Hospice Patients Research Articles

Bacterial Communities Associated with Houseflies (Musca domestica L.) Inhabiting Hospices in South Africa.

Houseflies are alleged reservoirs as well as vectors of human and animal pathogens, including bacteria, because they frequently have contact with animal excreta and decaying organic substances. The rapid adaptation process of ingested microbes in the insect gut may involve gene transfer, including antibiotic resistance determinants among different bacterial strains. Six hundred and fifty-seven (n = 657) houseflies were collected from hospices and were identified morphologically and genetically using the 16S rRNA, CO1, and ITS2 barcoding genes. This study also characterized the bacterial communities harboured by the captured houseflies using 16S rRNA metabarcoding on the next-generation sequencing (NGS) platform and further sought to detect antibiotic resistance traits by using gene-specific PCR assays. Generated sequences for the targeted gene fragments matched with Musca domestica and all the sequences were deposited to the GenBank database. The 16S rRNA metabarcoding analysis revealed that the most abundant phyla detected with variable abundance observed among all the houseflies were Proteobacteria, followed by Firmicutes, and Bacteroidetes. Furthermore, the NGS data revealed the presence of multiple bacterial genera, including Providencia, Enterobacter, Dysgonomonas, Escherichia-Shigella, Klebsiella, Pseudomonas, and Streptococcus, which are known to harbour potentially pathogenic species of animals and humans. Antibiotic resistance genes detected from the housefly DNA in this study included ermB, tetA, blaSHV, and blaTEM. Moreover, these genes are associated with resistance to erythromycin, tetracycline, and beta-lactams antibiotics, respectively. The presence of bacterial pathogens and the detection of antibiotic resistance genes from the houseflies collected from the hospices indicates the possible health risk to patients in hospices and the surrounding community. Therefore, it is imperative to keep high standards of hygiene, food preparation, safety, and control of houseflies in hospices.

Determinants of quality of life in primary family caregivers of patients with advanced cancer: a comparative study in southern China.

To examine and compare the quality of life (QoL) of the primary family caregivers (PFCs) of inpatients with advanced cancer and the PFCs of home hospice patients with advanced cancer and to analyze the determinants of QoL. Four hospices and three comprehensive or tumor hospitals in Guangdong Province, China were research sites. QoL was measured using paper-based and online questionnaires. Multiple stepwise linear regression was used to analyze the determinants of QoL of PFCs. The PFCs of inpatients had significantly better QoL than did the PFCs of home hospice patients (p < 0.01). One-way ANOVA results indicated the following: for the PFCs of inpatients, PFC age (t = 2.411, p < 0.05), type of relationship with patient (F = 2.985, p < 0.05), and family economic situation (F = 3.423, p < 0.05) significantly affected PFCs' QoL; for the PFCs of home hospice patients, family economic situation (F = 3.757, p < 0.05) and care experience (t = 2.021, p < 0.05) significantly affected PFCs' QoL. A multiple stepwise linear regression was conducted: for the PFCs of inpatients, family economic situation and whether the PFC was the patient's immediate family member were included as predictors of QoL; for the PFCs of home hospice patients, family economic situation and care experience were included as predictors of QoL. Our findings can help improve the home hospice care service model in mainland China. In particular, the QoL of the PFCs of home hospice patients requires urgent attention. The PFCs of home hospice patients requires more nursing guidance and interactions with community.

Assessing the Impact of the Center for Medicare and Medicaid Services Policy Guidance on Part D Prescriptions Among Hospice Patients.

