Palliative Hospice Research Articles

THE EXAMINATION OF DETERMINANTS AND BARRIERS TO END-OF-LIFE DECISION MAKING AND PLANNING

As individuals are living longer, in many cases with chronic diseases, there is an increased focus on end-of-life (EOL) planning and decision making. This includes a broad spectrum of choices including advance care planning (ACP) and turning to palliative care or hospice care. Although there has been an increase in palliative and hospice care enrollment and ACP engagement over the past decade, participation remains low for certain subgroups of the population. The purpose of this symposium is to offer insight into reasons for these varying rates of engagement by exploring determinants and barriers to EOL decision making and planning and by examining caregiver knowledge of EOL decision making and planning from the service provider perspective. The first three studies examine various types of influences in EOL decision making and planning. Inoue and colleagues explore factors associated with the length of hospice stay, and Gaines and colleagues examine the impact of environmental characteristics in ACP. Ornstein and colleagues use Denmark registry data to assess the role of kinlessness at the time of death in EOL decision making and healthcare utilization. The final presentation by Noh and colleagues examines how service providers in rural areas perceive community residents’ knowledge of ACP and palliative care. The discussion following these presentations will compare findings across different forms of EOL decision making and planning, consider the impact of the varying methodological approaches used, and highlight implications of these works for potential interventions and policies related to EOL decision making and planning.

INNOVATIVE STRATEGIES TO SUPPORT OLDER ADULTS AND THEIR FAMILIES IN HOSPICE AND PALLIATIVE CARE

In order to better support older adults with life-limiting illness and their families, many initiatives utilize information technology and other innovative platforms to increase access to supportive services and bridge geographic distance. Such technologies cover a broad range of systems ranging from smart phone applications to wearables and traditional telehealth platforms. There is a growing evidence base for such interventions but technical, clinical and ethical challenges remain when utilizing technology in the context of hospice and palliative care especially for older adults, including the concerns for caregiver burden, privacy, security, confidentiality, obtrusiveness and accessibility. In this symposium we provide an overview of innovative tools available for interventions in palliative and hospice care designed for patients and/or family caregivers in urban and rural settings. We provide lessons learned from three NIH funded studies testing different technology-based interventions in various settings including home hospice and outpatient palliative care. Discussion will follow focused on the clinical, ethical and practical challenges of innovation and the unique considerations for technology-mediated intervention design in a variety of palliative and hospice care settings. This symposium aims to provide: 1. an overview of existing technology-based interventions for older adults and their families in palliative care and hospice 2. evidence-based recommendations resulting from clinical trials in urban and rural settings for the design and implementation of innovative tools in hospice and palliative care 3. a discussion of challenges and opportunities for the use of technology to support older adults and their families

1775 Tracheoesophageal Fistula Managed With Double Stenting of Bronchus and Esophagus

INTRODUCTION: Malignancy is responsible for 5-15% of acquired tracheoesophageal fistulas (TEF). Such patients have a short survival and management of these fistulas is a challenge. We present a case of TEF secondary to esophageal malignancy that was managed with double stenting of the bronchus and esophagus. CASE DESCRIPTION/METHODS: The patient is a 56 year old black female with no known past medical history who presented to our emergency department with complaints of chest pain, shortness of breath and a productive blood tinged cough. She had been recently discharged from another facility for a diagnosis of bronchitis, however symptoms had not abated. She reported a fifty-pound weight loss with poor oral intake. Her vital signs and labs on arrival were stable. Initial imaging in the ER was consistent with pneumonia of the right middle and lower lobes. She underwent a CT Neck, which showed esophageal wall thickening and a mass suspicious for an esophageal neoplasm. Due to concern of her recurrence of pneumonia and esophageal mass, she underwent an esophagram, which showed a stricture of the middle third of the esophagus with a fistula from the esophageal tumor to the right lower lobe bronchus. Due to concern of airway collapse with upper endoscopy, Pulmonology was consulted. The patient first underwent a bronchoscopy in which a Novatech Y-stent was deployed stabilizing the airway. The patient then underwent an endoscopy in which an esophageal stent was placed. Both procedures were successful and she tolerated oral intake well thereafter. She was discharged in stable condition to palliative hospice services. DISCUSSION: The case has relevance from both an interesting initial clinical presentation as well as management of this patient from both a technical and procedural aspect. This patient had continual infections from continuous overspill of esophageal contents into the respiratory tree. Although her prognosis to begin with was quite poor, these interventions allowed the patient some quality of life. This case also commands procedural respect. The patient’s left mainstem bronchus was extremely friable and actually ruptured during the initial course of balloon dilation. The stent in position did not completely cover the TEF however it did keep the central airway open. A long esophageal stent was placed by gastroenterology, which did completely cover the fistula. This patient’s case highlights potential difficulties in double stenting and anticipatory management by utilization of other services.

