Hospice Organizations: A National Survey of Hospice Clinicians and Medical Leadership.

Background: Unmet mental health needs are associated with a range of negative consequences for individuals at the end of life. Despite the high prevalence of mental health needs among individuals enrolled in hospice, there is a paucity of data describing mental health service integration in hospices in the United States. Objectives: 1. To identify patterns of mental health service integration in hospice organizations nationally; 2. To characterize gaps in mental health service delivery in hospice settings as perceived by hospice clinicians and medical leadership. Methods: A cross-sectional survey querying hospice clinicians and hospice medical leadership nationally. Results: A total of 279 surveys were included. Clinically significant mental health symptoms were common among hospice patients; the most frequently encountered symptom groups were depression, anxiety, dementia, and delirium. A minority of hospices maintained relationships with psychiatrists (23%, n = 60), psychiatric nurse practitioners (22%, n = 56), or psychologists (19%, n = 49). Only 38% (n = 99) of respondents were satisfied with their patients' access to services and only 45% (n = 118) were satisfied with the quality of these services. Common limitations to providing adequate mental health services included lack of specialist services, short length of stay for patients, and reluctance of patients to engage in these services. Conclusions: Significant mental health symptoms are common among hospice patients, and hospice organizations perceive these needs are not being met. Further research is needed to better understand the current treatment landscape and design interventions to address these needs.

Promising Impact of Telenovela Intervention for Caregivers of Hospice Patients: A Pilot Study.

Hospice family caregivers (HFCGs) support the needs of their loved ones but are at risk of developing distress and anxiety. NOVELA is a four-chapter telenovela-style educational video to support topics related to hospice caregiving. Telehealth visits are scheduled in 4 weekly sessions consisting of a chapter and subsequent discussion with an interventionist. This feasibility pilot study tested NOVELA's effect to change HFCGs' outcomes, session and outcome measure completion (defined a priori as >70%). This is a single-group pretest-posttest study of HFCGs of care recipients with PPS score >20% from 3 hospices in the U.S. Mid-Atlantic region. At baseline and at final posttest, participants completed a web-based survey assessing 3 outcomes: anxiety, self-efficacy, and satisfaction with intervention. Descriptive, t-test, and chi-square statistics were computed. Participants in our study (N = 59) were mainly collage educated, White, female, adult children of home-bound people with a non-cancer diagnosis. Outcomes changed in the expected direction (P > .05) with higher self-efficacy (Cohen's d = -.08 [95% CI -.4 to .2) and lower anxiety (Cohen's d = .2 [95% CI -.1 to .5]) scores from final to baseline, 86% of HFCGs were satisfied or very satisfied with NOVELA, session (33/59) and outcome measure (43/59) completion averaged 68%. Encouraging trends in NOVELA's estimation of effect suggests that NOVELA may buffer stressful aspects of hospice caregiving. However, further refinement of NOVELA is needed. Supporting HFCGs through supportive educational interventions may reduce distress and anxiety with broad implications for quality improvement.

Mixed-Methods Study of End-of-Life Experiences of Patients With Hematologic Malignancies in Social Hospice Residential Home Care Settings.

Hospice is underutilized by patients with hematologic malignancies (HM), and when patients are referred, they are typically more ill, hospitalized, and with shorter length of stay (LOS) than patients with solid tumors (ST), limiting research about home hospice care experiences of patients with HM. In this mixed-methods study, we examined the hospice experiences of patients with HM who died at residential care homes (RCHs), home-based settings in which volunteer caregivers and hospice staff provide end-of-life (EOL) care under the social hospice model. We queried a registry of 535 hospice patients who died at RCHs between 2005 and 2020 that included quantitative medication administration data as well as qualitative data from hospice intake forms and written volunteer caregiver narratives. Qualitative data were analyzed by collective case study methodology. Quantitative comparisons of LOS and liquid morphine use were performed with matched patients with ST. The registry yielded 29 patients with HM, of whom qualitative data were available for 18 patients. Patients with HM exhibited common EOL symptoms (pain, dyspnea, and agitation). Instances of bleeding were low (22%), and notable HM-specific care concerns were described regarding bone fractures, skin integrity, and delirium. Most (78%) experienced good symptom management and peaceful or comfortable deaths. In only one case were symptoms described as severe and poorly managed. Patients with HM had comparable LOS on hospice and at the RCHs to patients with ST, with no group differences in liquid morphine use. In this registry cohort, most patients with HM achieved good symptom management in home care settings with volunteer caregivers and hospice support. Caregivers may require additional counseling and palliative medications for HM-specific EOL symptoms.

