Pub Date : 2024-09-03DOI: 10.1177/10499091241282087
Valerie T Cotter, Danetta H Sloan, Daniel L Scerpella, Kelly M Smith, Martha Abshire Saylor, Jennifer L Wolff
Background and Objectives: Traditional methods of fidelity monitoring are not possible in pragmatic trials in real-world clinical settings. We describe our approach to monitoring and reinforcing the fidelity to ACP conversations for a hard-to-reach subpopulation by using standardized patients in a pragmatic trial. Research Design and Methods: We developed standardized patient scenarios grounded in the Respecting Choices First Steps™ Advance Care Planning curriculum to provide an opportunity to reinforce and assess ACP facilitator competency. Scenarios represented one-on-one encounters. The first case was a standardized patient with cognitive impairment and the second case involved a standardized patient with dementia and their care partner. A previously validated fidelity checklist was used to score skills and behaviors observed during simulations including encounter set-up, ACP topics, and general communication. Simulations involved voice teleconferencing to align primary modality of ACP in the pragmatic trial. Results: Six facilitators completed two standardized patient cases each. Overall fidelity scores were moderately high (78.8% ± 11.7; 63.4 - 95.6) for the case with cognitive impairment and for the case with the patient with dementia and care partner (76.2% ± 13.0; 54.4 - 91.5). Discussion and Implications: Simulation using standardized patients supported fidelity monitoring and provided coachable feedback to support facilitator competency. Our study can help inform future research and training related to advance care planning in older adults living with Alzheimer's disease and related disorders.
{"title":"Feasibility of Using Simulation to Evaluate Implementation Fidelity in an Advance Care Planning Pragmatic Trial.","authors":"Valerie T Cotter, Danetta H Sloan, Daniel L Scerpella, Kelly M Smith, Martha Abshire Saylor, Jennifer L Wolff","doi":"10.1177/10499091241282087","DOIUrl":"https://doi.org/10.1177/10499091241282087","url":null,"abstract":"<p><p><b>Background and Objectives:</b> Traditional methods of fidelity monitoring are not possible in pragmatic trials in real-world clinical settings. We describe our approach to monitoring and reinforcing the fidelity to ACP conversations for a hard-to-reach subpopulation by using standardized patients in a pragmatic trial. <b>Research Design and Methods:</b> We developed standardized patient scenarios grounded in the Respecting Choices First Steps™ Advance Care Planning curriculum to provide an opportunity to reinforce and assess ACP facilitator competency. Scenarios represented one-on-one encounters. The first case was a standardized patient with cognitive impairment and the second case involved a standardized patient with dementia and their care partner. A previously validated fidelity checklist was used to score skills and behaviors observed during simulations including encounter set-up, ACP topics, and general communication. Simulations involved voice teleconferencing to align primary modality of ACP in the pragmatic trial. <b>Results:</b> Six facilitators completed two standardized patient cases each. Overall fidelity scores were moderately high (78.8% ± 11.7; 63.4 - 95.6) for the case with cognitive impairment and for the case with the patient with dementia and care partner (76.2% ± 13.0; 54.4 - 91.5). <b>Discussion and Implications:</b> Simulation using standardized patients supported fidelity monitoring and provided coachable feedback to support facilitator competency. Our study can help inform future research and training related to advance care planning in older adults living with Alzheimer's disease and related disorders.</p>","PeriodicalId":94222,"journal":{"name":"The American journal of hospice & palliative care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142127782","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2023-11-22DOI: 10.1177/10499091231218455
Hillary D Lum, Stacy Fischer, Kate Ytell, Laura Scherer, Sean T O'Leary, Ronit Elk, Susan Hurley, Karla T Washington, Matthew DeCamp
Home health aides (HHAs) care for patients highly vulnerable to COVID-19 and are disproportionately women from minority communities that have been adversely impacted by COVID-19. Yet, direct care workers are less likely to be vaccinated against COVID-19 compared to others. As the pandemic evolves, interest in vaccination may decrease suggesting the need for relevant vaccine messaging to HHAs. Objectives: (1) to describe HHAs and administrators' perspectives related to COVID-19 vaccination messaging, and (2) to co-design a Communication Toolkit to create COVID-19 vaccine messages. Methods: HHAs and administrators from 4 geographically diverse Palliative Care Research Cooperative (PCRC) hospice agencies were recruited for a multi-method process involving qualitative interviews (17 HHAs and 5 administrators), community engagement (CE) studios, and development of a Communication Toolkit. Interviews were guided by the PEN-3 conceptual framework to explore barriers and facilitators to vaccination. Data were analyzed using qualitative content analysis. Results: Despite power differences, HHAs and administrators share a commitment to protecting patients affected by serious illness. HHAs desire vaccine messaging that includes personal narratives, good news about the vaccine, and facts about benefits and risks of the vaccine. Preferred message formats include the agency intranet, daily briefings, or "little seeds" (ie, short, high-impact information). Through the studios, HHAs provided input on a Toolkit prototype with messages tailored to the context of home care. Conclusions: Grounded in the commitment of HHAs and administrators to protecting vulnerable patients, we co-created an adaptable Communication Toolkit to address COVID-19 vaccination misinformation and mistrust among direct care workers.
