Hospice Physicians Research Articles

Integrating an Interventional Pain Management Curriculum in Hospice and Palliative Medicine Fellowship Training: A Feasibility Study.

Pain is a common symptom for patients with cancer. Hospice and Palliative Medicine (HPM) physicians are expected to be experts in both pharmacologic and non-pharmacologic treatment of pain for this patient population. Insufficient knowledge of non-pharmacologic, interventional approaches to pain management is a barrier to providing optimal care. This study assesses the feasibility and effectiveness of an interventional pain management curriculum on HPM fellow knowledge at a single institution. The primary objective was to implement an interventional pain management curriculum for HPM fellows' and secondly to measure its effects on their knowledge and confidence in interventional pain management approaches. We executed an interventional pain management curriculum for HPM fellows. The curriculum consisted of 6 fifty-minute virtual lectures. Anonymous pre- and post-curriculum surveys were used to assess curricular impact. Post-course surveys showed a significant increase in HPM fellows' knowledge and confidence in interventional pain management techniques. An interventional pain management curriculum for HPM fellows is a feasible and promising intervention to significantly impact fellows' knowledge and confidence in non-pharmacologic treatment of cancer pain.

Outpatient Training During Hospice and Palliative Medicine Fellowship: A National Survey

ContextOutpatient palliative care (PC) has strong evidence demonstrating impact across serious illnesses, resulting in growing demand for skilled outpatient PC clinicians. However, there is limited literature examining the existing state and quality of outpatient PC education during postgraduate training. ObjectivesCharacterize the current state of outpatient training in United States (US) Hospice and Palliative Medicine (HPM) physician fellowships and elicit perceptions regarding quality of outpatient PC education. MethodsA cross-sectional survey of US adult HPM fellowship program directors (PDs) or their designee conducted between March and July, 2023. ResultsOf 161 programs, 85 participated (53% response rate) with representation across all US regions. HPM fellows spend a median of 4.8 weeks in outpatient PC compared to 24 weeks inpatient PC and 10.5 weeks in hospice settings. Over half (51%) of fellows saw outpatients from primarily one disease type with limited exposure to patients with other serious illnesses. Across programs, fellows’ clinic structure, interdisciplinary team composition, and didactic experiences varied. On a 5-point rating scale, PDs reported significantly lower quality outpatient versus inpatient training (mean rating: 3.58 vs. 4.62, P<0.001) and perceived fellows as less prepared for independent outpatient practice upon graduation (mean: 4.06 vs. 4.73, P<0.001). ConclusionOur survey of US HPM fellowships identified multiple gaps between outpatient and inpatient PC education and training during fellowship and raises concern about the adequacy of outpatient PC training. To prepare the HPM workforce to meet the diverse needs of seriously ill populations and ensure adequate access, outpatient PC training requires reform.

US Medicare Hospice and Palliative Medicine Physician Workforce and Service Delivery in 2008-2020

ContextDespite clinical benefits of early palliative care, little is known about Medicare physician workforce specialized in Hospice and Palliative Medicine (HPM) and their service delivery settings. ObjectivesTo examine changes in Medicare HPM physician workforce and their service delivery settings in 2008–2020. MethodsUsing the Medicare Data on Provider Practice and Specialty from 2008 to 2020, we identified 2375 unique Medicare Fee-For-Service (FFS) physicians (15,565 physician-year observations) with self-reported specialty in “Palliative Care and Hospice”. We examined changes in the annual number of HPM physicians, average number of Medicare services overall and by care setting, total number of Medicare FFS beneficiaries, and total Medicare allowed charges billed by the physician. ResultsThe number of Medicare HPM physicians increased 2.32 times from 771 in 2008 to 1790 in 2020. The percent of HPM physicians practicing in metropolitan areas increased from 90% to 96% in 2008–2020. Faster growth was also observed in female physicians (52.4% to 60.1%). Between 2008 and 2020, we observed decreased average annual Medicare FFS beneficiaries (170 to 123), number of FFS services (467 to 335), and Medicare allowed charges billed by the physician ($47,230 to $37,323). The share of palliative care delivered in inpatient settings increased from 47% to 68% in 2008–2020; whereas the share of services delivered in outpatient settings decreased from 37% to 19%. ConclusionDespite growth in Medicare HPM physician workforce, access is disproportionately concentrated in metropolitan and inpatient settings. This may limit receipt of early outpatient specialized palliative care, especially in nonmetropolitan areas.