“Am I Going to Die?” Considering the Preparation for Research on an Example of Hospice Patients

This article concerns the situations experienced by the researcher in one of the sensitive research groups—hospice patients. The article is based on the author’s experiences in three studies in Poland—94 in-depth interviews and observations in inpatient and home care hospices. Through the seven presented categories the author faced during the interviews, she analyzes the dilemmas of conducting qualitative research from a practical perspective. During studies, we learn about our preferences, sometimes defining ourselves on one of the sides—becoming a quantitative or qualitative researcher, thus deciding further scientific paths. Conducting qualitative research requires specific activities, including knowledge of the literature, selection of the proper method, and analysis of the research group (Silverman 2012). These principles turn out to be only the beginning of the process in which we intuitively, through trial and error, pave the way to deal with demanding situations, previously inexperienced emotions, coordination, and technical and ethical problems. Some studies require special preparation, particularly considering the specificity of certain research groups, such as hospice patients, who will face the dying process soon.

End-of-life conversations about death and dying from volunteer perspectives: A qualitative study.

Although often unrecognized, volunteers fulfill many essential roles in hospices and other end-of-life care settings. Volunteers complement the actions of professionals in fulfilling many extra care needs, such as delivering newspapers and tidying bedsides. We explored end-of-life conversations about death and dying between hospice volunteers and terminally ill people, with a particular emphasis on any expressed desire to die. Our 2 research questions were as follows: (1) What is the nature of end-of-life conversations between hospice patients and hospice volunteers? and (2) How do hospice volunteers experience conversations about death and dying with patients who are at the end-of-life? We conducted semi-structured interviews using an interpretive phenomenological analysis. We recruited hospice volunteers from 4 hospices in Calgary, Edmonton, and Red Deer; 3 larger cities in the province of Alberta, Canada. We interviewed 12 participants to saturation. Four themes emerged: (1) trusting conversations about death and dying in the context of a safe place; (2) normalcy of conversations about death and dying; (3) building meaningful relationships; and (4) end-of-life conversations as a transformative experience. Our results emphasize the importance of preparing volunteers for conversations about death and dying, including the desire to die. The safe environment of the hospice, the commitment to patient confidentiality, and the ability of volunteers to meet the basic and emotional needs of dying people or simply just be present without having formal care duties that need to be completed contribute to volunteers being able to participate in timely and needed conversations about death and dying, including the desire to die. In turn, hospice experiences and end-of-life conversations provide a transformative experience for volunteers.

The Impact of Hospice Care Structures on Care Processes: A Retrospective Cohort Study.

Background: Palliative care is subject to substantial variations in care, which may be shaped through adapting the organisational structures through which care is provided. Whilst the goal of these structures is to improve patient care, there is a lack of evidence regarding their effect on care processes and patient outcomes. Aims: This study aims to describe the relationship between care structures and the quantity and domains of care processes in hospice care. Design: Retrospective cohort study. Settings/Participants: Data were collected from Dutch hospice patient's clinical records and hospice surveys, detailing hospice structures, patient clinical characteristics and care processes. Results: 662 patients were included from 42 hospices, mean age 76.1years. Hospices were categorised according to their care structures - structured clinical documentation and multidisciplinary meetings. Patients receiving care in hospices with structured multidisciplinary meetings had an increased quantity of documented care processes per patient on admission through identification (median 4 vs 3, P < .001), medication (2 vs 1, P = .004) and non-medication (1 vs 0, P < .001) interventions, monitoring (2 vs 1, P < .001) and evaluation (0 vs 0, P = .014), and prior to death. Similar increases were identified for patients who received care in hospices with structured documentation upon admission, but these changes were not consistent prior to death. Conclusions: This study details that the care structures of documentation and multidisciplinary meetings are associated with increased quantity and breadth of documentation of care processes in hospice care. Employing these existing structures may result in improvements in the documentation of patient care processes, and thus better communication around patient care.