Hospice care facilities are required to provide prescription drugs related to a hospice patient's terminal illness. From October 2010 to present, the Center for Medicare and Medicaid Services (CMS) has issued a series of communications regarding Medicare paying for hospice patients' prescription drugs under Part D that should be covered under the hospice Medicare Part A benefit. On April 4, 2011, CMS issued specific policy guidance to providers aimed at preventing inappropriate billing. While CMS has documented Part D prescription decreases in hospice patients, no research exists that connects these decreases and the policy guidance. This study aims to evaluate the effect of the April 4, 2011, policy guidance on hospice patients' Part D prescriptions. This study employed generalized estimating equations to assess (1) total monthly average prescriptions of all medications and (2) four categories of commonly prescribed hospice medications in pre-and-post policy guidance. This research used the Medicare claims of 113,260 Part D-enrolled Medicare male patients aged 66 and older between April 2009 and March 2013, including 110,547 non-hospice patients and 2713 hospice patients. Hospice patients' monthly average total Part D prescriptions decreased from 7.3 pre-policy guidance to 6.5 medications following the issuing of the guidance, while the four categories of hospice-specific medications decreased from .57 to .49. The findings of this study show that CMS's guidance issued to providers to prevent the inappropriate billing of hospice patients' prescriptions to the Part D benefit may lead to Part D prescription decreases as observed in this sample.

Alzheimer's Disease and Related Dementias: Caregiver Perspectives on Hospice Re-Enrollment Following a Hospice Live Discharge.

Background: The number of individuals dying of Alzheimer's disease and related dementias (ADRDs) is steadily increasing and they represent the largest group of hospice enrollees. In 2020, 15.4% of hospice patients across the United States were discharged alive from hospice care, with 5.6% decertified due to being "no longer terminally ill." A live discharge from hospice care can disrupt care continuity, increase hospitalizations and emergency room visits, and reduce the quality of life for patients and families. Furthermore, this discontinuity may impede re-enrollment into hospice services and receipt of community bereavement services. Objectives: The aim of this study is to explore the perspectives of caregivers of adults with ADRDs around hospice re-enrollment following a live discharge from hospice. Design: We conducted semistructured interviews of caregivers of adults with ADRDs who experienced a live discharge from hospice (n = 24). Thematic analysis was used to analyze data. Results: Three-quarters of participants (n = 16) would consider re-enrolling their loved one in hospice. However, some believed they would have to wait for a medical crisis (n = 6) to re-enroll, while others (n = 10) questioned the appropriateness of hospice for patients with ADRDs if they cannot remain in hospice care until death. Conclusions: A live discharge for ADRD patients impacts caregivers' decisions on whether they will choose to re-enroll a patient who has been discharged alive from hospice. Further research and support of caregivers through the discharge process are necessary to ensure that patients and their caregivers remain connected to hospice agencies postdischarge.

‘It’s tough. It is hard’: A qualitative interview study of staff and volunteers caring for hospice in-patients with delirium

Background: Delirium is a distressing condition often experienced by hospice in-patients. Increased understanding of current multidisciplinary care of delirium is needed to develop interventions in this setting. Aim(s): To explore hospice staff and volunteers’ practice, its influences and what may need to change to improve hospice delirium care. Design: Qualitative interview study using behaviour change theory from a critical realist stance. Setting/participants: Thirty-seven staff, including different professional groups and roles, and volunteers were purposively sampled from two in-patient hospices. Results: We found that participants’ practice focus was on managing hyperactive symptoms of delirium, through medication use and non-pharmacological strategies. Delirium prevention, early recognition and hypoactive delirium received less attention. Our theoretically-informed analysis identified this focus was influenced by staff and volunteers’ emotional responses to the distress associated with hyperactive symptoms of delirium as well as understanding of delirium prevention, recognition and care, which varied between staff groups. Non-pharmacological delirium management was supported by adequate staffing levels, supportive team working and a culture of person-centred and family-centred care, although behaviours that disrupted the calm hospice environment challenged this. Conclusions: Our findings can inform hospice-tailored behaviour change interventions that develop a shared team understanding and engage staff’s emotional responses to improve delirium care. Reflective learning opportunities are needed that increase understanding of the potential to reduce patient distress through prevention and early recognition of delirium, as well as person-centred management. Organisational support for adequate, flexible staffing levels and supportive team working is required to support person-centred delirium care.

Telehospice for Cancer Patients Discharged from a Tertiary Care Hospital in Western Kenya.

