Settings of Care within Hospice: New Options and Questions about Dying "At Home"

Social Model Hospice Home: A Concept Analysis

The term social model hospice first appeared late in the 20th century as a label for a complementary model to medical hospice care. Two decades later, the term is inconsistently defined and used by scholars, health care providers, public consumers, and those within the movement. The purpose of this review is to trace the development of the concept and confirm an evolving definition based on Rodgers' evolutionary method. Database and hand searching was done for the years 1975 to 2020, resulting in 25 publications for analysis. Unique antecedents include presence of a resource crisis, unmet needs falling outside the scope of medical hospice care, and desire to experience death outside the medical system and/or personal home. Attributes include a dedicated home, round-the-clock, individualized end-of-life care; care option when dying at home becomes unmanageable; collaboration with medical hospice services; nonprofit organization funded by community philanthropy; environment to support loved ones; and community volunteer involvement. Noted consequences are effective end-of-life care for dying patients and their families, innovative health care design, nationwide network of like-minded providers, and platform for end-of-life community education. Clarity of the concept will facilitate access to end-of-life care, further the model's development, formalize research endeavors, and foster community education.

Palliative Paracentesis in the Home Setting: A Case Series

BACKGROUND

Management of ascites-related symptoms in home hospice and palliative care patients can be challenging. Ultrasound-guided paracentesis is a standard intervention for this indication, but generally requires transfer to a hospital or outpatient interventional-radiology (IR) setting; thus, such interventions are often not practical or attainable for home hospice and palliative care patients.

OBJECTIVE

To describe a mobile, in-home service that provides home-based palliative paracentesis (HBPP) as an interventional palliative option for patients with distressing symptoms related to ascites.

DESIGN

Retrospective case series. Setting/Subjects: Thirty patients with ascites, confirmed by portable bedside ultrasound, who underwent HBPP at their residence.

RESULTS

Thirty-three patients were referred for HBPP for symptomatic abdominal distention from March 1, 2019 to March 1, 2020. Thirty (91%) patients had ultrasound-confirmed ascites and received HBPP. All 30, verbalized appreciable symptom relief post-intervention. There were no reported post-procedural complications.

CONCLUSION

Home-based palliative paracentesis is a safe, effective, and convenient intervention for hospice and palliative care patients with symptomatic ascites.

Transforming End-of-Life Care by Implementing a Patient-Centered Care Model: Findings From an Action Research Project

Patient-centered care is valued by health care professionals working in palliative care settings. However, studies have revealed the difficulty of adopting patient-centered care in daily practice and of sharing its meaning within the interdisciplinary team. The aim of this study was to report the process of transforming end-of-life care by implementing a patient-centered model of care in an Italian hospice. An action research process was conducted between June 2012 and June 2014. The following phases were performed: (a) "looking" phase: the diagnosis was established by collecting data through semistructured interviews in the field study and through the administration of the Frommelt Attitude Toward the Care of the Dying Scale Form B-Italian Version; (b) "thinking" phase: staff members, guided by a research team, redesigned practice by identifying priorities in improvements and actions through multiprofessional focus groups; (c) "acting" phase: actions identified in the previous phase were implemented; and (d) "relooking" phase: the same data collection processes used in the looking phase were applied to evaluate the outcomes achieved. Three areas of improvement have been established: (1) symptoms were intensively audited through patient self-reports by using validated tools; (2) patients' family needs were also regularly collected, documented in clinical records, and addressed; (3) patients' family members were involved in the plan of care through support and education. Inpatient hospice health carers in this study were aware of the concept of patient-centered care. However, its actual implementation was lacking. An action research approach helped them to implement expected changes.

Predicting Length of Hospice Stay: An Application of Quantile Regression

BACKGROUND

Use of the Medicare hospice benefit has been associated with high-quality care at the end of life, and hospice length of use in particular has been used as a proxy for appropriate timing of hospice enrollment. Quantile regression has been underutilized as an alternative tool to model distributional changes in hospice length of use and hospice payments outside of the mean.

OBJECTIVE

To test for heterogeneity in the relationship between patient characteristics and hospice outcomes across the distribution of hospice days.

SETTING

Medicare Beneficiary Summary File and survey data (2014) for hospice beneficiaries in North and South Carolina with common terminal diagnoses.

MEASUREMENTS

Distributional shifts associated with patient characteristics were evaluated at the 25th and 75th percentiles of hospice days and hospice payments using quantile regressions and compared to the mean shift estimated by ordinary least squares (OLS) regression.

PRINCIPAL FINDINGS

Significant (p < 0.001) heterogeneity in the marginal effects on hospice days and costs was observed, with patient characteristics associated with generally larger shifts in the 75th percentile than the 25th percentile. Mean effects estimated by OLS regression overestimate the magnitude of the median marginal effects for all patient characteristics except for race. Results for hospice payments in 2014 were similar.

CONCLUSIONS

Methodological decisions can have a meaningful impact in the evaluation of factors influencing hospice length of use or cost.