Evaluation of an outreach programme for patients with COVID-19 in an integrated healthcare delivery system: a retrospective cohort study

ObjectivesIn the first year of the COVID-19 pandemic, health systems implemented programmes to manage outpatients with COVID-19. The goal was to expedite patients’ referral to acute care and prevent overcrowding...

Quality of Life Among Cancer Patients Who Discharged Home from Inpatient Hospices, Comparing with Those of Cancer Patients Who Died at HospicesA Nation-ｗide Survey Among Bereaved Families of Advanced Cancer Patients

Quality of Life Among Cancer Patients Who Discharged Home from Inpatient Hospices, Comparing with Those of Cancer Patients Who Died at HospicesA Nation-ｗide Survey Among Bereaved Families of Advanced Cancer Patients

Describing the characteristics and symptom profile of a group of urban patients experiencing socioeconomic inequity and receiving palliative care: a descriptive exploratory analysis.

Individuals experiencing socioeconomic inequity have worse health outcomes and face barriers to palliative and end-of-life care. There is a need to develop palliative care programs tailored to this underserved population. To understand the characteristics and symptom profiles of a group of urban patients experiencing socioeconomic inequity and receiving palliative care. Descriptive exploratory analysis of a patient dataset. The patient dataset was generated through a pilot research study with patients experiencing socioeconomic inequity and life-limiting illness who received a community-based palliative care intervention. The intervention took place over 1 year in the Palliative Care Outreach and Advocacy Team, a community-based urban palliative care clinic in Edmonton, Alberta, Canada, serving persons experiencing socioeconomic inequity. Participants had to be at least 18 years of age, be able to communicate in English, require palliative care for a life-limiting illness, and be able to consent to inclusion in the study. Twenty-five participants were enrolled. Participants predominantly identified as male and Indigenous, experienced poverty and housing instability, and had metastatic cancer. Our participants rated their pain, shortness of breath, and anxiety as more severe than the broader community-based palliative care population in the same city. Most patients died in inpatient hospices (73%). Our analysis provides an in-depth picture of an understudied, underserved population requiring palliative care. Given the higher symptom severity experienced by participants, our analysis highlights the importance of person-centered palliative care. We suggest that socioeconomic inequity should be considered in patients with life-limiting illnesses. Further research is needed to explore palliative care delivery to those facing socioeconomic inequity.

"Before I came to the hospice, I had nobody". A qualitative exploration of what patients, family-caregivers, clinicians and volunteers valued most about home, day therapy or inpatient hospice services.

Globally, the demand for hospice care continues to grow resulting in substantial resource burden. Whilst some countries are able to rely on fixed government contributions, statutory funding for palliative care in the United Kingdom is unequally distributed. These unstable funding streams and increased demand means that hospices need to evidence their value. This study explored the experiences of patients and family-caregivers to determine what they valued most from accessing hospice services in Wales. In this large multi-site qualitative study, 94 semi-structured interviews and 2 focus groups were conducted with hospice patients (n = 45), family-caregivers (n = 18), hospice staff (n = 31) and volunteers (n = 10). The audio recordings were transcribed verbatim and analysed using Framework analysis. Seven themes described patient and family-caregiver experiences and what they valued most: relationships with staff and volunteers, greater support networks which reduced social isolation and loneliness, provision of information and advice which improved patient autonomy, symptom management and subsequent reduction in psychological distress, improvements in patient functionality, mobility and overall physical health and respite relief which promoted improved relationships. This is the largest study to explore what patients and family-caregivers value from hospice care. Findings indicate that hospice care provides a truly needs-led and strengths-based service to those who are nearing and at the end-of-life, which is highly valued by patients and family members.

Measurement Invariance of the Hospice Quality of Life Index-14 in Lung Cancer and Nonlung Cancer Patients Admitted to Hospice.

Background and Purpose: Establishing measurement invariance (MI) is important in the questionnaire validation process. This study examined the MI of the Hospice Quality of Life Index-14 (HQLI-14) when comparing hospice patients with lung cancer and those with non-lung cancers. Methods: The HQLI-14 contains 14 items to measure multidimensional concepts of quality of life. A series of confirmatory factor analyses were performed to test configural, metric, and scalar invariance. Results: The MI of the HQLI-14 was supported by increasing equality constraints on item parameters between groups. Although the configural and metric invariances were both supported, one item regarding breathlessness was noninvariant between the groups with lung and nonlung cancers. Conclusions: The HQLI-14 shows early evidence of meeting the requirements for configural, metric, and partial scalar invariance. It may be used to make meaningful comparisons between patients with lung cancer and nonlung cancers.