Outcomes of Patients Receiving Inotropes for Palliative Indication versus as a Bridge to Surgical Therapy

Introduction Use of long-term, continuous intravenous inotropic support (CIIS) has increased in prevalence over the past decade. Published evidence indicates that CIIS improves NYHA functional class but does not impact survival. Robust data regarding clinical outcomes of patients receiving inotropic support for palliative indication (i.e. not being considered for mechanical circulatory support (MCS) or orthotopic heart transplantation (OHT)) are lacking. Objective Describe the outcomes of patients receiving CIIS for palliative indication versus as a bridge to surgical therapy, including length of use, mortality, and referral to palliative care and/or hospice. Methods With institutional review board approval, we conducted a retrospective cohort study examining outcomes in patients discharged from an urban, tertiary-care, academic hospital on CIIS between 2010 and 2016. Patients were stratified by indication for initiation of inotropic support. Electronic health record review was conducted to abstract patient demographics, clinical characteristics, duration of inotrope use, reason for CIIS discontinuation, and composite end-point of hospice referral or death at the end of the study period. Results We identified 380 patients (24.7% female; 66% African American) who were discharged on CIIS during the study period. Average age of the study participants was 59.2 +/14.5 years. Thirty-two percent of patients had ischemic cardiomyopathy, 66% had nonischemic cardiomyopathy, 4% had mixed-etiology cardiomyopathy. All patients had stage D HFrEF, with mean ejection fraction of 19.4% +/- 4.5%. Of these, 129 patients (34%) were receiving CIIS for palliative indication, and the remaining 251 patients (66%) as a bridge to definitive surgical therapy (MCS or OHT). Of patients receiving CIIS for palliative indication, the mean length of use was 202 +/- 214 days, with a composite end-point of hospice referral or death occurring in n=122 (95%). The majority of patients receiving inotropes for palliative indication n=92 (71%) received a palliative care consult and were referred to hospice n=79 (61%). Of patients receiving CIIS as a bridge to surgical therapy, 151 (62.5%) received MCS/OHT and 51 (20.3%) died prior to receiving surgical therapy, with lower rates of referral to palliative care (n=24 or 47%) and hospice (n=13 or 25%). Conclusions In this large, racially diverse sample of patients, those receiving CIIS for palliative indication lived on average for about 6.5 months, though with a large variation between patients. Patients who are initiated on CIIS as bridge to surgical therapy have a high mortality while awaiting surgical therapy, but are less likely to receive palliative care and hospice services.

End-of-Life Care: Redesigning Access Through Leveraging the Institute of Medicine Future of Nursing Recommendations.