A Report on the Innovative University of Colorado Community Hospice and Palliative Medicine Fellowship.

Background: Predictive health services modeling signals a shortage of board-certified Hospice and Palliative Medicine (HPM) physicians. Methods: This article introduces the Community Hospice and Palliative Medicine (CHPM) Fellowship, an Accreditation Council for Graduate Medical Education (ACGME) Advancing Innovation in Residency Education (AIRE) project designed to enable mid-career physicians (at least five years out from residency or fellowship) to achieve eligibility for board certification in HPM. Results: From 2020 to 2023, 24 fellows have completed or are currently participating in the CHPM fellowship which is evaluated using the Kirkpatrick model. Conclusion: This program shows promise in addressing the impending HPM workforce shortage by allowing physicians to complete a fellowship in their local communities.

Factors Associated With Benzodiazepine and Antipsychotic Prescribing in Hospice: A Qualitative Study of Hospice Prescribers.

Benzodiazepine and antipsychotic medications are common components of the hospice toolkit and are routinely prescribed for behavioral symptom management at end of life. These medications have significant associated risks but, despite their frequent use, little is known about how clinicians weigh prescribing decisions for individuals in hospice. In this qualitative study, we examined the key factors that influence the decision to initiate a benzodiazepine and antipsychotic medication for management of behavioral symptoms at end of life. A qualitative study using semi-structured interviews and descriptive qualitative analysis. We conducted semi-structured interviews with prescribing hospice physicians and nurse practitioners working in hospice settings across the United States. Hospice clinicians were asked to describe factors that influence prescribing decisions to initiate benzodiazepine and antipsychotic medications for the management of behavioral symptoms. Data from audio-recorded sessions were transcribed, coded to identify relevant concepts, and reduced to determine major themes. We completed 23 interviews with hospice physicians and nurse practitioners. On average, participants had worked in a hospice setting for a mean of 14.3years (SD: 10.9); 39% had geriatrics training. Major themes related to benzodiazepine and antipsychotic prescribing were (1) caregiving factors strongly influence the use of medications, (2) patient and caregiver stigma and concerns regarding medication use limit prescribing, (3) medications are initiated to avoid hospitalization or transition to a higher level of care, and (4) nursing home hospice care brings unique challenges. Caregiver factors and the setting of hospice care strongly influence clinician decisions to initiate benzodiazepines and antipsychotics in hospice. Caregiver education about medication use at end of life and support in managing challenging behaviors may help promote optimal prescribing.

A Gift Twice-Given is Truly Received.

Transplant Nephrologist turned Palliative Care – Hospice physician recounts personal experience in palliative care of patients with end-stage liver disease validating his conviction that Palliative Care is not just for dying patients.

Knowledge Gaps in End-Of-Life Family Caregiving for Persons Living With Dementia: A Study of Hospice Clinician Perspectives.

More than 35% of hospice care recipients 65 and older have a dementia diagnosis. Yet family care partners of persons living with dementia report feeling unprepared to address their hospice recipient's changing needs nearing end of life. Hospice clinicians may have unique insight into the knowledge needs of family care partners and strategies for end-of-life dementia caregiving. Semi-structured interviews were conducted with 18 hospice physicians, nurse practitioners, nurses, and social workers. Interview transcripts were deductively analyzed using thematic analysis to examine clinicians' perspectives on gaps and strategies related to family care partner knowledge about end-of-life dementia caregiving. We identified 3 themes related to gaps in family care partners' knowledge: dementia is a progressive, fatal disease; end-of-life symptoms and symptom management in persons living with advanced dementia; and understanding hospice goals and guidelines. Three themes related to clinicians' strategies to increase knowledge included: providing education; teaching strategies to facilitate coping and preparedness for end-of-life care; and communicating with empathy. Clinicians perceive gaps in knowledge specific to dementia and end of life among family care partners. These gaps include a lack of understanding of Alzheimer's symptom progression and strategies to manage common symptoms. Recommendations for approaches to reduce knowledge gaps include providing education and strategies delivered with empathy toward the family care partner experience. Clinicians who work with persons living with dementia receiving hospice care have valuable insights regarding family care partners' gaps in knowledge. Implications on the training and preparation of hospice clinicians working with this care partner population are discussed.