BEHAVIORAL HEALTH INTERVENTIONS IN THE HOSPICE SETTING: A SCOPING REVIEW

Abstract Hospice is a model of care for individuals with a life expectancy of less than six months who choose to focus their treatment on quality-of-life rather than extending life. In 2019, half of all Medicare decedents elected to receive hospice care. Behavioral health comorbidities are prevalent in hospice patients; approximately 40% experience significant depression and/or anxiety. Such comorbidities are associated with poor outcomes including increased physical symptoms, worse function, and lower quality-of-life. Despite the impact of behavioral health comorbidities on hospice patient outcomes, little research has focused on the use of behavioral health interventions in the hospice setting. We conducted a scoping review to characterize the types of behavioral health interventions administered to patients receiving hospice care. We searched four databases, generating 6,842 unique citations over any time period. 70 texts were reviewed and 31 were retained for analysis. Studies examined both psychotherapeutic (n=10) and psychopharmacologic (n=10) interventions, as well as other non-pharmacologic interventions (n=11). Duration of study follow-up was available for 17 of the studies, ranging from six days to six months. 14 studies reported information on interventionists, who were most commonly music (n=3) or massage therapists/acupuncturists (n=3). Average interventions were 47 minutes for six sessions. 18 studies presented statistically significant results related to primary outcomes, most commonly depression (n=9), anxiety (n=6), and pain (n=4). Our findings demonstrate a dearth of behavioral health interventions targeting hospice patients, suggesting the need for increased research and clinical focus on developing, evaluating, and implementing behavioral health interventions in the hospice setting.

IMPLEMENTATION OF VIRTUAL REALITY TO IMPROVE QUALITY OF LIFE FOR VETERANS IN HOSPICE AND PALLIATIVE CARE

Abstract Virtual Reality (VR) is a safe and effective adjunctive care option with multiple clinical applications. An interdisciplinary VR program aimed at improving quality of life for veterans receiving inpatient hospice and palliative care was implemented at the VA Bedford Health Care System. Principles from the 4Ms of Geriatrics (Mentation, Mobility, Medications, and Matters Most) guided evaluation and outcomes. Implementation involved decision-making around hardware and software, learning about processes at other facilities, financing, and creating policies and procedures. Project development began in 2021 and data collection began in March 2023. Veteran residents enrolled in inpatient hospice and palliative care were invited to participate. As of August 2023, 22 VR visits were conducted with 13 veterans. Preliminary data suggests VR can be used with a wide range of individuals receiving hospice and palliative care. Analysis of pre-post measures indicate improvement in mood (62%) and overall day (81%), and reduced pain. Barriers to engagement include staffing (e.g., availability), technology (e.g., VR technical issues), hospital procedures/policies (e.g., infection control, COVID-19), and patient factors (e.g., interest, symptoms). Facilitators include hospital support, interdisciplinary collaboration, and understanding of the setting and patient preferences/ needs. Although conception to implementation took two years, a VR program to improve quality of life for veterans enrolled in hospice and palliative care appears to be feasible and clinically beneficial. Experience has shown that flexibility, adaptability, and an individualized approach facilitate engagement. Best practices in the application of VR within the hospice and palliative care setting will continue to be evaluated and honed.

COLLABORATIVE RESEARCH WITH A MIXED-METHOD DATASET USING DECEDENT DATA

Abstract This presentation will present opportunities and challenges in building and sharing a mixed method dataset of terminally ill hospice patients from residential homes for the dying (social model hospice). As nonprofit, community-based settings, residential homes for the dying document care decisions using paper files and handwritten notes, and files range in size based on length of stay (with some files being hundreds of pages in length). Through a multi-site community-university partnership, we have scanned over 500 patient records, extracted quantitative data, and de-identified data for qualitative analysis. We will share the challenges of data management and organization, extraction, and de-identification. We will also discuss ethical issues related to working with decedent data, community-engaged research, and multi-site collaboration. Based on our experiences with qualitative data analysis of resident files, we will share strategies for extracting qualitative data from decedent records, using qualitative data analysis software, and sharing data for collaborative research.

