Does Diagnosis Make a Difference? Comparing Hospice Care Satisfaction in Matched Cohorts of Heart Failure and Cancer Caregivers

Hospice Satisfaction Among Patients, Family, and Caregivers: A Systematic Review of the Literature

Background: Hospice care is an underused form of intervention at the end of life. The experiences of patients, families, and other caregivers are important to consider in thinking about how to encourage greater use of hospice care, through policies and advocacy that promote its benefits. Specifically, patient, family, and other caregiver satisfaction with hospice care is important to understand better. Methods: A PRISMA-guided review of the research on hospice care satisfaction and its correlates among patients, families, and other caregivers. Included in the review is research published over the time period 2000-2023 identifying a hospice care satisfaction finding. Results: Thirty-eight studies were included in the review. Key findings were: (a) higher levels of hospice care satisfaction among patients, families, and other caregivers; and (b) correlates of hospice care satisfaction falling into the categories of communication, comfort, and support. The published literature had fewer findings related to demographic correlates of satisfaction such as age or race/ethnicity and was lacking in comparative research examining satisfaction across different types of hospice care settings. Discussion: Extant research demonstrates a consistently higher level of hospice care satisfaction among patients, families, and other caregivers. This satisfaction appears related to specific aspects of care delivery that involve effective care coordination and communication; pain and symptom management; and emotional support. Strengthening future research involves testing additional interventions aimed at enhancing satisfaction; including more comparative research across hospice care settings; and more studies that include patients as the key respondents.

How Do We Start Palliative Care for Patients With End-Stage Liver Disease?

Patients with end-stage liver disease undergo repetitive patterns of recovery and deterioration and are burdened with uncertainty. Although quality of life is low in patients with end-stage liver disease and their family members, few studies have been conducted to identify what palliative care should be provided for them. This integrative review aimed to explore palliative care for patients with end-stage liver disease, focusing on the components and outcome measurements for further research. After searching for studies on palliative care for end-stage liver disease published between 1995 and 2017, 12 studies that met the inclusion criteria were analyzed. The common components of palliative care for patients with liver disease were: (a) an interdisciplinary approach, (b) early palliative care, (c) discussion goals of care with patient and family members, (d) symptom management, and (e) psychosocial support. It was reported that patients who were provided palliative care had improved itching, well-being, appetite, anxiety, fatigue, and depression, increased the number of do-not-resuscitate orders, palliative care consultations, and decreased length of stay. These findings could guide the development of palliative care for end-stage liver disease patients.

Quality of life of older adults with complicated grief: A thematic analysis

Approximately 15% of the general population has complicated grief (CG). Understanding how older adults with CG describe their quality of life (QOL) is crucial to healthcare workers especially in hospice and mental health settings. Four themes for QOL emerged from the thematic analysis of semi-structured interviews. From highest to lowest endorsement, they were Mental Function (sub-themes: mental health, joy, and happiness), Self-management (sub-themes: self-efficacy and self-agency), Social Support, and Physical Function. This study provides new information related to the relationships between CG and QOL among older adults. Multidimensional aspects of QOL can provide insight into delivering individualized patient- and family-centered care.

Examining the Relationship Between Patient Fatigue-Related Symptom Clusters and Carer Depressive Symptoms in Advanced Cancer Dyads: A Secondary Analysis of a Large Hospice Data Set

BACKGROUND

Most symptom management takes place in the community, conducted by patient and/or informal carer dyads with guidance from clinicians. Given the prevalence of cancer, there is a critical need for examination of the impact of managing multiple symptoms, particularly those that cluster with fatigue, on informal carers.

OBJECTIVES

To (1) examine clustering of patient fatigue-related symptom severity and distress in individuals with cancer and (2) test the hypothesis that patient fatigue-related symptom clusters (severity, distress) will be positively associated with carer depressive symptoms.

METHODS

Secondary analysis of 689 hospice patient/informal carer dyads using exploratory factor analysis and structural equation modeling. Patient symptoms were measured by the Memorial Symptom Assessment Scale, and carer depressive symptoms were measured by the Center for Epidemiological Study-Depression Scale.