{"title":"Elevating Home Health Aide Input in Co-Creation of COVID-19 Vaccine Messaging.","authors":"Hillary D Lum, Stacy Fischer, Kate Ytell, Laura Scherer, Sean T O'Leary, Ronit Elk, Susan Hurley, Karla T Washington, Matthew DeCamp","doi":"10.1177/10499091231218455","DOIUrl":"10.1177/10499091231218455","url":null,"abstract":"<p><p>Home health aides (HHAs) care for patients highly vulnerable to COVID-19 and are disproportionately women from minority communities that have been adversely impacted by COVID-19. Yet, direct care workers are less likely to be vaccinated against COVID-19 compared to others. As the pandemic evolves, interest in vaccination may decrease suggesting the need for relevant vaccine messaging to HHAs. <b>Objectives:</b> (1) to describe HHAs and administrators' perspectives related to COVID-19 vaccination messaging, and (2) to co-design a Communication Toolkit to create COVID-19 vaccine messages. <b>Methods:</b> HHAs and administrators from 4 geographically diverse Palliative Care Research Cooperative (PCRC) hospice agencies were recruited for a multi-method process involving qualitative interviews (17 HHAs and 5 administrators), community engagement (CE) studios, and development of a Communication Toolkit. Interviews were guided by the PEN-3 conceptual framework to explore barriers and facilitators to vaccination. Data were analyzed using qualitative content analysis. <b>Results:</b> Despite power differences, HHAs and administrators share a commitment to protecting patients affected by serious illness. HHAs desire vaccine messaging that includes personal narratives, good news about the vaccine, and facts about benefits and risks of the vaccine. Preferred message formats include the agency intranet, daily briefings, or \"little seeds\" (ie, short, high-impact information). Through the studios, HHAs provided input on a Toolkit prototype with messages tailored to the context of home care. <b>Conclusions:</b> Grounded in the commitment of HHAs and administrators to protecting vulnerable patients, we co-created an adaptable Communication Toolkit to address COVID-19 vaccination misinformation and mistrust among direct care workers.</p>","PeriodicalId":94222,"journal":{"name":"The American journal of hospice & palliative care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11109014/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138292613","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2023-09-30DOI: 10.1177/10499091231205841
Michael Pottash, Kayla Saikaly, Maximilian Stevenson, Benjamin Krohmal
Introduction: Little is known about the identity and moral experience of clinicians who provide the option of aid in dying to terminally ill Americans.
Methods: In May 2023 we distributed an email survey to clinicians registered for the American Clinician's Academy on Medical Aid in Dying listserv.
Results: Of the 72 clinicians who responded, 90% were of white race, 50% were over 60 years old, and 47% had been in practice for over 20 years. Most clinicians report practicing primary care (39%) or hospice/palliative care (33%); 25% of clinicians had training in palliative medicine. 22% described their practice as a specialized "aid-in-dying practice" and 26% either "rarely" or "never" cared for the terminally ill outside the context of aid in dying. A majority (56%) of clinicians were either affiliated with an independent practice or unaffiliated. Before they began aid-in-dying work, 26% of clinicians reported having felt "somewhat" or "very" morally conflicted; after having written an aid in dying prescription, 96% felt "hardly" or "not at all" conflicted. On average, clinicians felt that aid-in-dying laws balance protection of patients with access; 39% believed that the laws were "somewhat" or "overly" protective.
Conclusion: Many responding clinicians report caring for patients considering aid in dying in specialized practices or otherwise in unaffiliated or independent practice. Clinicians report that providing aid in dying (and writing an aid-in-dying prescription) resulted in less reported moral conflict toward aid in dying.