Hospice Court—Star Witness: Hospice Physicians Adeptly Addressing Audits (P03)

Hospice Court—Star Witness: Hospice Physicians Adeptly Addressing Audits (P03)

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.

Palliative radiation therapy pathway for patients on hospice in a statewide quality improvement collaborative.

201 Background: Patients on hospice receive care directed at alleviating symptoms with the goal of reducing burdensome and unnecessary healthcare. Single-fraction radiation therapy is an effective palliative treatment for cancer‐related bleeding. Hospice physicians and radiation oncologists are driven by the same goals of relieving symptoms and decreasing the burden of treatment. In general, hospices are not able to support the costs of providing palliative radiation in eligible patients. The inability to receive radiation therapy may pose a barrier to hospice enrollment. Methods: The Michigan Oncology Quality Consortium (MOQC), a collaborative of nearly 90% of oncologists in Michigan, partnered with radiation oncologists, hospice directors, and patients and caregivers to create a pathway for the referral and treatment of patients with cancer-related bleeding. Through regular meetings, the collaboration created a pathway for patients on hospice or eligible for hospice who were candidates for palliative radiation therapy for bleeding. In patients with cancer-related bleeding, the hospice clinician collaborates with a participating radiation oncologist to confirm eligibility. This decreases the hospice costs of treatment, increases access to palliative radiation, and alleviates the financial and emotional burdens on the patient and family. Results: In Michigan radiation oncology practices and hospices with statewide representation approved the pathway. Radiation oncologists in 19 practices across the state agreed to high value radiation treatment (focused level 3 consultation, complex isodose planning, single fraction treatment). Eligible patients may be seen via virtual consultation and then treated within 1 to 2 days with a single fraction of 8 Gy. A second fraction can be given in patients who continue to have bleeding. MOQC established direct connection to members of the collaborative whose contact information is available on MOQC website. In addition to this treatment pathway, the previously adopted palliative radiation pathway for oncology patients with bone metastases may be found on MOQC website. Conclusions: The radiation therapy pathway for patients with bleeding ensures a unified approach to providing a patient-focused care in patients with limited life expectancy. Challenges to the implementation of the pathway include dissemination of the document across over 100 Michigan hospices and the upfront effort required to screen patients.[Table: see text]

Availability of and factors related to interventional procedures for refractory pain in patients with cancer: a nationwide survey

BackgroundCancer pain may be refractory to standard pharmacological treatment. Interventional procedures are important for quality of analgesia. The aim of the present study was to clarify the availability of four interventional procedures (celiac plexus neurolysis/splanchnic nerve neurolysis, phenol saddle block, epidural analgesia, and intrathecal analgesia), the number of procedures performed by specialists, and their associated factors. In addition, we aimed to establish how familiar home hospice physicians and oncologists are with the different interventional procedures available to manage cancer pain.MethodsA cross-sectional survey using a self-administered questionnaire was conducted. Subjects were certified pain specialists, interventional radiologists, home hospice physicians, and clinical oncologists.ResultsThe numbers of valid responses/mails were 545/1,112 for pain specialists, 554/1,087 for interventional radiology specialists, 144/308 for home hospice physicians, and 412/800 for oncologists. Among pain specialists, depending on intervention, 40.9-75.2% indicated that they perform each procedure by themselves, and 47.5-79.8% had not performed any of the procedures in the past 3 years. Pain specialists had performed the four procedures 4,591 times in the past 3 years. Among interventional radiology specialists, 18.1% indicated that they conduct celiac plexus neurolysis/splanchnic nerve neurolysis by themselves. Interventional radiology specialists had performed celiac plexus neurolysis/splanchnic nerve neurolysis 202 times in the past 3 years. Multivariate analysis revealed that the number of patients seen for cancer pain and the perceived difficulty in gaining experience correlated with the implementation of procedures among pain specialists. Among home hospice physicians and oncologists, depending on intervention, 3.5-27.1% responded that they were unfamiliar with each procedure.ConclusionsAlthough pain specialists responded that the implementation of each intervention was possible, the actual number of the interventions used was limited. As interventional procedures are well known, it is important to take measures to ensure that pain specialists and interventional radiology physicians are sufficiently utilized to manage refractory cancer pain.