In 2010, the Institute of Medicine published the vision for how to transform healthcare to achieve a more seamless patient-centered, high-quality system of care. Among the recommendations were four specifically focused on leveraging nursing which is the largest group of healthcare workers: (1) Ensure that nurses can practice to the full extent of their education and training, (2) Improve nursing education, (3) Provide opportunities for nurses to assume leadership positions and to serve as full partners in healthcare redesign and improvement efforts, and (4) Improve data collection for workforce planning and policy making. At the Care New England Health Care System's Visiting Nurse Association, located in the state of Rhode Island, we redesigned access to end-of-life care by leveraging these recommendations. An experienced palliative care nurse practitioner (NP) leads the program development to improve care delivered by home healthcare nurses and NP specialists. This program was designed to allow patients to remain in their preferred setting of care-their home-until the end of their life. In the 5 years of this program's existence, it has achieved a yearly impact on community-based palliative care and hospice services. The number of documented advance directives increased by 75%, referrals to palliative care and hospice increased by 300% and the length of time on hospice doubled. In addition, NP home visits became an accepted referral source and improvements in both the quality and satisfaction scores for the home healthcare agency were realized.

Perceptions of palliative care and hospice services among gynecology oncology physicians

Perceptions of palliative care and hospice services among gynecology oncology physicians

Initial Assessment and Care Planning in Palliative Hospice Care: Focus on Assessment Tools

Initial Assessment and Care Planning in Palliative Hospice Care: Focus on Assessment Tools

A community oncology palliative program: Early results for cost and quality measures within OCM program claims data.

11585 Background: Oncology Care Model (OCM) is an initiative of the Centers for Medicare and Medicaid Innovation which aims to provide higher quality and more coordinated oncology care while lowering the cost. Oncology Division of Michigan Health Professionals (MHP) participates in OCM. Palliative and End of Life care was identified as one of the quality improvement areas. A community oncology Palliative care (PC) program was launched in October 2017. Methods: The multidisciplinary PC team was led by Board certified palliative care and hospice physicians. Patients appropriate for PC referral were identified by participating medical oncologists. Patients were contacted by the PC team. If the patients agreed a Nurse Practitioner (NP) would assess and follow the patients at home. Care was coordinated by the NP’s in communication with the palliative care team and the primary medical oncologists. Last 30-day (limited by the OCM episode or patient death) OCM program claims data was analyzed by IntegraConnect. Results: From October 2017 to October 2018 a total of 273 patients were referred to the PC program. Fifty-eight patients were identified as having OCM episodes, of these 36 patients had claims data through June 30, 2018. Twenty patients accepted and were engaged with PC,16 patients declined or were unable to reach for PC and formed the comparison group. Even when drug and office costs were excluded, PC engaged patients spent 17% less versus the comparison group (93k vs 112k) in last 30-day claims data. PC engaged patients had a lower acute care facility costs which accounted for 50% (46k) of reimbursement, compared with 95% (105k) for the comparison group. Fourteen OCM patients referred to Palliative program died within episode. 80% (8/10) of engaged patients met quality measure for OCM-3, at least 3 days in hospice vs. 0% (0/4) of patients who declined palliative care, before episode-death. Conclusions: Palliative engaged OCM patients experienced more care at their homes at a lower cost. Palliative program improved practice performance in OCM-3 quality measure. MHP Palliative program is reaching patients in OCM episodes but the numbers are still small.

Virtual visits for children, adolescents, and young adults with cancer.