Worldwide, most patients lack access to hospice services. Assess the feasibility of telephone monitoring (Telehospice) in providing symptom management for patients discharged from a tertiary care hospital in Western Kenya. Inclusion criteria included adults with cancer no longer eligible for chemo-radiation and receiving opioid therapy. Thirty patients were enrolled in a weekly monitoring program assessing physical symptoms and patient and caregiver distress. The participants also had access to a 24-hour hotline. Symptom assessment included 18 questions with 8 from the African Palliative Outcome Scale. Participants were followed for eight weeks or until death or admission to an inpatient hospital or hospice. The primary objective was participation in weekly calls, and we obtained 100% participation. A secondary objective was the use of "comfort kits" which contained 30 doses of six medications. Most patients utilized one or more of the provided medications, with high usage of bisacodyl, paracetamol, and omeprazole. While 12% of weekly calls and 24% of hotline calls led to medication changes, participants continued to express worry and there was only a modest decrease in pain scores despite having morphine available throughout the follow-up period. Family confidence in providing care and access to information remained high. At the end of the eight-weeks of observation, eight participants were alive, 10 died at home, and 12 were admitted to an in-patient facility. Patient and family participation in Telehospice is feasible and may provide an interim solution to managing end-of-life patients who lack access to home hospice.

Dying in the Hospital: A Quality Improvement Project to Increase Inpatient Hospice Utilization (QI105)

Dying in the Hospital: A Quality Improvement Project to Increase Inpatient Hospice Utilization (QI105)

Music Therapy Intervention to Reduce Caregiver Distress at End of Life: A Feasibility Study.

Music therapy (MT) can relieve distressing end-of-life symptoms, but little is known regarding its effect on caregivers who are at risk for emotional distress as their loved ones approach death. Quality of life (Linear Analogue Self-Assessment), depressive and anxiety symptoms (Patient Health Questionnaire for Depression and Anxiety), and stress (Role Overload Measure) pre-MT, post-MT and at 6-month follow-up, as well as a satisfaction survey post-MT. Single MT session for 20-45 minutes OUTCOMES: 15/20 completed MT intervention, 14 also completed pre-MT and post-MT assessments, and 9 completed assessments at all 3 timepoints. Post-MT satisfaction survey (n=14) showed 100% of caregivers were very satisfied with MT and would recommend to others, and found MT very effective for emotional support (85.7%), stress relief (78.6%), spiritual support (71.4%), general feeling of wellness (71.4%), relaxation (69.2%), and pain relief (33.3%). Research on MT is feasible for caregivers of inpatient hospice patients. ClinicalTrials.gov Identifier: NCT03322228.

Scheduled Opioid Administration in Hospice Patients Before and After Targeted Caregiver Education.

Hospice and palliative care have been shown to increase patient satisfaction and improve symptom control at the end of life. Opioid analgesics are typically given around the clock at the end of life to maintain symptom control and prevent the need for larger doses later. Many hospice patients have some degree of cognitive impairment, putting them at risk of being undertreated for pain. This was a retrospective, quasi-experimental study at a 766-bed community hospital with hospice and palliative care services. Adult patients admitted to inpatient hospice care with active orders for scheduled opioids for at least 12 hours with at least 1 dose administered were included. The primary intervention was the creation and dissemination of education to non-intensive care nursing staff. The primary outcome was the administration rate of scheduled opioid analgesics to hospice patients before and after targeted caregiver education. Secondary outcomes included the rate of use of 1-time or as-needed opioids, the rate of use-of-reversal agents, and the impact of COVID-19 infection status on administration rates of scheduled opioids. A total of 75 patients were included in the final analysis. The rate of missed doses was 5% in the pre-implementation cohort and 4% in the post-implementation cohort (P = .21). The rate of delayed doses was 6% in the pre-implementation cohort and 6% in the post-implementation cohort (P = .97). Secondary outcomes were similar between the two groups with the exception of a higher rate of delayed doses in patients with confirmed COVID-19 as compared to those without COVID-19 (P = .047). The creation and dissemination of nursing education were not associated with a decrease in missed or delayed doses of scheduled opioids in hospice patients.

A Comparison of Hospice Care Utilization Between Rural and Urban Children in Appalachia: A Geographic Information Systems Analysis.