RESULTS

Patients were 73 (SD, 12) years old, and 43% were female. Carers were 65 years (SD, 14) years old, and 74% were female. For symptom severity, dyspnea, dry mouth, lack of appetite, drowsiness, cough, dizziness, and difficulty swallowing clustered with fatigue. For symptom distress, dyspnea, cough, and dry mouth clustered with fatigue. Structural equation modeling results indicated that the patient fatigue severity cluster was positively related to carer depressive symptoms (b = 0.12, P < .05), but distress was not.

CONCLUSION

Managing multiple symptoms that cluster with fatigue negatively impacts informal carers.

IMPLICATIONS FOR PRACTICE

When patients complain of severe fatigue, clinicians need to explore all causes and ask about other symptoms while exploring whether the informal carer is feeling burdened or depressed.

Care for carers: A concept analysis of support for carers of ill relatives

The aim of the study is to clarify the concept "care for carers," and enhance our understanding of caring for carers of ill relatives. Healthcare professionals often refer to "care for carers" when discussing methods to support the carers of ill family relatives. These carers do not always receive the support they need. A literature search of electronic databases and search engines, using the keywords carer, caregiver, caring for the carer, caring for the caregiver was done. Peer-reviewed research articles published between 2014 and 2019 and written in the English language were analyzed. Following retrieval, research articles were analyzed to describe the uses, attributes, antecedents, consequences, and empirical referents of the concept "care for carers." Research articles describing borderline, related, contrary, and illegitimate examples were included. "Care for carers" addresses the unique support needs of those taking care of ill family members. Carers may derive a sense of empowerment from receiving individualized and proactively rendered support. Carers should be supported to develop control over their circumstances, to find meaning in their caring, to become resilient when experiencing challenges, and to confirm their identity as carers of their ill relatives.

Psychosocial needs and interventions for heart failure patients and families receiving palliative care support: a systematic review

Although diseases of the heart are the leading cause of death in the USA, palliative care research has largely focused on populations of cancer patients. However, a diagnosis of heart failure differs substantially than that of cancer. They differ in terms of signs and symptoms, disease trajectories, treatment options, stigma, and prognosis. Additionally, the populations affected by these differing illnesses are also unique in a number of fundamental ways. Based on these differences, it is reasonable to hypothesize that palliative care patients with heart failure, and their families, have a distinct set of psychosocial needs. The purpose of this review is to describe the psychosocial needs of palliative care heart failure patients, and their families, as well as the interventions that address those needs. Six electronic databases were searched in June 2016 resulting in 962 identified abstracts. After removal of 388 duplicates, 574 abstracts were screened based on the following criteria: (1) available in English, (2) peer-reviewed, (3) empirical data reported, (4) patient receiving palliative or hospice care, and (5) measured psychosocial needs of heart failure patients and/or their family caregivers. After screening 574 abstracts and conducting a full-text review of 150 articles, a total of 17 studies were identified in our review. Only three intervention studies were identified, two of which evaluated the impact of palliative care over usual care. The remaining study was a clinical trial of a psycho-educational support intervention, which failed to demonstrate beneficial outcomes. Heart failure patients and their family caregivers receiving palliative or hospice care have unique psychosocial needs that are largely unexamined by previous research. The need for further research is discussed.

Quality of Hospice Care at Home Versus in an Assisted Living Facility or Nursing Home

OBJECTIVES

To describe differences in perceived quality of hospice care for individuals living at home or in a nursing home (NH) or assisted living facility (ALF) through analysis of after-death surveys of family members.

DESIGN

Retrospective cohort study using hospice medical record data and Family Evaluation of Hospice Care (FEHC) survey data.

SETTING

Large, national hospice provider.

PARTICIPANTS

Individuals who died while receiving routine hospice care and family caregivers who completed after-death quality-of-care surveys.

MEASUREMENTS

Survey results for 7,510 individuals were analyzed using analysis of variance and chi-square tests. Logistic regression was used to assess relationship between location of care and overall service quality.

RESULTS

The overall survey response rate was 27%; 34.5% of families of individuals in ALFs in hospice, 27.4% of those at home, and 22.9% of those in NHs returned the survey (P < .001). Differences in return rate according to primary diagnosis were significant, although differences were not large. Most (84.3%) respondents reported that hospice referral had occurred at the right time, and 63.4% rated service quality as excellent. Hospice care in the NH was less likely to be perceived as excellent.