6622 Background: Children, adolescents, and young adults have rare cancers and standard-of-care treatment is commonly very aggressive. Virtual visits provide include many of the nuances of face-to face communication. These are much friendlier than phone calls or email and can be scheduled and structured to provide a large amount of information efficiently. Methods: Cleveland Clinic uses HIPPA-compliant software from American Well (Boston, MA) that allows the health care provider and patient to use a phone, tablet, or desktop computer for video visits. Our intake process involves obtaining a Medical Record Number (MRN), sending a brief summary, uploading or sending a CD with images in DICOM, and having an administrative assistant schedule the virtual visit. Telemedicine sessions typically last <60 minutes. During the visit a summary is updated, images are reviewed, and this and other information shared via email after the visit. Results: In 2017+ 2018 we conducted 223 virtual visits; 85% were <30 years old (table). The summary has been a key to efficient and effective organization and includes not only contact information and past medical history, but also an “Opportunities to Improve Health" section (problem list /action plan). Topics discussed in solid tumor patients include: 1) local control, 2) medical therapy (chemotherapy), 3) imaging and tumor markers, 4) control of side effects and nutrition, 5) social issues and goals of care (which can include palliative care and hospice), and 6) follow-up. A power point with key images and the updated summary and articles are emailed at the end of the visit to the patient & caregivers and often referring physician, NP, or PA . Visit diagnoses have included osteosarcoma and Ewing sarcoma (73%), but also other rare cancers such as rhabdomyosarcoma, DSRCT, paraganglioma, and adrenal cortical carcinoma. Survivorship and cGVHD have also been discussed. Conclusions: A structured virtual visit to help young people and their caregivers understand complex multi-disciplinary cancer care is now possible for all regions of North America. A major source of satisfaction has been two-way sharing of information to improve not only cancer control, but also improved nutrition, communication, and proactive toxicity reduction. [Table: see text]

Investigating associations between pain and complicated grief symptoms in bereaved Japanese older adults

Objectives: About 10% of those who lose a loved one in hospice or palliative care settings will experience a mental health condition characterized by severe, prolonged grief responses. Criteria for this condition have evolved; we refer to this condition as Complicated Grief (CG) because it is one of the more common names. While there are some indications of associations between CG and poor physical health, explorations of the association between CG and pain is limited. The main objective of this study was to explore whether pain levels are higher in those with CG than those without, using a large population-based samples of Japanese older adults.Method: The study analyzed data from the Japan HOspice and Palliative care Evaluation (J-HOPE) study, a cross sectional study conducted in 2008 that examined the experiences and outcomes among adults throughout Japan who had lost a loved one within a palliative department or hospice setting, via self-report survey. We examined a subsample sample of 324 individuals aged 50 and above who completed a measure of CG.Results: Family members with high pain group had statistically significantly higher CG symptoms than those with low pain group (M = 66.95 vs. M = 52.05), an association which remained when controlling for demographic and loss-related factors.Conclusion: We found preliminary evidence of an association between CG symptoms and pain, which should be explored in additional samples. Should this finding be replicated, the mechanism of this association could be explored and treatment could potentially address both CG and pain.

Hospice Center Denied Real Property Tax Exemption

An Illinois appellate court, by decision dated February 25, affirmed a lower court's judgment denying an inpatient hospice care center's application for a property tax exemption as a charitable institution (Midwest Palliative Hospice and Care Center v. Beard).

Twelve-Step Programs and Spiritual Support at the End of Life.

Experts estimate that over 25 million Americans are in recovery from addiction to alcohol and other drugs. Many will be confronted with a serious progressive illness necessitating palliative care or hospice services. In current literature, substance use disorder has mostly been examined in relation to appropriate symptom assessment and management, opioid risk screening, and controlled substance prescribing practices. However, as hospice and palliative care (HPC) clinicians strive to provide whole person care for the seriously ill, awareness and facilitation of healthy psychosocial-spiritual coping strategies for recovering addicts should enhance such care. One of the more common support mechanisms to support recovery is the 12-step program, based on Alcoholics Anonymous. Twelve-step programs have been shown to provide effective coping strategies, not only to help facilitate ongoing abstinence but also to support other psychosocial-spiritual crises. The HPC providers may help to serve those living with addiction disorders better by assessing not only patient histories of substance use/abuse and other addictive behaviors but by facilitating their ongoing support recovery efforts. Here, we use 2 HPC cases to illustrate the value of 12-step recovery programs in patient support and provide recommendations for enhancing such healthy coping in HPC clinical settings.

Соціальні програми в контексті державної підтримки паліативної медицини в країнах Європейського Союзу (на прикладі Великобританії).