{"title":"A Survey of Clinicians Who Provide Aid in Dying.","authors":"Michael Pottash, Kayla Saikaly, Maximilian Stevenson, Benjamin Krohmal","doi":"10.1177/10499091231205841","DOIUrl":"10.1177/10499091231205841","url":null,"abstract":"<p><strong>Introduction: </strong>Little is known about the identity and moral experience of clinicians who provide the option of aid in dying to terminally ill Americans.</p><p><strong>Methods: </strong>In May 2023 we distributed an email survey to clinicians registered for the American Clinician's Academy on Medical Aid in Dying listserv.</p><p><strong>Results: </strong>Of the 72 clinicians who responded, 90% were of white race, 50% were over 60 years old, and 47% had been in practice for over 20 years. Most clinicians report practicing primary care (39%) or hospice/palliative care (33%); 25% of clinicians had training in palliative medicine. 22% described their practice as a specialized \"aid-in-dying practice\" and 26% either \"rarely\" or \"never\" cared for the terminally ill outside the context of aid in dying. A majority (56%) of clinicians were either affiliated with an independent practice or unaffiliated. Before they began aid-in-dying work, 26% of clinicians reported having felt \"somewhat\" or \"very\" morally conflicted; after having written an aid in dying prescription, 96% felt \"hardly\" or \"not at all\" conflicted. On average, clinicians felt that aid-in-dying laws balance protection of patients with access; 39% believed that the laws were \"somewhat\" or \"overly\" protective.</p><p><strong>Conclusion: </strong>Many responding clinicians report caring for patients considering aid in dying in specialized practices or otherwise in unaffiliated or independent practice. Clinicians report that providing aid in dying (and writing an aid-in-dying prescription) resulted in less reported moral conflict toward aid in dying.</p>","PeriodicalId":94222,"journal":{"name":"The American journal of hospice & palliative care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41172701","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-01-19DOI: 10.1177/10499091231225960
Ann E Vandenberg, Alexis A Bender, Candace L Kemp, Molly M Perkins
Background: In the U.S., assisted living (AL) is increasingly a site of death, and anxiety about dying has been identified in long-term care residents and their caregivers. Communication about death and dying is associated with better quality of life and care at end of life (EOL).
Objective: To understand communication behaviors used by AL residents and their informal caregivers (i.e., family members or friends) related to death and dying, and address communication needs or opportunities applicable to EOL care in AL.
Design: A thematic analysis of in-depth interviews and fieldnotes from a subsample of data from a 5-year NIA-funded study.
Setting/subjects: Participants included 15 resident-caregiver dyads from three diverse AL communities in Atlanta, Georgia in the U.S.
Measurements: Interview transcripts were coded for communication behavior. Concordances and discordances within dyads were examined.
Results: We identified a typology of four dyadic communication behaviors: Talking (i.e., both partners were talking with each other about death), Blocking (i.e., one partner wanted to talk about death but the other did not), Avoiding (i.e., each partner perceived that the other did not want to communicate about death), and Unable (i.e., dyads could not communicate about death because of interpersonal barriers).
Conclusions: Older residents in AL often want to talk about death but are blocked from doing so by an informal caregiver. Caregivers and AL residents may benefit from training in death communication. Recommendations for improving advance care planning and promoting better EOL communication includes timing these conversations before the opportunity is lost.
背景:在美国,辅助生活(AL)越来越多地成为死亡的场所,长期护理居民及其护理人员对死亡的焦虑已经得到确认。关于死亡和临终的交流与更好的生活质量和临终关怀有关:了解长期护理住院者及其非正式护理者(即家庭成员或朋友)与死亡和临终有关的沟通行为,并解决适用于长期护理住院者临终关怀的沟通需求或机会:对一项为期 5 年、由国家卫生研究所资助的研究中的子样本数据进行深入访谈和现场记录的主题分析:参与者包括来自美国佐治亚州亚特兰大市三个不同 AL 社区的 15 个居民-护理人员二人组:对访谈记录进行沟通行为编码。结果:我们发现了四种类型的居住者-护理者二人组:结果:我们确定了四种二人交流行为的类型:交谈(即双方都与对方谈论死亡)、阻止(即一方想谈论死亡,但另一方不想)、回避(即双方都认为对方不想谈论死亡)和无法(即由于人际障碍,两人无法就死亡进行交流):结论:住在养老院的老年居民通常都想谈论死亡,但却受到非正式照护者的阻挠。护理人员和老年住户可能会从死亡沟通的培训中受益。改善预先护理计划和促进更好的临终沟通的建议包括在失去机会之前把握好这些对话的时机。
{"title":"Resident and Caregiver Dyads Talk About Death and Dying in Assisted Living: A Typology of Communication Behaviors.","authors":"Ann E Vandenberg, Alexis A Bender, Candace L Kemp, Molly M Perkins","doi":"10.1177/10499091231225960","DOIUrl":"10.1177/10499091231225960","url":null,"abstract":"<p><strong>Background: </strong>In the U.S., assisted living (AL) is increasingly a site of death, and anxiety about dying has been identified in long-term care residents and their caregivers. Communication about death and dying is associated with better quality of life and care at end of life (EOL).</p><p><strong>Objective: </strong>To understand communication behaviors used by AL residents and their informal caregivers (i.e., family members or friends) related to death and dying, and address communication needs or opportunities applicable to EOL care in AL.</p><p><strong>Design: </strong>A thematic analysis of in-depth interviews and fieldnotes from a subsample of data from a 5-year NIA-funded study.</p><p><strong>Setting/subjects: </strong>Participants included 15 resident-caregiver dyads from three diverse AL communities in Atlanta, Georgia in the U.S.</p><p><strong>Measurements: </strong>Interview transcripts were coded for communication behavior. Concordances and discordances within dyads were examined.</p><p><strong>Results: </strong>We identified a typology of four dyadic communication behaviors: Talking (i.e., both partners were talking with each other about death), Blocking (i.e., one partner wanted to talk about death but the other did not), Avoiding (i.e., each partner perceived that the other did not want to communicate about death), and Unable (i.e., dyads could not communicate about death because of interpersonal barriers).</p><p><strong>Conclusions: </strong>Older residents in AL often want to talk about death but are blocked from doing so by an informal caregiver. Caregivers and AL residents may benefit from training in death communication. Recommendations for improving advance care planning and promoting better EOL communication includes timing these conversations before the opportunity is lost.</p>","PeriodicalId":94222,"journal":{"name":"The American journal of hospice & palliative care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11258204/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139503313","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2023-10-17DOI: 10.1177/10499091231206481
Jason Hotchkiss, Emily Ridderman, Brendan Hotchkiss
Background: Several studies chronicle profit-making negatively impacting US hospice care quality. However, no study has reported on caregiver satisfaction expressed online by hospice.