Development of Entrustable Professional Activities for Specialist Hospice and Palliative Care Pharmacists.

Entrustable professional activities (EPAs) translate competencies into explicit, practical terms that clearly state the expected roles and responsibilities of clinicians who have achieved proficiency and expertise in a field. EPAs are defined for Hospice and Palliative Medicine physicians but not for other members of Hospice and Palliative Care (HAPC) interprofessional teams, including pharmacists. The objective of this study was to develop EPAs for HAPC pharmacists. An 11-member workgroup of HAPC pharmacists was convened to develop candidate EPAs using nominal group and modified-Delphi methods. Content validity index was used as a measure of consensus, defined a priori at ≥ 60%. Vetting occurred via intra- and interprofessional stakeholder reactor groups and a national survey of HAPC pharmacists. Following an iterative process of workgroup and stakeholder consensus-building, 15 HAPC pharmacist EPAs were developed. Among the workgroup, all 15 EPAs reached ≥ 70% consensus, indicating appropriate internal validity. In a national survey of 185 HAPC pharmacists with a 20% response rate, 13 EPAs were rated by most respondents as "essential" and 2 were rated by most respondents as "important but not essential." Respondents indicated the 15 EPA set represented the core professional activities of HAPC pharmacists well (median rating of 5 on a Likert-like scale, IQR 1). Fifteen consensus EPAs describe essential activities of HAPC pharmacists in direct patient care, leadership, education, and scholarship. These EPAs will further guide pharmacist training programs, HAPC services seeking to incorporate a specialized pharmacist on the team, and currently practicing HAPC pharmacists.

Hospice and Palliative Medicine Fellowship after Surgical Training: A Roadmap to the Future of Surgical Palliative Care

Surgeons comprise only 2% of Hospice and Palliative Medicine (HPM) board-certified physicians. Little is known about the motivations of individuals who pursue this combined training or the perceived benefits of this pathway. This study aimed to capture the pathways and experiences of HPM fellowship trained surgeons and to establish recommendations for surgical trainees who may benefit from HPM fellowship training. A qualitative study was designed using semi-structured zoom interviews that elicited experiences of HPM trained surgeons. Data was analyzed using descriptive statistics and thematic analysis. Researchers were from the University of Kansas School of Medicine and the University of Alabama at Birmingham. Participants were trained and worked across the United States in a variety of settings. Eligibility included completion of a 1-year HPM fellowship and training in general surgery, general obstetrics and gynecology, or affiliated subspecialties. Seventeen interviews were conducted. All participants expressed satisfaction with their HPM fellowship training. Four themes emerged as recommendations for surgeons to pursue HPM fellowship training: 1) a commitment to joining the HPM workforce, 2) becoming ambassadors for HPM and surgical culture change, 3) desire for advanced communication and symptom management skills at the specialist level, and 4) specialist level HPM skills may enhance surgical career. HPM fellowship training is achievable through multiple pathways for surgeons from a variety of training backgrounds.

A parade of firsts: J. Randall Curtis, MD, MPH modeled a future for palliative care academics

Palliative care history is short, and the history of its research is even shorter. In 1997, when I first met Randy Curtis at a Project on Death in America Faculty Scholars meeting, the field of palliative care as we now know it did not exist. The American Academy of Hospice and Palliative Medicine (AAHPM), a tiny organization, had just emerged from the even tinier Academy of Hospice Physicians. American Board of Medical Specialties board certification would not appear for nearly another decade. And, whereas our clinical and educational infrastructure felt threadbare, the palliative care research landscape was completely unstitched.