The paper devoted to the issue of establishment and development of palliative care institute in Ukraine and abroad, as well as the role of the World Health Organization in solving the problems. The urgency of this problem is justified by the fact that the current Ukrainian society requires significant changes in this direction. Indeed, various domestic and international experts assessed the problem as unsatisfactory due to the low level of social care for the elderly and those who are incapable of self-care or are on the verge of life and death, namely the category of people in need of palliative care and hospice care. Social policy should be based on the development of effective mechanisms of public administration of palliative and hospice care, with the borrowing of the best practices of foreign experience. The systematic development of this issue, highly relevant for Ukrainian society, may be based on: WHO recommendations, international standards and the experience of the most developed countries in this area (especially the European Union countries). Palliative care is a relatively new component of modern medicine but has recently been recognized as one of the essential components of the health care system. The need for this type of care is constantly growing. According to WHO experts, 40 million people in the world annually need the care recent years. Almost 80% of those people live in low- and middle-income countries. The paper presents contemporary foreign experience of applying the organizational mechanism of state management of palliative and hospice care. The results of the study give reason to argue that different organizational mechanisms of public administration of palliative and hospice care, forms and approaches to providing such assistance are used in the world. It was noted that the best state of palliative and hospice care was observed in the United Kingdom.

A Study on Locations of Death and Factors Associated with Death among Cancer Patients in South Korea

Background: Location of death has been used to examine an indicator for good death. This study aims to examine location of death among patients with three major cancers (gastric, liver, and lung) and other factors associated with location of death in South Korea. Methods: We selected the medical and pharmacy claims data for health services and location of death among the 42,596 decedents with cancer (lung 16,632, liver 15,872, gastric 10,092) from 2009 to 2013. We used logistic regressions to identify factors associated with home death. Outcome measures are locations of death (hospital, outpatient clinics or emergency room and home). Results: Only 8.9% died at home whereas 46.5% died in hospital as inpatients. Patients with more than one comorbid cancer or receivers for any supportive care were significantly more likely to die in hospital. Female and younger than 55 years old liver cancer patients were associated with home death. Patients living in metropolitan area, or paying more insurance premium, or being public aid beneficiaries, were associated with home death. Conclusions: The supportive care service use prior to death was significantly associated with increasing odds to hospital death. Being older than 75, or having multiple cancers was significant factors associated with hospital death, whereas living in metropolitan area, lower income or emergency visit were significant factors with home death. These findings are opposite to what is found, as the palliative care and hospice is predominantly hospital-centered. The findings emphasize a need to available end-of-life care in community for dying patients.

Examining the intersection of palliative care, hospice, and concurrent care in Veterans Affairs (VA).

139 Background: The VA advocates for both palliative care and concurrent care (hospice care and cancer-directed treatment). Studies indicate that these policies have increased hospice use and have improved family-reported outcomes and other quality metrics. However, little is known about how palliative care, hospice care and concurrent care may interact to obtain these outcomes. Methods: This was a retrospective cohort study of veterans dying with stage IV non-small cell lung cancer in 2012. VA and Medicare administrative data were used to identify the cohort, chemotherapy and radiation use, hospitalizations, hospice use and length of stay (LOS). Palliative care use was determined by VA data only. Analyses included descriptive statistics, chi-square and analysis of variance. Results: Of the 1763 veterans, 850 (48.2%) received both palliative care and hospice, 392 (22.2%) received hospice only, 241 (13.7%) received palliative care only and 280 (15.9%) received neither. Receipt of cancer-directed treatment or hospitalization in the last 30 days of life was significantly different across these groups (p < 0.0001) and was highest at 65% (182/280) in the neither palliative care or hospice group. In the remaining groups, rates of cancer-directed treatment or hospitalization in the last 30 days were: 39.4% (95/241) in palliative care only, 29.3% (115/392) in hospice only and 23% (198/850) with both palliative care and hospice. Concurrent care was received by 314 veterans (17.8%), 275 also receiving palliative care. Among veterans receiving palliative care and Medicare hospice, concurrent care did not alter hospice utilization rates or LOS: 36.4% (100/275), LOS mean 22.3, median 16.5, range 1-97 and 37.2% (214/575), LOS mean 20.1, median 13, range 1-94, for concurrent care and non-concurrent care respectively. Conclusions: The rates of cancer-directed treatment or hospitalization in the last 30 days of life appeared to be reduced in a continuum from receipt of neither hospice nor palliative care, to receipt of palliative care or hospice alone, followed by receipt of both together. Concurrent care use was facilitated by palliative care without impacting Medicare hospice use or LOS in palliative care recipients.