Objectives: Assess the relationship between online caregiver sentiment, market share, profit status, and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) scores among the 50 largest US hospices.
Methods: Retrospective mixed methods of sentiment and multivariate regression analysis. Data sources were online caregiver reviews, provider CAHPS hospice survey data.
Results: Being a larger, for-profit predicted diminished caregiver and employee satisfaction. Caregiver Sentiment and CAHPS Composite were so highly associated (r = .862, P < .001), that they are converging on overall caregiver satisfaction. With large effect, CAHPS Star Rating was significantly higher than Review Star Rating. For-profits had significantly higher overall Emotional Intensity than non-profit hospices, again with large effect. Caregiver Sentiment, Review Star Rating, and Glassdoor Composite each predicted CAHPS Composite. Lack of staffing was more frequent among for-profits (13%) than non-profits (6%). Out-of-scope expectations prevalence was 9%.
Conclusion: Caregiver and employees had better experiences with non-profits than for-profits. Anger and frustration was expressed toward large, for-profit providers more focused on admissions, profiteering, and paying dividends than actual care. The CAHPS appears to draw more satisfied caregivers. Whereas, online reviewing provides open-ended, real-time voicing of care quality concerns. Even with distinct methods, CAHPS survey and review sentiment analysis converge on caregiver satisfaction, yet CAHPS paints a much rosier picture of hospice quality than online reviews. Future research should explore sentiments by topic and hospice to increase customer advocacy.
{"title":"Caregiver and Employee Experience Among Big Hospices-Ranking of the Largest US Hospices by Three Quality Indicators.","authors":"Jason Hotchkiss, Emily Ridderman, Brendan Hotchkiss","doi":"10.1177/10499091231206481","DOIUrl":"10.1177/10499091231206481","url":null,"abstract":"<p><strong>Background: </strong>Several studies chronicle profit-making negatively impacting US hospice care quality. However, no study has reported on caregiver satisfaction expressed online by hospice.</p><p><strong>Objectives: </strong>Assess the relationship between online caregiver sentiment, market share, profit status, and Consumer Assessment of Healthcare Providers and Systems (CAHPS<b>®)</b> scores among the 50 largest US hospices.</p><p><strong>Methods: </strong>Retrospective mixed methods of sentiment and multivariate regression analysis. Data sources were online caregiver reviews, provider CAHPS hospice survey data.</p><p><strong>Results: </strong>Being a larger, for-profit predicted diminished caregiver and employee satisfaction. <i>Caregiver Sentiment</i> and <i>CAHPS Composite</i> were so highly associated (<i>r</i> = .862, <i>P</i> < .001), that they are converging on overall caregiver satisfaction. With large effect, <i>CAHPS Star Rating</i> was significantly higher than <i>Review Star Rating</i>. For-profits had significantly higher overall <i>Emotional Intensity</i> than non-profit hospices, again with large effect. <i>Caregiver Sentiment</i>, <i>Review Star Rating,</i> and <i>Glassdoor Composite</i> each predicted <i>CAHPS Composite. Lack of staffing</i> was more frequent among for-profits (13%) than non-profits (6%). <i>Out-of-scope expectations</i> prevalence was 9%.</p><p><strong>Conclusion: </strong>Caregiver and employees had better experiences with non-profits than for-profits. Anger and frustration was expressed toward large, for-profit providers more focused on admissions, profiteering, and paying dividends than actual care. The CAHPS appears to draw more satisfied caregivers. Whereas, online reviewing provides open-ended, real-time voicing of care quality concerns. Even with distinct methods, CAHPS survey and review sentiment analysis converge on caregiver satisfaction, yet CAHPS paints a much rosier picture of hospice quality than online reviews. Future research should explore sentiments by topic and hospice to increase customer advocacy.</p>","PeriodicalId":94222,"journal":{"name":"The American journal of hospice & palliative care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41242764","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2023-11-06DOI: 10.1177/10499091231213640
Jonas Nilsson, Stefan Bergström, Hampus Hållberg, Anders Berglund, Michael Bergqvist, Georg Holgersson