CONCLUSION

There were significant differences in characteristics of individuals whose family members did and did not return surveys, which has implications for use of after-death surveys to evaluate hospice quality. Lower perceived quality of hospice care in NHs may be related to general dissatisfaction with receiving care in this setting. Survey results have the potential to set priorities for quality improvement, choice of provider, and potentially reimbursement. Underlying causes of differences of perceived quality in different settings of care should be examined.

Communication among cancer patients, caregivers, and hospice nurses: Content, process and change over time

OBJECTIVE

First, to describe communication of home hospice nurse visits to cancer patient-caregiver dyads. Second, to assess change in communication related to domains of care over the course of visits.

METHODS

Multi-site prospective observational longitudinal study of audio-recorded home hospice visits (N=537 visits; 101 patient-caregiver dyads; 58 nurses). Communication was coded using the Roter Interaction Analysis System to describe content and process. Conversation representing three care domains (physical, psychosocial/daily life, and emotional) was calculated from RIAS categories across speakers and analyzed to assess change in communication over time.

RESULTS

On average, nurses spoke 54% of total utterances, caregivers 29%, and patients 17%. For all participants, the predominant conversational focus was on physical care. Linear mixed effects models indicated that combined participant emotional talk showed a small systematic decrease over time; however, the results for all domains indicated variability unexplained by time or speaker effects.

CONCLUSIONS

Home hospice conversations are predominantly focused on physical care. Systematic change in communication versus responsiveness to the dynamic effects of patient death and family response over time are discussed.

PRACTICE IMPLICATIONS

Communication strategies already in use by hospice nurses could be leveraged and expanded upon to better facilitate family competence and confidence.

Hospice Enrollment in Patients With Advanced Heart Failure Decreases Acute Medical Service Utilization

BACKGROUND

Patients with advanced heart failure (HF) enroll in hospice at low rates, and data on their acute medical service utilization after hospice enrollment is limited.

METHODS AND RESULTS

We performed a descriptive analysis of Medicare fee-for-service beneficiaries, with at least one home health claim between July 1, 2009, and June 30, 2010, and at least 2 HF hospitalizations between July 1, 2009, and December 31, 2009, who subsequently enrolled in hospice between July 1, 2009, and December 31, 2009. We estimated panel-negative binomial models on a subset of beneficiaries to compare their acute medical service utilization before and after enrollment. Our sample size included 5073 beneficiaries: 55% were female, 45% were ≥85 years of age, 13% were non-white, and the mean comorbidity count was 2.38 (standard deviation 1.22). The median number of days between the second HF hospital discharge and hospice enrollment was 45. The median number of days enrolled in hospice was 15, and 39% of the beneficiaries died within 7 days of enrollment. During the study period, 11% of the beneficiaries disenrolled from hospice at least once. The adjusted mean number of hospital, intensive care unit, and emergency room admissions decreased from 2.56, 0.87, and 1.17 before hospice enrollment to 0.53, 0.19, and 0.76 after hospice enrollment.

CONCLUSIONS

Home health care Medicare beneficiaries with advanced HF who enrolled in hospice had lower acute medical service utilization after their enrollment. Their pattern of hospice use suggests that earlier referral and improved retention may benefit this population. Further research is necessary to understand hospice referral and palliative care needs of advanced HF patients.

Palliative Care in Heart Failure: What Triggers Specialist Consultation?

Heart failure (HF) continues to cause substantial death and suffering despite the availability of numerous medical, surgical, and technological therapeutic advancements. As a patient-centered holistic discipline focused on improving quality of life and decreasing anguish, palliative care (PC) has a crucial role in the care of HF patients that has been acknowledged by multiple international guidelines. PC can be provided by all members of the HF care team, including but not limited to practitioners with specialty PC training. Unfortunately, despite recommendations to routinely include PC techniques and providers in the care of HF patients, use of general PC strategies as well as expert PC consultation is limited by a dearth of evidence-based interventions in the HF population and knowledge as to when to initiate these interventions, uncertainty regarding patient desires, prognosis, and the respective roles of each member of the care team, and a general shortage of specialist PC providers. This review seeks to provide guidance as to when to employ the limited resource of specialist PC practitioners, in combination with services from other members of the care team, to best tend to HF patients as their disease progresses and eventually overcomes.