Long driving times from hospice providers to patients lead to poor quality of care, which may exacerbate in rural and highly isolated areas of Appalachia. This study aimed to investigate geographic patterns of pediatric hospice care across Appalachia. Using person-level Medicaid claims of 1,788 pediatric hospice enrollees who resided in the Appalachian Region between 2011 and 2013. A database of boundaries of Appalachian counties, postal addresses of hospices, and population-weighted county centroids of residences of hospice enrollees driving times from the nearest hospices were calculated. A choropleth map was created to visualize rural/urban differences in receiving hospice care. The average driving time from hospice to child residence was 28minutes (SD = 26). The longest driving time was in Eastern Kentucky-126minutes (SD = 32), and the shortest was in South Carolina-11min (SD = 9.1). The most significant differences in driving times between rural and urban counties were found in Virginia 28 (SD = 7.5) and 5minutes (SD = 0), respectively, Tennessee-43 (SD = 28) and 8minutes (SD = 7), respectively; and West Virginia-49 (SD = 30) and 12minutes (SD = 4), respectively. Many pediatric hospice patients reside in isolated counties with long driving times from the nearest hospices. State-level policies should be developed to reduce driving times from hospice providers.

When vision loss is beyond cataract: a case of fatal neurodegenerative disease (P1-9.010)

<h3>Objective:</h3> NA <h3>Background:</h3> Creutzfeldt Jakob disease (CJD) is a rare and fatal neurodegenerative disorder of unclear etiology. Presentation include myoclonic jerks, visual disturbances, pyramidal/extrapyramidal signs and rapidly progressive cognitive decline. Visual symptoms are a common manifestation of CJD. Here we present a case of progressive vision loss initially attributed to cataract with eventual diagnosis of CJD. <h3>Design/Methods:</h3> Patient is a 75-year-old woman with history of osteoporosis, dyslipidemia, and arthritis presented to the emergency (ED) with bilateral vision loss and cognitive decline. Symptoms started 8 weeks prior presentation with progressive vision loss and difficulty recognizing color and shapes. She also had intermittent horizontal diplopia. Patient was initially evaluated by an ophthalmologist where vision loss was attributed to cataract and underwent bilateral cataract extraction with no improvement in vision. Vision loss worsened and she became unable to recognize familiar faces or identify objects, and had recurrent falls. She suffered visual hallucination, progressive abnormal body posturing, memory loss, dysphagia and severe dysarthria. On her exam she was noted to be mute, unable to follow commands, and had stimulus induced myoclonic jerks of limbs. CXR, urine analysis, urine and blood cultures, and urine drug screen were all unrevealing. Serum and CSF paraneoplastic panel were negative. EEG showed absence of the posterior dominant rhythm. Brain MRI demonstrated cortical ribbon sign and hyperintensities of basal ganglia (image 1). CSF Rt-Quic was indeterminate. Given the history, exam and MRI findings, she was diagnosed with Heidenhain variant of CJD and passed away shortly after transfer to inpatient hospice. <h3>Results:</h3> NA <h3>Conclusions:</h3> CJD can present with isolated visual symptoms that precede cognitive decline by weeks. Detailed history and careful exam are essential for early diagnosis as this will allow patients and their families to prepare for the expected disease course, consider goals of care, and possibly have palliative care if desired. <b>Disclosure:</b> Dr. Abusamra has nothing to disclose. Dr. Ali has nothing to disclose. Dr. Sudhakar has nothing to disclose.

Hospice Capacity to Provide General Inpatient Care: Emergency Department Utilization and Live Discharge Among Cancer Patients