Background: The place of death of cancer patients is an important aspect of end-of-life care. However, little research has been conducted regarding factors that may influence the preferred and actual place of death in cancer patients and whether the patients die at their preferred place of death. In this study, we aimed to investigate the preferred and actual place of death for palliative cancer patients, and factors influencing these variables. Methods: Patients diagnosed with cancer and admitted to a palliative care team across three Swedish cities between 2019 and 2022 were asked for participation. Participants completed a questionnaire capturing sociodemographic data and preferred place of death. Further data regarding age, sex, and cancer type were collated at inclusion, and the actual place of death recorded for those deceased by 5-May-2023. Results: The study included 242 patients. A majority (79%) wanted to die at home which was the actual death location for 76% of the patients. When the place-of-death decision was made by the patient alone, 75% chose home, compared to 96% when decided jointly with relatives-a statistically significant variation (p = 0.0037). For the patients who wanted to die at home, 80% actually died at home, with insignificant disparities among subgroups. Conclusions: Most palliative cancer patients in this Swedish cohort preferred and achieved death at home. Involving relatives in decision-making may influence the preferred place of death, however larger studies are needed to comprehensively assess factors affecting the preferred and actual place of death in different subgroups of patients.
{"title":"Prospective Study of Preferred Versus Actual Place of Death Among Swedish Palliative Cancer Patients.","authors":"Jonas Nilsson, Stefan Bergström, Hampus Hållberg, Anders Berglund, Michael Bergqvist, Georg Holgersson","doi":"10.1177/10499091231213640","DOIUrl":"10.1177/10499091231213640","url":null,"abstract":"<p><p><b>Background:</b> The place of death of cancer patients is an important aspect of end-of-life care. However, little research has been conducted regarding factors that may influence the preferred and actual place of death in cancer patients and whether the patients die at their preferred place of death. In this study, we aimed to investigate the preferred and actual place of death for palliative cancer patients, and factors influencing these variables. <b>Methods:</b> Patients diagnosed with cancer and admitted to a palliative care team across three Swedish cities between 2019 and 2022 were asked for participation. Participants completed a questionnaire capturing sociodemographic data and preferred place of death. Further data regarding age, sex, and cancer type were collated at inclusion, and the actual place of death recorded for those deceased by 5-May-2023. <b>Results:</b> The study included 242 patients. A majority (79%) wanted to die at home which was the actual death location for 76% of the patients. When the place-of-death decision was made by the patient alone, 75% chose home, compared to 96% when decided jointly with relatives-a statistically significant variation (p = 0.0037). For the patients who wanted to die at home, 80% actually died at home, with insignificant disparities among subgroups. <b>Conclusions:</b> Most palliative cancer patients in this Swedish cohort preferred and achieved death at home. Involving relatives in decision-making may influence the preferred place of death, however larger studies are needed to comprehensively assess factors affecting the preferred and actual place of death in different subgroups of patients.</p>","PeriodicalId":94222,"journal":{"name":"The American journal of hospice & palliative care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11318221/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71490781","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Objectives: This study identifies the mechanisms through which supportive and palliative care services at the end-of-life helped prevent unnecessary use of acute care services.
Background: From 2016 to 2021, the Medicare Care Choices Model (MCCM) tested whether offering Medicare beneficiaries the option to receive supportive and palliative care services through hospice providers, concurrently with treatments for their terminal conditions, improved patients' quality of life and care and reduced Medicare expenditures. Previous MCCM evaluation results showed that the model achieved its goals, but did not examine in depth the causal mechanisms leading to these results.
Methods: Mixed-methods evaluation based on descriptive analysis of MCCM encounter data and qualitative analysis of interviews with staff from high-performing MCCM hospices.
Results: MCCM hospices provided 217 156 encounters to 7263 enrollees over 6 years. Enrollees received on average 30 encounters with hospice staff while enrolled in the model, representing about 10 encounters per month enrolled. Most encounters were delivered by clinically trained staff in the patient's home. Hospice staff identified five services critical for keeping patients from seeking acute care services: early and frequent needs assessments, direct observation of patients in their homes, immediate responses to patients' medical complaints, round-the-clock telephone access to nursing staff, and communication and coordination of care with primary care physicians and specialists.
