Association Between Attending Physicians' Rates of Referral to Palliative Care and Location of Death in Hospitalized Adults With Serious Illness: A Population-based Cohort Study

BACKGROUND

Patients who receive palliative care are less likely to die in hospital.

OBJECTIVE

To measure the association between physician rates of referral to palliative care and location of death in hospitalized adults with serious illness.

RESEARCH DESIGN

Population-based decedent cohort study using linked health administrative data in Ontario, Canada.

SUBJECTS

A total of 7866 physicians paired with 130,862 hospitalized adults in their last year of life who died of serious illness between 2010 and 2016.

EXPOSURE

Physician annual rate of referral to palliative care (high, average, low).

MEASURES

Odds of death in hospital versus home, adjusted for patient characteristics.

RESULTS

There was nearly 4-fold variation in the proportion of patients receiving palliative care during follow-up based on attending physician referral rates: high 42.4% (n=24,433), average 24.7% (n=10,772), low 10.7% (n=6721). Referral to palliative care was also associated with being referred by palliative care specialists and in urban teaching hospitals. The proportion of patients who died in hospital according to physician referral rate were 47.7% (high), 50.1% (average), and 52.8% (low). Hospitalized patients cared for by a physician who referred to palliative care at a high rate had lower risk of dying in hospital than at home compared with patients who were referred by a physician with an average rate of referral [adjusted odds ratio 0.91; 95% confidence interval, 0.86-0.95; number needed to treat=57 (interquartile range 41-92)] and by a physician with a low rate of referral [adjusted odds ratio 0.81; 95% confidence interval, 0.77-0.84; number needed to treat =28 patients (interquartile range 23-44)].

CONCLUSIONS AND RELEVANCE

An attending physicians' rates of referral to palliative care is associated with a lower risk of dying in hospital. Therefore, patients who are cared for by physicians with higher rates of referral to palliative care are less likely to die in hospital and more likely to die at home. Standardizing referral to palliative care may help reduce physician-level variation as a barrier to access.

Concurrent Hospice Care and Cancer-Directed Treatment for Advanced Lung Cancer and Receipt of Aggressive Care at the End of Life in the Veteran's Health Administration

Background: Aggressive care at the end of life (EOL) is a persistent issue for patients with stage IV nonsmall cell lung cancer (NSCLC). We evaluated the use of concurrent care (CC) with hospice care and cancer-directed treatment simultaneously within the Veteran's Health Administration (VHA) and aggressive care at the EOL. Objective: To determine whether VHA facility-level CC is associated with changes in aggressive care at the EOL. Design/Setting: Veterans with stage IV NSCLC who died between 2006 and 2012 and received lung cancer care within the VHA. Measurements: The primary outcome was aggressive care at EOL (i.e., hospital admissions, chemotherapy, and intensive care unit) within the last month of life. To compare aggressive care across VHA facilities, we used a random intercept multilevel logistic regression model to examine the association between facility-level CC within each study year (<10%, 10% to 19%, and ≥20%) and aggressive care at the EOL among the decedents as a binary outcome. Results: In total, 18,371 veterans with NSCLC at 154 VHA facilities were identified. Facilities delivering CC for ≥20% of veterans (high CC) increased from 20.0% in 2006 to 43.2% in 2012 (p < 0.001). Overall, hospice care significantly increased and aggressive care at EOL decreased over the study period. However, facility-level CC adoption was not associated with any difference in aggressive care at EOL (adjusted odds ratio high CC vs. low CC: 0.91 [95% CI, 0.79 to 1.05], p = 0.21). Conclusions: Although the VHA adoption of CC increased hospice use among patients with NSCLC, additional measures may be needed to decrease aggressive care at the EOL.

Physician Characteristics Strongly Predict Patient Enrollment In Hospice

Individual physicians are widely believed to play a large role in patients' decisions about end-of-life care, but little empirical evidence supports this view. We developed a novel method for measuring the relationship between physician characteristics and hospice enrollment, in a nationally representative sample of Medicare patients. We focused on patients who died with a diagnosis of poor-prognosis cancer in the period 2006-11, for whom palliative treatment and hospice would be considered the standard of care. We found that the proportion of a physician's patients who were enrolled in hospice was a strong predictor of whether or not that physician's other patients would enroll in hospice. The magnitude of this association was larger than that of other known predictors of hospice enrollment that we examined, including patients' medical comorbidity, age, race, and sex. Patients cared for by medical oncologists and those cared for in not-for-profit hospitals were significantly more likely than other patients to enroll in hospice. These findings suggest that physician characteristics are among the strongest predictors of whether a patient receives hospice care-which mounting evidence indicates can improve care quality and reduce costs. Interventions geared toward physicians, both by specialty and by previous history of patients' hospice enrollment, may help optimize appropriate hospice use.