Being-in-the-Chemotherapy-Suite versus Being-in-the-Oncology-Ward: An Analytical View of Two Hospital Sites Occupied by People Experiencing Cancer

How do people with cancer occupy places within the health system during their journey through palliative care? The answer to this question was explored by the authors as part of a wider ethnographic study of eight people's journeys from referral to palliative care services to the end of life. This article reports on findings that have emerged from ongoing analysis that has been completed in the years proceeding data collection. An ethnographic research design was used to collect data about the participants and their family members over a three-year period. Data was collected using participant observation and semi-structured interviews. Over 380 transcripts based on field note entries and taped interviews were produced during the 1121 h of contact with participants and family members that made up the research period. Analysis of these texts identified two focal sites within Christchurch Hospital that were occupied by the participants. These were the Chemotherapy Suite and the Oncology Ward. Drawing on literature concerning previous anthropological analysis, research was conducted to understand how places affect people and how people affect places. The researchers have used a model outlined by the American ethnographer Miles Richardson to analyse two distinct sites within one hospital. As explained in Richardson's article, whose title is used to model the title of this article, a sense of place becomes apparent when comparing and contrasting two sites within the same location. Richardson's article is highly interpretative and relies not only on pre-existing theoretical frameworks but also on personal interpretation. The same approach has been used in the current article. Here, ethnographic methods require the researcher's interpretation of how participants occupied these sites. Following this approach, the Chemotherapy Suite is presented as a place where medicine dominates illness, and appears as distinct from the Oncology Ward, where disease predominates and death is secreted away.

Quality of End-of-Life Care Provided to Patients With Different Serious Illnesses

IMPORTANCE

Efforts to improve end-of-life care have focused primarily on patients with cancer. High-quality end-of-life care is also critical for patients with other illnesses.

OBJECTIVE

To compare patterns of end-of-life care and family-rated quality of care for patients dying with different serious illnesses.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cross-sectional study was conducted in all 146 inpatient facilities within the Veteran Affairs health system among patients who died in inpatient facilities between October 1, 2009, and September 30, 2012, with clinical diagnoses categorized as end-stage renal disease (ESRD), cancer, cardiopulmonary failure (congestive heart failure or chronic obstructive pulmonary disease), dementia, frailty, or other conditions. Data analysis was conducted from April 1, 2014, to February 10, 2016.

MAIN OUTCOMES AND MEASURES

Palliative care consultations, do-not-resuscitate orders, death in inpatient hospices, death in the intensive care unit, and family-reported quality of end-of-life care.

RESULTS

Among 57 753 decedents, approximately half of the patients with ESRD, cardiopulmonary failure, or frailty received palliative care consultations (adjusted proportions, 50.4%, 46.7%, and 43.7%, respectively) vs 73.5% of patients with cancer and 61.4% of patients with dementia (P < .001). Approximately one-third of patients with ESRD, cardiopulmonary failure, or frailty (adjusted proportions, 32.3%, 34.1%, and 35.2%, respectively) died in the intensive care unit, more than double the rates among patients with cancer and those with dementia (13.4% and 8.9%, respectively) (P < .001). Rates of excellent quality of end-of-life care reported by 34 005 decedents' families were similar for patients with cancer and those with dementia (adjusted proportions, 59.2% and 59.3%; P = .61), but lower for patients with ESRD, cardiopulmonary failure, or frailty (54.8%, 54.8%, and 53.7%, respectively; all P ≤ .02 vs patients with cancer). This quality advantage was mediated by palliative care consultation, setting of death, and a code status of do-not-resuscitate; adjustment for these variables rendered the association between diagnosis and overall end-of-life care quality nonsignificant.

CONCLUSIONS AND RELEVANCE

Family-reported quality of end-of-life care was significantly better for patients with cancer and those with dementia than for patients with ESRD, cardiopulmonary failure, or frailty, largely owing to higher rates of palliative care consultation and do-not-resuscitate orders and fewer deaths in the intensive care unit among patients with cancer and those with dementia. Increasing access to palliative care and goals of care discussions that address code status and preferred setting of death, particularly for patients with end-organ failure and frailty, may improve the overall quality of end-of-life care for Americans dying of these illnesses.

Same agency, different teams: perspectives from home and inpatient hospice care

Tremendous growth in hospice over the past 30 years in the United States has increased the number of terminally ill patients dying at home. Recently, however, more hospice patients are dying at inpatient facilities. To understand the varying perceptions about care in the home and inpatient hospice, we conducted semistructured interviews with 24 interdisciplinary team (IDT) members and analyzed the data using the constant comparative method. Core interdisciplinary tasks, including identifying the focus of energy, tailoring family caregiver involvement, acknowledging who is in charge, and knowing both sides differed in the home and inpatient settings. Despite the overarching umbrella of hospice care, home and inpatient hospice settings create different foci for IDT members, burdens and privileges for family caregivers, and control of the care plan. Key differences between home and inpatient hospice processes of care highlight the complexity of patient-centered end-of-life care in the United States.