Conclusions: Palliative care approaches that are high-touch, employ clinically trained staff who visit patients in their homes, routinely evaluate how to manage patient symptoms, and are available when needs arise can improve outcomes and decrease costs at the end of life.
{"title":"Supportive Services at End of Life can Help Reduce Acute Care Services: Observations From the Medicare Care Choices Model.","authors":"Patricia Rowan, Danielle Whicher, Marlena Luhr, Lynn Miescier, Keith Kranker, Boyd Gilman","doi":"10.1177/10499091231216887","DOIUrl":"10.1177/10499091231216887","url":null,"abstract":"<p><strong>Objectives: </strong>This study identifies the mechanisms through which supportive and palliative care services at the end-of-life helped prevent unnecessary use of acute care services.</p><p><strong>Background: </strong>From 2016 to 2021, the Medicare Care Choices Model (MCCM) tested whether offering Medicare beneficiaries the option to receive supportive and palliative care services through hospice providers, concurrently with treatments for their terminal conditions, improved patients' quality of life and care and reduced Medicare expenditures. Previous MCCM evaluation results showed that the model achieved its goals, but did not examine in depth the causal mechanisms leading to these results.</p><p><strong>Methods: </strong>Mixed-methods evaluation based on descriptive analysis of MCCM encounter data and qualitative analysis of interviews with staff from high-performing MCCM hospices.</p><p><strong>Results: </strong>MCCM hospices provided 217 156 encounters to 7263 enrollees over 6 years. Enrollees received on average 30 encounters with hospice staff while enrolled in the model, representing about 10 encounters per month enrolled. Most encounters were delivered by clinically trained staff in the patient's home. Hospice staff identified five services critical for keeping patients from seeking acute care services: early and frequent needs assessments, direct observation of patients in their homes, immediate responses to patients' medical complaints, round-the-clock telephone access to nursing staff, and communication and coordination of care with primary care physicians and specialists.</p><p><strong>Conclusions: </strong>Palliative care approaches that are high-touch, employ clinically trained staff who visit patients in their homes, routinely evaluate how to manage patient symptoms, and are available when needs arise can improve outcomes and decrease costs at the end of life.</p>","PeriodicalId":94222,"journal":{"name":"The American journal of hospice & palliative care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136400882","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2023-11-21DOI: 10.1177/10499091231218261
John G Cagle, Peiyuan Zhang, Sarah Clem
Hospice is touted as an exemplary model for end-of-life care. However, there is little generalizable evidence estimating benefits of hospice at the national level. Using a national population-based probability sample of U.S. adults with weights applied (data collected Spring/Summer 2015), we conducted six logistic regression models to evaluate linkages between hospice involvement and end-of-life outcomes (pain, home death, presence of family, access to life-prolonging care, respect for spiritual/religious beliefs, financial burden) from N = 235 informal caregivers of decedents prior to death. Respondents were M = 55 years old (SD = 17), 55% female, 77% White, 91% non-Hispanic, and 71% had cared for a hospice recipient. In fully adjusted analyses, hospice users had better reported outcomes observed in two models: (a.) presence of family/friends at death (OR = 2.82, SE = .48, P < .05), and (b.) respect for spiritual/religious beliefs (OR = 9.52, SE = .73, P < .01). Hospice utilization was not statistically significant (P > .05) in all other adjusted models. Although more research is needed, findings support claims that hospice remains a high quality option for end-of-life care in the U.S.