Palliative Wound Care at the End of Life

Wound care, a form of palliative care, supports the health care needs of dying patients by focusing on alleviating symptoms. Although wound care can be both healing and palliative, it can impair the quality of the end of life for the dying if it is done without proper consideration of the patient’s wishes and best interests. Wound care may be optional for dying patients. This article will discuss the ethical responsibilities and challenges of providing wound care for surgical wounds, pressure ulcers, and wounds associated with cancer as well as wound care in home health compared to end of life.

The development and piloting of the REnal specific Advanced Communication Training (REACT) programme to improve Advance Care Planning for renal patients

BACKGROUND

In recent years, the End-Stage Kidney Disease population has increased and is ever more frail, elderly and co-morbid. A care-focused approach needs to be incorporated alongside the disease focus, to identify those who are deteriorating and improve communication about preferences and future care. Yet many renal professionals feel unprepared for such discussions.

AIM

To develop and pilot a REnal specific Advanced Communication Training (REACT) programme to address the needs of End-Stage Kidney Disease patients and renal professionals.

DESIGN

Two-part study: (1) development of the REnal specific Advanced Communication Training programme informed by multi-professional focus group and patient survey and (2) piloting of the programme.

SETTING/PARTICIPANTS

The REnal specific Advanced Communication Training programme was piloted with 16 participants (9 renal nurses/health-care assistants and 7 renal consultants) in two UK teaching hospitals.

RESULTS

The focus group identified the need for better information about end-of-life phase, improved awareness of patient perspectives, skills to manage challenging discussions, 'hands on' practice in a safe environment and follow-up to discuss experiences. The patient survey demonstrated a need to improve communication about concerns, treatment plans and decisions. The developed REnal specific Advanced Communication Training programme was acceptable and feasible and was associated with a non-significant increase in confidence in communicating about end-of-life issues (pre-training: 6.6/10, 95% confidence interval: 5.7-7.4; post-training: 6.9/10, 95% confidence interval: 6.1-7.7, unpaired t-test - p = 0.56), maintained at 3 months.

CONCLUSION

There is a need to improve end-of-life care for End-Stage Kidney Disease patients, to enable them to make informed decisions about future care. Challenges include prioritising communication training among service providers.

Hospices' enrollment policies may contribute to underuse of hospice care in the United States

Hospice use in the United States is growing, but little is known about barriers that terminally ill patients may face when trying to access hospice care. This article reports the results of the first national survey of the enrollment policies of 591 US hospices. The survey revealed that 78 percent of hospices had at least one enrollment policy that may restrict access to care for patients with potentially high-cost medical care needs, such as chemotherapy or total parenteral nutrition. Smaller hospices, for-profit hospices, and hospices in certain regions of the country consistently reported more limited enrollment policies. We observe that hospice providers' own enrollment decisions may be an important contributor to previously observed underuse of hospice by patients and families. Policy changes that should be considered include increasing the Medicare hospice per diem rate for patients with complex needs, which could enable more hospices to expand enrollment.

Developing and Testing a Web-Based Survey to Assess Educational Needs of Palliative and End-of-Life Health Care Professionals in Connecticut

Institute of Medicine reports have identified gaps in health care professionals' knowledge of palliative and end-of-life care, recommending improved education. Our purpose was to develop and administer a Web-based survey to identify the educational needs of multidisciplinary health care professionals who provide this care in Connecticut to inform educational initiatives. We developed an 80-item survey and recruited participants through the Internet and in person. Descriptive and correlational statistics were calculated on 602 surveys. Disciplines reported greater agreement on items related to their routine tasks. Reported needs included dealing with cultural and spiritual matters and having supportive resources at work. Focus groups confirmed results that are consistent with National Consensus Project guidelines for quality palliative care and indicate the End-of-Life Nursing Education Consortium modules for education.

Understanding their options: determinants of hospice discussion for older persons with advanced illness

BACKGROUND

Clinicians' discussions about hospice with patients and families are important as a means of communicating end-of-life options.

OBJECTIVE

To identify determinants of clinicians' hospice discussions and the impact of such discussions on hospice use.

DESIGN

We interviewed 215 patients age > or = 60 years with advanced cancer, chronic obstructive pulmonary disease (COPD), or heart failure (HF) at least every 4 months for up to 2 years. Participants provided information about their health status and treatment preferences. Clinicians completed a questionnaire every 6 months about their estimates of patient life expectancy and their communication with the patient and family about hospice.