General inpatient (GIP) hospice care is used only minimally for hospice patients, and more than a quarter of Medicare hospice facilities do not provide GIP care. To determine the impact of hospices' capacity to provide on emergency department use during hospice enrollment and live discharge from hospice, we used Surveillance, Epidemiology, and End Results-Medicare linked data and CMS Provider of Services data from 2007 to 2013 from ten states and two metropolitan regions. Grouping hospices into three GIP care provision categories: 1) no-GIP; 2) GIP-contract; and 3) GIP-IHF where hospices directly provide GIP care in their own inpatient hospice facility (IHF), we built a multilevel logistic model that accounted for unobserved hospice characteristics. Nearly 9% of the study sample received GIP care, of which 82% received such care in the last week of discharge. GIP-IHF hospices had lower live discharge rates than no-GIP hospices (AOR: .61; 95% CI: .47-.79; P < .001) and GIP-contract hospices (AOR: .84; 95% CI: .70-1.00; P < .05). Similarly, GIP-contract hospices were also associated with a decreased risk of live discharge, compared to no-GIP hospices (AOR: .76; CI: .62-.92; P < .05). There was no difference in emergency department use between no-GIP hospices and hospices with such capacity. Our results suggest that hospices capable of providing GIP care have lower live discharge rates than their counterparts. However, the fact that GIP care tends to be provided too close to death limits its effectiveness in preventing avoidable emergency department use.

Core Roles and Responsibilities of Physicians in Hospice Care: A Statement by and for U.S. Hospice and Palliative Care Physicians.

Physicians are integral members of hospice interdisciplinary teams (IDTs). This statement delineates the core roles and responsibilities of hospice medical directors (HMDs) and hospice physicians who are designated by the hospice program to fulfill core HMD responsibilities. In addition, we describe the basic elements of hospice programs' structure and function required for hospice physicians to fulfill their roles and responsibilities. Finally, we call attention to hospice program characteristics and circumstances of the work environment that should raise a hospice physician's concerns that hospice patients and families are at risk of receiving low-quality care. Such factors include lack of a functioning IDT, minimal physician involvement in direct patient care and clinical IDT meetings, inadequate responses to symptom emergencies in patients' homes, and no or limited access to general inpatient and continuous home hospice care. We write as individual physicians who are concerned about troubling variability in access to and quality of U.S. hospice care. This statement arises from the need to protect the safety and well-being of vulnerable seriously ill people with their families from low-quality hospice care. This statement is primarily intended to be a resource to hospice physicians in negotiating employment agreements and justifying staffing and programmatic resources necessary to perform their jobs well. This statement may also serve as a resource and reference for patient advocacy groups, hospice industry leaders, health services oversight organizations, accountability agencies, and legislatures in efforts to ensure the safety, quality, and reliability of hospice care in the United States.

Private Equity and Your Doctor: Profits Before Patients

Older Americans have unique health needs that require specialized care and support. As people age, they are more likely to develop multiple chronic conditions such as cancer, diabetes, heart disease, and arthritis, which can greatly affect their quality of life (Boyd et al., 2019). Additionally, older adults may also experience physical and cognitive declines, which can make it difficult for them to manage their own healthcare. Access to healthcare and supportive services is crucial for older Americans to maintain their health and independence. Services such as home healthcare, nursing homes, and hospice care play a vital role in helping older adults lead fulfilling lives and maintain their quality of life for as long as possible. The majority of hospice patients are diagnosed with one or more chronic conditions, with cancer being the most common (29.6%), followed by circulatory or heart disease (17.4%) and dementia (15.6%) (Hospice Facts & Figures, 2020). Meanwhile, as the American population of persons aged 65 years and over will soon outnumber those under 18 year of age, there are concerns about the quality of care for older Americans as the healthcare industry shifts towards private equity (PE) ownership (Braun, Stevenson, et al., 2021).

The Effect of Private Equity on Hospice

Hospice is a unique service in the American health care system and an anomaly in the Medicare program. It started in the United States in the 1970s as a social movement to provide a more supportive and dignified end-of-life experience in a distinct hospice facility as an alternative to intensive curative treatment in a hospital intensive care unit. Congress added a hospice benefit to Medicare in 1983 with the requirement that patients electing hospice have a terminal illness with an expected prognosis of 6 months or less if the disease follows its normal course and agree to forego curative treatment. Initially, most hospice patients had advanced cancer with relatively short hospice stays. Medicare payment was a set daily (per diem) amount for each patient adjusted to four levels of care with an initial limit of 210 days. This limit was later changed to allow 60 days recertification as long as the hospice patient continued to have an expected prognosis of 6 months or less (Centers for Medicare and Medicaid [CMS], 2005). This change and expansion of hospice in nursing facilities made hospice care profitable when a provider chose to focus on patients with an expected long length of stay.