临终关怀被吹捧为临终关怀的典范。然而,在国家层面上,很少有可概括的证据来评估安宁疗护的好处。我们使用基于全国人口的美国成年人概率样本(数据收集于2015年春夏),采用六个逻辑回归模型来评估临终关怀参与与临终结果(疼痛、家庭死亡、家人在场、获得延长生命的护理、对精神/宗教信仰的尊重、经济负担)之间的联系,这些数据来自N = 235名死者生前的非正式照护者。受访者年龄为M = 55岁(SD = 17), 55%为女性,77%为白人,91%为非西班牙裔,71%曾照顾过临终关怀接受者。在完全调整后的分析中,安宁疗护使用者在两个模型中观察到较好的结果:(a)死亡时家人/朋友的存在(OR = 2.82, SE = 0.48, P < 0.05)和(b)对精神/宗教信仰的尊重(OR = 9.52, SE = 0.73, P < 0.01)。其他调整后的模型中,安宁疗护使用率差异无统计学意义(P > 0.05)。虽然还需要更多的研究,但研究结果支持了临终关怀仍然是美国临终关怀的高质量选择的说法
{"title":"Estimating the Impact of Hospice Care on Key Patient-Family Care Outcomes Using a Nationwide U.S. Probability Sample.","authors":"John G Cagle, Peiyuan Zhang, Sarah Clem","doi":"10.1177/10499091231218261","DOIUrl":"10.1177/10499091231218261","url":null,"abstract":"<p><p>Hospice is touted as an exemplary model for end-of-life care. However, there is little generalizable evidence estimating benefits of hospice at the national level. Using a national population-based probability sample of U.S. adults with weights applied (data collected Spring/Summer 2015), we conducted six logistic regression models to evaluate linkages between hospice involvement and end-of-life outcomes (pain, home death, presence of family, access to life-prolonging care, respect for spiritual/religious beliefs, financial burden) from N = 235 informal caregivers of decedents prior to death. Respondents were M = 55 years old (SD = 17), 55% female, 77% White, 91% non-Hispanic, and 71% had cared for a hospice recipient. In fully adjusted analyses, hospice users had better reported outcomes observed in two models: (a.) presence of family/friends at death (OR = 2.82, SE = .48, <i>P</i> < .05), and (b.) respect for spiritual/religious beliefs (OR = 9.52, SE = .73, <i>P</i> < .01). Hospice utilization was not statistically significant (<i>P</i> > .05) in all other adjusted models. Although more research is needed, findings support claims that hospice remains a high quality option for end-of-life care in the U.S.</p>","PeriodicalId":94222,"journal":{"name":"The American journal of hospice & palliative care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138292614","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2023-12-15DOI: 10.1177/10499091231213359
Theodore Zanker, Joseph Sacco, James Prota, Michelle Palma, Kyoung A Viola Lee, Ruixiao Rachel Wang, Yixuan Liang, James Cunningham, Mona Mackary, Polina Ovchinnikova
Background: Opioid therapy is critical for pain relief for most hospice patients but may be limited by adverse side effects. Combining medical cannabis with opioids may help mitigate adverse effects while maintaining effective pain relief. Aim: This single-arm study investigated the impact of combined medical cannabis/opioid therapy on pain relief, opioid dose, appetite, respiratory function, well-being, nausea, and adverse events in hospice inpatients. Design: Adult hospice inpatients using scheduled oral, parenteral, or transdermal opioids for pain were administered standardized oral medical cannabis, 40 mg CBD/1.5 mg THC or 80 mg CBD/3 mg THC. Descriptive statistics detailed demographic and clinical baseline characteristics, the Mann-Whitney test compared outcomes, and the longitudinal mixed effects regression model analyzed longitudinal effects of combined therapy. Setting/Participants: Sixty-six inpatients at The Connecticut Hospital, Inc. were assessed over 996 treatment days; average age was 68.2 ± 12.9 years, 90.9% were white. Cancer was the most common diagnosis. Results: The medical cannabis/opioid combination showed a significant longitudinal reduction in pain intensity (P = .0029) and a non-significant trend toward lower opioid doses. Well-being, appetite, nausea, and respiratory function showed non-statistically significant changes. Three patients (4.5%) experienced minor, reversible adverse events potentially related to medical cannabis. No serious or life-threatening adverse events were seen. Conclusion: Combination medical cannabis/opioid therapy showed statistically significant pain relief and may have the potential for reducing opioid dose and mitigating opioid toxicity, offering a safe pain management alternative to opioids alone for patients in end-of-life care settings, and warrants further investigation in larger controlled trials.