Health-Care Utilization After Hospice Enrollment in Patients With Heart Failure and Cancer

This study aimed to examine the role of diagnosis in health-care utilization patterns after hospice enrollment. Using 2007 National Home and Hospice Care Survey data from hospice patients with heart failure (n = 311) and cancer (n = 946), we analyzed emergency service use and discharge to hospital via logistic regression pre- and postpropensity score matching. Prematching, patients with heart failure had twice the odds of emergency services use than patients with cancer ( P < .001) and twice the odds of discharge to hospital ( P = .02). Differences were reduced postmatching for emergency service use (odds ratio [OR]: 1.6, P = .05) and eliminated for discharge to hospital (OR: 1.32, P = .45). Health-care utilization correlates included diagnosis, place of care, and advance directives. Attention to the unique needs of patients with heart failure is needed, along with improved advanced care planning.

A Prognostic Indicator for Patients Hospitalized with Heart Failure

BACKGROUND

Current methods for identifying patients at risk of dying within six months suffer from clinician biases resulting in underestimation of this risk. As a result, patients who are potentially eligible for hospice and palliative care services frequently do not benefit from these services until they are very close to the end of their lives.

OBJECTIVE

To develop a prospective prognostic indicator based on actual survival within Centers for Medicare and Medicaid Services (CMS) claims data that identifies patients with congestive heart failure (CHF) who are at risk of six-month mortality.

METHODS

CMS claims data from January 1, 2008 to June 30, 2009 were reviewed to find the first hospitalization for CHF patients with episode of care diagnosis-related groups (DRGs) 291, 292, and 293. Univariate and multivariable analyses were used to determine the associations between demographic and clinical factors and six-month mortality. The resulting model was evaluated for discrimination and calibration.

RESULTS

The resulting prospective prognostic model demonstrated fair discrimination with an ROC of 0.71 and good calibration with a Hosmer-Lemshow statistic of 0.98. Across all DRGs, 5% of discharged patients had a six-month mortality risk of greater than 50%.

CONCLUSION

This prospective approach appears to provide a method to identify patients with CHF who would potentially benefit from a clinical evaluation for referral to hospice care or for a palliative care consult due to high predicted risk of dying within 180 days after discharge from a hospital. This approach can provide a model to match at-risk patients with evidenced-based care in a more consistent manner. This method of identifying patients at risk needs further prospective evaluation to see if it has value for clinicians, increases referrals to hospice and palliative care services, and benefits patients and families.

Unique Correlates of Heart Failure and Cancer Caregiver Satisfaction With Hospice Care

CONTEXT

Heart failure patients, along with their informal caregivers are increasingly enrolling in hospice care. Caregiver satisfaction with hospice care is a key quality indicator. The role that diagnosis plays in shaping satisfaction is unclear.

OBJECTIVES

Our aim was to identify unique correlates of caregiver satisfaction in heart failure and cancer caregivers and explore whether the identified correlates differ between the two diagnosis groups.

METHODS

This was a retrospective cohort study of national data collected in 2011 by the National Hospice and Palliative Care Organization using the 61-item Family Evaluation of Hospice Care survey. We used complete Family Evaluation of Hospice Care responses of adult heart failure (n = 7324) and cancer (n = 23,871) caregivers. Multiple logistic regression was used to examine the relationship between possible correlates and caregiver satisfaction. Correlates examined included caregiver and patient demographics, patient clinical characteristics, and hospice characteristics.

RESULTS

Caregiver-reported patient dyspnea was associated with global and symptom management satisfaction in the heart failure cohort, whereas caregiver race was associated with global and symptom management satisfaction in the cancer cohort. Nursing home placement was associated with lower satisfaction odds in both cancer and heart failure cohorts, but heart failure patients were twice as likely as cancer patients to receive care in a nursing home.

CONCLUSION

This study generated hypotheses about unique factors related to caregiver satisfaction among two diagnosis cohorts that require further study, particularly the impact of race on satisfaction in the cancer cohort and the management of dyspnea in heart failure hospice patients.