RESULTS

In their final survey, clinicians reported discussing hospice with 46% of patients with cancer, compared to 10% with COPD and 7% with HF. Apart from diagnosis of cancer, the factors most strongly associated with hospice discussion were clinicians' estimate of and certainty about patient life expectancy (P < 0.001). However, clinicians were unable to anticipate the deaths of a considerable portion of patients (40%). Although patient unwillingness to undergo minor medical interventions was associated with hospice discussion (P < 0.05), a sizeable portion of clinicians (40%) whose patients reported this characteristic did not have the discussion. Clinicians' discussion of hospice independently increased the likelihood of hospice use (OR = 5.3, 95% CI = 2.3-13).

CONCLUSIONS

Clinicians' discussion of hospice for patients with advanced illness, and, ultimately, patients' use of hospice, relies largely on clinician estimates of patient life expectancy and the predictability of disease course. Many clinicians whose patients might benefit from learning about hospice are not having these discussions.

Communication in end-stage cancer: review of the literature and future research

Concerns have been raised about the quality of life and health care received by cancer patients at the end of life (EOL). Many patients die with pain and other distressing symptoms inadequately controlled, receiving burdensome, aggressive care that worsens quality of life and limits patient exposure to palliative care, such as hospice. Patient-physician communication is likely a very important determinate of EOL care. Discussions of EOL with physicians are associated with an increased likelihood of the following (1) acknowledgment of terminal illness, (2) preferences for comfort care over life extension, and (3) receipt of less intensive, life-prolonging and more palliative EOL care; while this appears to hold for White patients, it is less clear for Black, advanced cancer patients. These results highlight the importance of communication in determining EOL cancer care and suggest that communication disparities may contribute to Black-White differences in EOL care. We review the pertinent literature and discuss areas for future research.

Care in the months before death and hospice enrollment among older women with advanced breast cancer

BACKGROUND

Variations in hospice use are not well understood.

OBJECTIVE

Assess whether care before death, including the types of physicians seen, number of outpatient visits, and hospitalizations, was associated with hospice use and the timing of enrollment.

DESIGN/SETTING

Observational study of a population-based sample of advanced breast cancer patients included in the Surveillance, Epidemiology, and End Results--Medicare database.

PATIENTS

There were 4,455 women aged > or =65 diagnosed with stage III/IV breast cancer during 1992-1999 who died before the end of 2001.

MEASUREMENTS

Hospice use and, among enrollees, enrollment within 2 weeks of death. Independent variables of interest included hospitalizations, outpatient visits, and physicians seen before death.

RESULTS

Adjusted hospice use rates were higher for hospitalized patients (45% if hospitalized for 1-7 days, 46% if 8-20 days, 35% if > or =21 days) than those not hospitalized (31%, P < 0.001). Adjusted rates were also higher among patients seeing a cancer specialist and primary care provider (PCP; 41%) and those seeing a cancer specialist and no PCP (38%) than among those seeing a PCP and no cancer specialist (30%) or neither type of physician (22%; P < 0.001). Hospice use also increased with increasing frequency of outpatient visits (P < 0.001). Hospitalizations, physicians seen, and visits were not associated with referral within 2 weeks of death (all P > or = 0.10).

DISCUSSION

Care before death is associated with hospice use among older women with advanced breast cancer. Additional research is needed to understand better how differences in patient characteristics and disease status influence cancer care before death and the role of various types of physicians in hospice referrals.

Common myths about caring for patients with terminal illness: opportunities to improve care in the hospital setting

BACKGROUND

Shortcomings in the quality of care of hospitalized patients at the end of life are well documented. Although hospitalists and residents are often involved in the care of hospitalized patients with terminal illness, little is known about their knowledge and beliefs concerning terminal illness, despite the importance of such physicians to the quality of care at the end of life.

DESIGN

In 2006 we conducted an exploratory study at a large academic medical center to examine the knowledge, attitudes, and practices of hospitalists and residents (n = 52, response rate = 85.2%) about the care of terminally ill patients. Data were collected using a 22-item survey instrument adapted from previously published instruments.

RESULTS

Several common myths about treating terminally ill patients were identified. These myths pertained to essential aspects of end-of-life care including pain and symptom control, indications for various medications, and eligibility for hospice. Physicians reported positive attitudes about hospice care as well as the belief that many patients who would benefit from hospice do not receive hospice at all or only late in the course of their illness.

CONCLUSIONS

Our findings identified misunderstandings that hospitalists and residents commonly have, including about facts essential to know in order to provide appropriate pain and symptom management. Future interventions to improve knowledge need to focus on specific clinical knowledge about opioid therapy, as well as information about eligibility rules for hospice.

Demographic factors and awareness of palliative care and related services

BACKGROUND

Palliative care is not accessed by all those who can benefit from it. Survey aim: To explore awareness of palliative care and related services among UK oncology out-patients, and to analyse the relationship between demographic characteristics and knowledge.

DESIGN

Cross-sectional interview-based survey. Analysis comprised univariate and multiple logistic regression.