{"title":"Medical Marijuana for Pain Management in Hospice Care as a Complementary Approach to Scheduled Opioids: A Single Arm Study.","authors":"Theodore Zanker, Joseph Sacco, James Prota, Michelle Palma, Kyoung A Viola Lee, Ruixiao Rachel Wang, Yixuan Liang, James Cunningham, Mona Mackary, Polina Ovchinnikova","doi":"10.1177/10499091231213359","DOIUrl":"10.1177/10499091231213359","url":null,"abstract":"<p><p><b>Background</b>: Opioid therapy is critical for pain relief for most hospice patients but may be limited by adverse side effects. Combining medical cannabis with opioids may help mitigate adverse effects while maintaining effective pain relief. <b>Aim</b>: This single-arm study investigated the impact of combined medical cannabis/opioid therapy on pain relief, opioid dose, appetite, respiratory function, well-being, nausea, and adverse events in hospice inpatients. <b>Design</b>: Adult hospice inpatients using scheduled oral, parenteral, or transdermal opioids for pain were administered standardized oral medical cannabis, 40 mg CBD/1.5 mg THC or 80 mg CBD/3 mg THC. Descriptive statistics detailed demographic and clinical baseline characteristics, the Mann-Whitney test compared outcomes, and the longitudinal mixed effects regression model analyzed longitudinal effects of combined therapy. <b>Setting/Participants</b>: Sixty-six inpatients at The Connecticut Hospital, Inc. were assessed over 996 treatment days; average age was 68.2 ± 12.9 years, 90.9% were white. Cancer was the most common diagnosis. <b>Results</b>: The medical cannabis/opioid combination showed a significant longitudinal reduction in pain intensity (<i>P</i> = .0029) and a non-significant trend toward lower opioid doses. Well-being, appetite, nausea, and respiratory function showed non-statistically significant changes. Three patients (4.5%) experienced minor, reversible adverse events potentially related to medical cannabis. No serious or life-threatening adverse events were seen. <b>Conclusion</b>: Combination medical cannabis/opioid therapy showed statistically significant pain relief and may have the potential for reducing opioid dose and mitigating opioid toxicity, offering a safe pain management alternative to opioids alone for patients in end-of-life care settings, and warrants further investigation in larger controlled trials.</p>","PeriodicalId":94222,"journal":{"name":"The American journal of hospice & palliative care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138812708","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2023-10-02DOI: 10.1177/10499091231204943
Ethan Molitch-Hou, Hui Zhang, Pooja Gala, Alexandra Tate
Purpose: Code status orders are standard practice impacting end-of-life care for individuals. This study reviews the impact of a COVID unit on physician behaviors towards goal-concordant end-of-life care at an urban academic tertiary-care hospital. Methods: We conducted a retrospective cohort study of code status ordering on adult inpatients comparing the pre-pandemic period to patients who tested positive, negative and were not tested during the pandemic from January 1, 2019, to December 31, 2020. Results: We analyzed 59,471 unique patient encounters (n = 35,317 pre-pandemic and n = 24,154 during). 1,631 cases of COVID-19 were seen. The rate of code status orders among all inpatients increased from 22% pre-pandemic to 29% during the pandemic (P < .001). Code status orders increased for both patients who were COVID-negative (32% P < .001) and COVID-positive (65% P < .001). Being in a cohorted COVID unit increased code status ordering by an odds of 4.79 (P < .001). Compared to the pre-pandemic cohort, the COVID-positive cohort is less female (50% to 56% P < .001), more Black (66% to 61% P < .001), more Hispanic (6.5% to 5%) and less white (26% to 30% P < .001). Compared to Black patients, white patients had lower odds (.86) of code status ordering (P < .001). Other race/ethnicity categories were not significant. Conclusions: Code status ordering remains low. Compared to pre-pandemic rates, the frequency of orders placed significantly increased for all patients during the pandemic. The largest increase occurred in patients with COVID-19. This increase likely occurred due to protocols in the COVID unit and disease uncertainty.
{"title":"Impact of the COVID-19 Public Health Crisis and a Structured COVID Unit on Physician Behaviors in Code Status Ordering.","authors":"Ethan Molitch-Hou, Hui Zhang, Pooja Gala, Alexandra Tate","doi":"10.1177/10499091231204943","DOIUrl":"10.1177/10499091231204943","url":null,"abstract":"<p><p><b>Purpose:</b> Code status orders are standard practice impacting end-of-life care for individuals. This study reviews the impact of a COVID unit on physician behaviors towards goal-concordant end-of-life care at an urban academic tertiary-care hospital. <b>Methods:</b> We conducted a retrospective cohort study of code status ordering on adult inpatients comparing the pre-pandemic period to patients who tested positive, negative and were not tested during the pandemic from January 1, 2019, to December 31, 2020. <b>Results:</b> We analyzed 59,471 unique patient encounters (n = 35,317 pre-pandemic and n = 24,154 during). 1,631 cases of COVID-19 were seen. The rate of code status orders among all inpatients increased from 22% pre-pandemic to 29% during the pandemic (<i>P</i> < .001). Code status orders increased for both patients who were COVID-negative (32% <i>P</i> < .001) and COVID-positive (65% <i>P</i> < .001). Being in a cohorted COVID unit increased code status ordering by an odds of 4.79 (<i>P</i> < .001). Compared to the pre-pandemic cohort, the COVID-positive cohort is less female (50% to 56% <i>P</i> < .001), more Black (66% to 61% <i>P</i> < .001), more Hispanic (6.5% to 5%) and less white (26% to 30% <i>P</i> < .001). Compared to Black patients, white patients had lower odds (.86) of code status ordering (<i>P</i> < .001). Other race/ethnicity categories were not significant. <b>Conclusions:</b> Code status ordering remains low. Compared to pre-pandemic rates, the frequency of orders placed significantly increased for all patients during the pandemic. The largest increase occurred in patients with COVID-19. This increase likely occurred due to protocols in the COVID unit and disease uncertainty.</p>","PeriodicalId":94222,"journal":{"name":"The American journal of hospice & palliative care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10985045/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41149653","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}