Recommendations for antimicrobial stewardship during end-of-life patient care

Background: Antimicrobials are frequently used during end-of-life care and may be prescribed without a clear clinical indication. Overuse of antimicrobials is a major public health concern because of the development of multidrug resistant organisms (MDROs). Antimicrobial stewardship programs are associated with reductions in antibiotic resistance and antibiotic-associated adverse events. We sought to identify and describe opportunities to successfully incorporate stewardship strategies into end-of-life care. Methods: We completed semistructured interviews with 15 healthcare providers at 2 VA medical centers, 1 inpatient setting and 1 long-term care setting. Interviews were conducted via telephone between November 2020 and June 2021 and covered topics related to antibiotic prescribing for hospice and palliative-care patients, including how to improve antimicrobial stewardship during the end-of-life period. We targeted healthcare providers who are involved in prescribing antibiotics during the end-of-life period, including hospitalists, infectious disease physicians, palliative care and hospice physicians, and pharmacists. All interviews were recorded, transcribed, and analyzed using consensus-based inductive and deductive coding. Results: End-of-life care, particularly hospice care, was described as an underutilized resource for patients, who are often enrolled in their final days of life rather than earlier in the dying process. Even at facilities with established antimicrobial stewardship programs, healthcare providers interviewed believed that opportunities for antimicrobial stewardship in the hospice and palliative care settings were missed. Recommendations for how stewardship should be incorporated in end-of-life care included receiving feedback on antimicrobial prescribing, increasing pharmacist involvement in prescribing decisions, and targeted education for providers on end-of-life care, including the value of shared decision making with patients around antibiotic use. Conclusions: Improved antibiotic prescribing during end-of-life care is critical in the effort to combat antimicrobial resistance. Healthcare providers discussed antimicrobial stewardship activities during end-of-life patient care as a potential avenue to improve appropriate antibiotic prescribing. Future research should evaluate the feasibility and effectiveness of incorporating these strategies into end-of-life patient care.Funding: NoneDisclosures: None

Homeward.

Homeward.

Differences between dedicated and not dedicated hospice physicians in symptoms and signs improvement among advanced cancer patients.

The hospice and palliative care can improve the symptoms and signs of terminal cancer patients. The purposes of this study are how to improve terminally ill cancer patients’ symptoms and signs and how the dedicated palliative care service effects on these improvements.From January 2017 to March 2019, among 919 terminally ill cancer patients admitted to the palliative care units in 11 hospitals of South Korea, we analyzed 334 patients with prospective cohort method and categorized them into non-dedicated hospice care group of 234 and dedicated hospice care group of 100.Symptoms improvement of dyspnea, fatigue, drowsiness, and dry mouth during the first week of admission were respectively 298 (89.2%), 25 (7.5%), 204 (61.1%), 76 (22.8%). Signs improvement of myoclonus, respiratory secretion, leg edema, and ascites between admission and a week after were 5 (1.5%), 41 (12.3%), 47 (14.1%), 12 (3.6%). Significant differences between dedicated hospice care physician group and non-dedicated hospice care physician group were shown in drowsiness (67.5% vs 46%, P < .001) and respiratory secretion (15% vs 6%, P < .028). Compared to non-dedicated care group, the odds ratio for more than 2 symptoms or signs was 1.78 (95% confidence interval, 1.05–3.02) in the dedicated care group after adjusting confounding variables.In conclusion, terminally ill cancer patients who received palliative or hospice service showed significant improvement in symptoms and signs. And, family doctors (dedicated hospice physician group) performed better than oncologists (non-dedicated physician group).

Primary Addiction Medicine Skills for Hospice and Palliative Medicine Physicians: A Modified Delphi Study