Expert Perspectives on the Additional Benefit of Day Hospices and Palliative Day Care Clinics in Germany: A Qualitative Approach.

Background: In Germany, hospice and palliative care is well covered through inpatient, outpatient, and home-based care services. It is unknown if, and to what extent, there is a need for additional day care services to meet the specific needs of patients and caregivers. Methods: Two day hospices and two palliative day care clinics were selected. In the first step, two managers from each facility (n = 8) were interviewed by telephone, using a semi-structured interview guide. In the second step, four focus groups were conducted, each with three to seven representatives of hospice and palliative care from the facilities' hospice and palliative care networks. Interviews and focus groups were audio recorded, transcribed verbatim and analyzed using qualitative content analysis. Results: The interviewed experts perceived day care services as providing additional patient and caregiver benefits. Specifically, the services were perceived to meet patient needs for social interaction and bundled treatments, especially for patients who did not fit into inpatient settings (due to, e.g., their young age or a lack of desire for inpatient admission). The services were also perceived to meet caregiver needs for support, providing short-term relief for the home care situation. Conclusions: The results suggest that inpatient, outpatient, and home-based hospice and palliative care services do not meet the palliative care needs of all patients. Although the population that is most likely to benefit from day care services is assumed to be relatively small, such services may meet the needs of certain patient groups more effectively than other forms of care.

Optimal timing and outcomes among COVID-19 patients undergoing tracheostomy.

Patients who require mechanical ventilation secondary to severe COVID-19 infection have poor survival. It is unknown if the benefit of tracheostomy extends to COVID-19 patients. If so, what is the optimal timing? Retrospective cohort study within a large hospital system in the United States. The population included patients with COVID-19 from January 1, 2020 to September 30, 2020. In total, 93,918 cases were identified. They were excluded if no intubation or tracheostomy, underwent tracheostomy before intubation, <18 years old, hospice patients before admission, and bacterial pneumonia. In total, 5,911 patients met the criteria. Outcomes between patients who underwent endotracheal intubation only versus tracheostomy were compared. The primary outcome was inpatient mortality. All patients who underwent tracheostomy versus intubation only were compared. Three cohort analysis compared early (<10 days) versus late (>10 days) tracheostomy versus control. Eight cohort analysis compared days 0-2, days 3-6, days 7-10, days 11-14, days 15-18, days 19-22, and days 23+ to tracheostomy versus control. There was an overall inpatient mortality rate of 37.5% in the tracheostomy cohort compared to 54.4% in the control group (P < .0001). There was an early tracheostomy group inpatient mortality rate of 44.7% (adjusted odds ratio 0.73, 95% confidence interval 0.52-1.01) compared to 33.1% (adjusted odds ratio 0.44, 95% confidence interval 0.34-0.58) in the late tracheostomy group. COVID-19 patients with tracheostomy had a significantly lower mortality rate compared to intubated only. Optimal timing for tracheostomy placement for COVID-19 patients is 11 days or later. Future studies should focus on early tracheostomy patients.

The Functioning of Hospice in the Perception of Family Members of Cancer Surgery and Hospice Patients

Palliative care in Poland is for all dying people and their families to have timely access to quality care services. The study aimed to assess the perception of the role of hospice care by families of patients treated in oncological surgery departments and hospices. The study included 211 family members of cancer patients, comprising 108 family members of cancer surgery patients (Group I) and 103 hospice patients (Group II). The study used a diagnostic survey method with a proprietary questionnaire. 74.9% of people in Group I and 84.6% in Group II experienced positive associations with hospice care. 86% of respondents from Group I believed that hospice is a place where patients can die with dignity, while 68.3% of those from Group II believed it is where patients receive professional care. 56.7% from Group I and 65.4% from Group II did not feel anxious about hospice care. According to 68.6% of people in Group I, informing the patient that he or she is in hospice as well as about his or her disease should depend on the patient's condition. In the opinion of 75% of Group II, the patient should always be informed. In Group I (68.3%) and Group II (91.5%), the dominant opinion was that the family should take part in the care and treatment of the patient. 78.4% of respondents in Group I and 96.4% in Group II recommend hospice to other families. Most families of cancer patients from both the oncological surgery departments (Group I) and hospice (Group II) had positive first associations with hospice care. However, families from Group II had more critical remarks on hospice functioning.