When is the best time to transfer terminally ill cancer patients from hospitals to palliative hospice home care? Analysis of a questionnaire survey of 1,055 surviving families.

61 Background: It is difficult to know when the best timing is to transfer terminally ill cancer patients from hospitals to palliative hospice home care for their quality of life to death. This study aimed to articulate the best time for medical teams working in hospitals to refer their terminally ill cancer patients to palliative home care. Methods: A statistical analysis of a survey was conducted with 1,055 surviving families whose members had died with palliative home care from 1995 to 2014. The questionnaire included the following 8 contents: 1. transfer timing from hospitalization to the home care; A. appropriate, B. too late, C. too early; and the contextual items ware, 2. peacefulness of patient at dying, 3. peacefulness of patient all through the care, 4. physical pain, 5. mental pain, 6. spiritual pain, 7. alleviation of family sufferings, 8. satisfaction of family as care-givers. The response rate is 31% (311 persons). However, we excluded responses without names on the questionnaire, of non-cancer patients, with death location out of home, and without answer to question 1, resulting in 166 responses for analysis. Results: Focusing on the question 1, number of responders are A; 113 (68%), B; 52 (31%), C; 1 (0.6%). The medians of home care days to death are A; 66, B; 23, C; analysis impossible. Comparison of respondents’ satisfaction according to number of days of palliative home care revealed that 89.4% people with two months or more before their patients’ death were satisfied (A), while 10.6% of those who had less than two month were unsatisfied (B+C). Conclusions: Most surviving families were satisfied if they had two months or more for palliative home care. This survey suggests the relevancy to start preparation for discharge that enables the patients to stay home with their family members for two months or more. [Table: see text]

Palliative Care in Patients with Leukemia: When and How?

Patients with hematologic malignancies get more aggressive treatment and the end-of-life, more ICU deaths, and prolonged hospital stays. In comparison to solid tumors, their access to palliative care and hospice is less. Multiple factors seem to play a role including curative goals, different treatment options, stronger relationship between patients and oncologist, symptom burden, and limitations of hospice care. Improving the perception of palliative care in these patients, characterizing their needs, and more education can help to increase referrals and access to palliative care. Innovative ways to improve integration between hematology-oncology and palliative care are needed.

End of life: A focus upon making doing the right thing easier in challenging conversations.

174 Background: Communication surrounding end of life decisions is difficult for patients and their loved ones as well as the clinicians involved in their care. An audit of end of life measures brought to light an area of opportunity across a national network of five geographically dispersed medical centers that resulted in a quality improvement project which sought to enhance communication processes among clinicians and patients. Methods: Utilizing principals of complexity theory, a multidisciplinary task force developed a communication tool to guide clinicians in discussions with patients and improved upon the electronic health record (EHR) to make documentation clearer, easier and more meaningful. “Words that Matter” with scenarios and suggestions for clinicians to introduce palliative care or hospice to patients were established. EHR enhancements included structured fields for hospice discussion and referral based upon network defined objective clinical criteria. A hospice referral field was also created to allow physicians to place an order along with discontinuing chemotherapy without leaving the note. Education was provided to clinicians in various formats. Implementation occurred early fall 2017. Results: Structured fields allow for easier electronic data pulls for reports to measure process improvement and communication. Outcome measures of interest include: chemotherapy administered in the last 14 days of life and timeliness of referral to hospice. Additional process metrics are in place to measure utilization of supporting resources. Conclusions: Effective communication of end of life issues and timely hospice referral is an integral part of care. Communication tools and criteria prompt our physicians to engage in discussions and refer patients earlier in their journey, when appropriate. Providing structured fields in the EHR has made documentation more complete.[Table: see text]