ContextHospice and palliative medicine (HPM) physicians frequently care for patients with substance use disorders (SUDs), but there is no consensus on which primary addiction medicine (AM) skills are essential. ObjectivesIdentify key primary AM skills that physicians should acquire during an ACGME-accredited HPM fellowship program. MethodsA modified Delphi study consisting of 18 experts on SUD in HPM and medical education. A literature review and expert input identified initial AM skills. In three Delphi rounds, participants rated each skill on a nine-point scale from “not at all important to include” to “crucial to include.” We calculated medians (IQRs), analyzed panelists’ comments, and grouped skills using the RAND / UCLA appropriateness method. ResultsAmong 62 proposed AM skills, 53 skills were rated as appropriate to include (38 of which achieved agreement), and nine skills were rated as uncertain. AM skills most relevant to HPM included 1) defining chemical coping, median 8.5 (IQR 2); 2) balancing life expectancy with risks of opioid use for patients with SUD, 9 (IQR 0); 3) explaining best practices to dispose unused opioids postmortem, 8 (IQR 2); 4) managing pain for hospice patients with SUD, 9 (IQR 0.75); and 5) partnering with hospice to manage patients on methadone and buprenorphine, 9 (IQR 2). Experts did not achieve consensus on whether HPM physicians should be encouraged to learn to prescribe buprenorphine for patients with opioid use disorder, 6 (IQR 3). ConclusionHPM fellowships should consider incorporating the primary AM skills identified in this study in their curricula.

Identifying Areas of Improvement for Care of Hospice-Enrolled Patients Presenting to the Emergency Department (QI720)

1.Describe the current framework for management of hospice-enrolled patients presenting to the Emergency Department.2.Identify how many patients enrolled in a large hospice organization present to the Emergency Department over a 2-month period and most common chief complaints.3.Describe a potential intervention to assist hospice-enrolled patients experiencing perceived emergencies at home or in congregate settings. While there are some emergencies that require hospice-enrolled patients to present to the Emergency Department (ED) (such as lacerations or equipment malfunction), some hospice-related and predictable emergencies may be equally or superiorly treated at home or inpatient hospice (such as shortness of breath or pain). Although Emergency Medicine and Hospice and Palliative Medicine physicians have opinions on why hospice-enrolled physicians present to the Emergency Department, there is little research on the most common reasons leading hospice-enrolled patients presentation to the ED. To identify the most common reasons hospice-enrolled patients in a large hospice organization present to the Emergency Department and design chief complaint-focused interventions to avoid undesired and unnecessary ED visits. Using triage notes and input from hospice nurses and physicians, I identified hospice-enrolled patients who presented to the ED over between January 1, 2020 and February 28, 2020. Over a 2-month period, 44 hospice-enrolled patients presented to the ED. The most common hospice diagnoses were cancer, cardiovascular disease, COPD, Alzheimer’s disease and cirrhosis. 26 patients came from home and 18 came from a nursing facility. 18 out of the 44 patients presented after a fall. The other presentations were for respiratory issues (7), gastrointestinal issues (6), equipment malfunction (4), agitation or altered mental status (4), pain (3), and rash (2). ED presentation was relatively common over a 2-month period among our hospice-enrolled patients. Falls were by far the most common reasons for presentation. This was not a commonly identified emergency in the literature related to hospice-enrolled patients presenting to the ED. In response to this, I created an Emergency Plan sheet related to falls. In the future, this will be given to patients upon enrollment.

COVID-19 Pandemic Impacts on U.S. Hospice Agencies: A National Survey of Hospice Nurses and Physicians.

Hospice agencies face unique challenges during times of widespread public health emergencies. The pandemic of novel coronavirus disease COVID-19 is widely affecting global healthcare systems. This study assesses effects of the COVID-19 pandemic on U.S. hospice agencies, staff, and patients as reported by hospice agency staff. An anonymous electronic survey was developed. Free-text comments were assessed for impacts on hospice agencies, staff, and patients and their families. The target audience was members of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association who self-identified as being active with hospice agencies in the United States. Reported impacts include inadequate supplies of personal protective equipment, changes in hospice services, and decreased access by hospice personnel to patients in long term care facilities. Flow of patients through hospice care settings was impeded. Agencies experienced changes in workforce availability and increased emotional support needs of staff. Patient and families experienced increased bereavement needs. Nearly one-third of respondents reported negative effects on patient outcomes, such as inadequate symptom management and negative psychosocial effects. Respondents indicate that the COVID-19 pandemic had negative effects on both hospice patient care and hospice agency functioning. Hospice agencies appear to face challenges unique among U.S. healthcare agencies due to their service delivery model and focus on interdisciplinary care. There is need for further exploration of the effects that the COVID-19 pandemic has on hospice agencies in order to improve care for their patient population during public health emergencies.