Hospice agency characteristics associated with benzodiazepine and antipsychotic prescribing.

Benzodiazepine and antipsychotic medications are routinely prescribed for symptom management in hospice patients, but have significant risks for older adults. We explored the extent to which patient and hospice agency characteristics are associated with variations in their prescribing. Cross-sectional analysis of hospice-enrolled Medicare beneficiaries aged ≥65 years in 2017 (N = 1,393,622 in 4219 hospice agencies). The main outcome was the hospice agency-level rate of enrollees with benzodiazepine and antipsychotic prescription fills divided into quintiles. Rate ratios were used to compare the agencies with the highest and lowest prescription across patient and agency characteristics. In 2017, hospice agency prescribing rates varied widely: for benzodiazepines, from a median of 11.9% (IQR 5.9,22.2) in the lowest-prescribing quintile to 80.0% (IQR 76.9,84.2) in the highest-prescribing quintile; for antipsychotics, it ranged from 5.5% (IQR 2.9,7.7) in the lowest to 63.9% (IQR 56.1,72.0) in the highest. Among the highest benzodiazepine- and antipsychotic- prescribing hospice agencies, there was a smaller proportion of patients from minoritized populations (benzodiazepine: non-Hispanic Black rate ratio [RR] [Q5/Q1] 0.7, 95% CI 0.6-0.7, Hispanic RR 0.4, 95% CI 0.3-0.5; antipsychotic: non-Hispanic Black RR 0.7, 95% CI 0.6-0.8, Hispanic RR 0.4, 95% CI 0.3-0.5). A greater proportion of rural beneficiaries were in the highest benzodiazepine-prescribing quintile (RR 1.3, 95% CI 1.2-1.4), whereas this relationship was not present for antipsychotics. Larger hospice agencies were over-represented in the highest prescribing quintile for both benzodiazepines (RR 2.6, 95% CI 2.5-2.7) and antipsychotics (RR 2.7, 95% CI 2.6-2.8), as were for-profit agencies (benzodiazepine: RR 2.4, 95% CI 2.3-2.4; antipsychotic: RR 2.3, 95% CI 2.2-2.4). Prescribing rates varied widely across Census regions. Prescribing in hospice settings varies markedly across factors other than the clinical characteristics of enrolled patients.

Hospice Patients’ End-of-Life Dreams and Visions: A Systematic Review of Qualitative Studies

When conscious, about 50% to 60% of hospice patients report a "visitation" by someone who is not there while they dream or are awake: a phenomenon known as End-of-Life Dreams and Visions (ELDVs). Since the dying process is frequently complicated by delirium, ELDVs risk being misidentified as such by professionals and caregivers. To observe these phenomena from patients' perspectives, we conducted a systematic review to aggregate and synthesize the findings from the qualitative studies about ELDVs of patients assisted in hospices to indicate future directions for research and care. MEDLINE/PubMed, Embase, CINAHL, PsycINFO, Scopus, and Web of Science databases were searched, yielding 293 documents after duplicates were removed. Six qualitative articles reporting on five unique studies conducted in hospice settings were included in the meta-synthesis. We generated three main categories: i) typologies of ELDVs reported, ii) emotional consequences, and iii) intersubjective meaning-making. The ELDVs reported were experiences that remained intimate and unsocialized and thus preventing participants from defining a shared sense in their relationships. Training healthcare professionals to recognize ELDVs and take advantage of them in the care relationship is desirable. We also encourage the patient's family members to listen and understand ELDVs when they occur actively. For caregivers to know how to interpret these phenomena may provide them with additional strategies for supporting, reassuring, and strengthening their relationships with their loved ones. The review allowed us to inform healthcare professionals and caregivers about how to help patients share their emotional and identity-related experiences and meaning-making in end-of-life.