UNDERUTILIZATION OF HOSPICE CARE IN OLDER BLACK ADULTS

Abstract Hospice is underutilized in Black Americans despite evidence that Black Americans benefit from hospice services. There are several potential reasons hospice is underutilized in Black Americans including lack of knowledge of hospice, poor opinions of hospice, and low self-efficacy in end-of-life decision-making. Patient decision aids are one technique used to improve patient knowledge and agency in making medical decisions. This research project endeavored to addresses potential barriers to hospice enrollment in Black adults and evaluates if a hospice specific patient decision aid could improve hospice knowledge, opinions of hospice, and decision-making self-efficacy. The study was a pilot randomized controlled trial that enrolled Black adults aged ≥ 65 years. The three primary outcomes for the study included hospice knowledge measured by the Hospice Knowledge Scale, opinions of hospice measured by the Hospice Beliefs and Attitudes Scale, and confidence in making decisions measured by the Decision Self-Efficacy Scale. Additionally acceptability and usability outcomes of the decision aid were collected. All participants completed the three baseline surveys prior to randomization. Those randomized to the intervention were provided with the hospice patient decision aid while those in the control did not receive the decision aid. Hospice knowledge, opinions of hospice, and decision self-efficacy improved from baseline to one-month follow-up in the intervention group, but between group (intervention vs control) differences were not statistically significant. Overall acceptability outcomes were favorable, and participants stated the patient decision aid would be beneficial in facilitating hospice decision making.

PRESIDENTIAL SYMPOSIUM: IMPACT OF DISCRIMINATORY POLICIES ON LGBTQ+ OLDER ADULTS’ HEALTH AND WELL-BEING AND HOW TO COMBAT THEM

Abstract Despite some advances in LGBTQ+ rights over the past few decades, many states lack legal protections against discrimination based on sexual orientation or gender identity, and the current political climate raises concerns about future challenges to LGBTQ+ rights. This symposium explores the implications of discriminatory policies on the health, housing, and economic well-being of LGBTQ+ older adults, and solutions for promoting empowerment, equity, and inclusion throughout the care continuum, from long-term services and supports to end-of-life care. The first presentation describes a complex paradox in which sexual and gender minority (SGM) older adults avoid formal services due to fear of discrimination and poor treatment despite significant health disparities and a lack of informal support, discusses opportunities to improve access and health through education and awareness, and elucidates implications for policy and research. The second presentation describes geographic variations in access to, and receipt of gender-affirming surgery among transgender and gender-diverse Medicare beneficiaries using national Medicare data and discusses policy implications. The third paper focuses the role of spirituality and faith in the lives of LGBTQ+ older adults and reports findings from a mixed-methods study on how involvement in faith communities shape their end-of-life care perceptions and preparation. The fourth presentation describes barriers and facilitators to communicating with SGM hospice patients and caregivers about their sexual orientation and gender identity and recommendations for developing communication training to promote authentic end-of-life care for this population. Karen Frederickson-Goldsen as discussant will provide policy and practice implications of these important works.

Management of Critical Glucose Values in Hospice.

Objectives: This quality improvement (QI) project was to lean the process for managing critical high and low glucose levels in the hospice unit and to simplify the pharmacologic options for hypoglycemic management for nursing staff. Methods: The process for developing and refining the recommendations involved a modified Delphi approach with a team of key stakeholders with overlapping expertise in hospice care practice. Recommendations were based on literature review, judgement of experts, and clinical experience. Stakeholders ranked six potential solutions and two were prioritized within the scope of this project. Results: From 1/1/21 - 12/31/21, there were 48 veterans with insulin sliding scale orders in the hospice unit, of which there were six critical values acted on. A standard operating procedure (SOP) for the management of critical glucose values in hospice was developed based on updated processes. In addition, hospice patient specific insulin sliding scale order sets were created and endorsed for utilization and dissemination. Following implementation on 3/1/22, no critical values were found in the hospice unit from 3/1/22 - 6/1/22 during the sustainment period. Conclusions: The implementation of hospice insulin sliding scale order sets and SOP on the management of critical glucose values in hospice reduced the number of critical glucose values.