LVAD-DT as the Final Destination: End-of-Life Experiences

Introduction As the number of persons living with advanced heart failure (HF) continues to increase, so does the implantation of mechanical circulatory support devices. Over half of the left ventricular assist devices (LVADs) currently implanted are indicated for destination therapy (DT) but there is a gap in the current evidence regarding the end-of-life experiences (EOL) of this group. Purpose To investigate the EOL experiences of LVAD-DT recipients and their family caregivers throughout the LVAD-DT trajectory including: 1) pre-implantation experiences, 2) conversations about device deactivation, 3) use of EOL services including palliative care and hospice, and 4) device deactivation prior to death. Methods Thirty five individuals and their family caregivers (n=70) from 2 longitudinal prospective studies participated in qualitative interviews that occurred approximately every month for up to 24 months or until the death of the LVAD-DT recipient. After the death of LVAD-DT recipient, the caregiver was interviewed about LVAD deactivation and use of EOL services. Qualitative content analysis was utilized to explore the experiences of participants through the EOL. EOL service utilization determined via EMR review. Results During study enrollment LVAD-DT recipients had on average 6 readmissions. The main reasons for readmission included: infection/ sepsis, GI bleed, RHF, and anemia. Sixty percent of the dyads (21/35) received a palliative care consult prior to implantation. Of those only 19% (4/21) recalled the consultation. Six out of thirty five (17%) had an advance directive in the EMR. All advance directives were completed prior to LVAD-DT implantation and none included documentation of wishes for device deactivation. The main results from the content analysis highlighted the lack of EOL planning. LVAD-DT recipients and caregivers did not recall advance care planning or conversations regarding device deactivation throughout the LVAD trajectory. Six patients died with an LVAD in place. Of those, 2 received no EOL services, 3 had EOL services only during their terminal hospitalization, and 1 had ongoing EOL services during the last month of life with deactivation in the home setting prior to death. Conclusions The pre-implantation period is a very busy time, if palliative care consults occurred they often were not remembered by the LVAD recipient or their family member. EOL services were not routinely initiated nor did they transition across episodes of care or settings, despite frequent hospitalizations in the post-implantation period. Additional research is needed on the role of improved EOL care coordination across settings and episodes of care.

Survey on the Accompanying Experience of Palliative Hospice Volunteers in Peking Union Medical College Hospital

Objective To investigate the experience of accompanying dying patients among hospice and palliative care (HPC) volunteers. Methods By applying the methodologies of phenomenological research and participatory observation,the experiences,awareness,and expectations of accompanying dying patients of 10 volunteers in our center were investigated. Results The experiences of 10 volunteers in HPC could be summarized into three subjects:volunteer personal cognition,volunteer demand and family support,and volunteers' expectations of hospital and society. These could be further divided into 6 sub-themes regarding the personal cognition and feelings of the volunteers:unknown,hostile,suspicious,helpless,role positioning,and passing the message of illness. Three sub-themes associated with individual needs and family support were:self motivation,family ties,and family support. Five sub-themes concerning volunteers' expectations for hospitals and society were:confusion of concept,lack of palliative idea,reach-out service,humanistic care,and adoption of palliative concept. Conclusion sHPC team should widely promote the concept of HPC,seeking supports from individuals,families,and the whole society. A strong volunteer team with robust volunteer service mode and standardized admittance,training,and supervision systems are needed. In particular,strengthened supervision and training of HPC volunteers and standard volunteer system are conducive to the improvement of HPC services in hospitals.