PARTICIPANTS AND SETTINGS

Oncology out-patients receiving curative treatments at two district general hospitals in north-west London between December 2004 and April 2005.

RESULTS

A total of 252 (94%) eligible clinic patients were interviewed. Only 47 (18.7%) patients recognised the term 'palliative care', but 135 (67.8%) understood the role of the hospice, and 164 (66.7%) understood the role of Macmillan nurses. Age-adjusted multiple logistic regression showed that recognizing the term 'palliative care' was more likely among the most socially and materially affluent patients than those who were the poorest (OR: 8.4, CI: 2.17-31.01, p =0.002). Understanding the role of Macmillan nurses was also more likely among the most socially and materially affluent patients compared with the poorest patients (OR: 7.0, CI: 2.41-18.52, p <0.0001), and was independently less likely among patients from black and minority ethnic groups than those who were classified as being white British (OR=0.5, CI:0.25-0.96, p =0.04).

CONCLUSIONS

Awareness of palliative care and related services was low among black and minority ethnic groups, and the least affluent.

Variations in hospice use among cancer patients

BACKGROUND

Previous studies have documented that hospice enrollment by terminally ill cancer patients varies substantially by patient characteristics and across broad geographic regions, but little is known about how local practice patterns and individual physicians contribute to these variations. We examined hospice use within a regional integrated health care delivery system that provides consistent insurance coverage and hospice availability for its members to evaluate the relative importance of patient characteristics, physician characteristics, individual physicians, and local health centers in explaining variations in hospice enrollment.

METHODS

We examined data for 3805 Kaiser Permanente of Northern California health plan enrollees who were diagnosed with and died of lung, colorectal, breast, or prostate cancer from January 1, 1996, through June 30, 2001. We used a random-effects linear probability hierarchical model to estimate adjusted hospice enrollment rates and identify factors associated with hospice enrollment. All P values are two-sided.

RESULTS

Overall, 65.4% of patients enrolled in hospice care before death. In adjusted analyses, hospice enrollment did not vary by patients' race/ethnicity or marital status (all P>.2) but varied substantially among the 11 health centers where patients were treated (standard deviation [SD] of random effect = 10.0 percentage points, corresponding to an estimated adjusted hospice enrollment rate for two-thirds of centers (2 SDs) ranging from 55% to 75%, P = .02). Hospice enrollment varied less among the 675 individual physicians (SD = 4.6 percentage points; P = .09).

CONCLUSIONS

Health care within a large integrated delivery system has the potential to eliminate racial and ethnic disparities in hospice use, but substantial variation in hospice use persists among local health centers. Focused efforts to understand how patients, physicians, and hospices interact at the local level are important to ensure equal access to hospice care for all terminally ill cancer patients.

Communication between physicians and family caregivers about care at the end of life: when do discussions occur and what is said?

BACKGROUND

Few studies have examined physician-family caregiver communication at the end of life, despite the important role families have in end-of-life care decisions. We examined family caregiver reports of physician communication about incurable illness, life expectancy, and hospice; the timing of these discussions; and subsequent family understanding of these issues.

DESIGN

Mixed methods study using a closed-ended survey of 206 family caregivers and open-ended, in-depth interviews with 12 additional family caregivers.

SETTING/SUBJECTS

Two hundred eighteen primary family caregivers of patients with cancer enrolled with hospice between October 1999 and June 2002.

MEASUREMENTS

Family caregiver reports provided at the time of hospice enrollment of physician discussions of incurable illness, life expectancy, and hospice.

RESULTS

Many family caregivers reported that a physician never told them the patient's illness could not be cured (20.8%), never provided life expectancy (40% of those reportedly told illness was incurable), and never discussed using hospice (32.2%). Caregivers reported the first discussion of the illness being incurable and of hospice as a possibility occurred within 1 month of the patient's death in many cases (23.5% and 41.1%, respectively). In open-ended interviews, however, family caregivers expressed ambivalence about what they wanted to know, and their difficulty comprehending and accepting "bad news" was apparent in both qualitative and quantitative data.

CONCLUSION

Our findings suggest that ineffective communication about end-of-life issues likely results from both physician's lack of discussion and family caregiver's difficulty hearing the news. Future studies should examine strategies for optimal physician-family caregiver communication about incurable illness, so that families and patients can begin the physical, emotional, and spiritual work that can lead to acceptance of the irreversible condition.

At the crossroads: Making the transition to hospice

Objective:Previous studies reveal that many terminally ill patients never receive hospice care. Among those who do receive hospice, many enroll very close to the time of death. Nationally, between 1992 and 1998, the median length of stay at hospice declined 27%, from 26 to 19 days. In our prior study of 206 patients diagnosed with terminal cancer and using hospice, we found that one-third enrolled with hospice within 1 week prior to death. Late hospice enrollment can have deleterious effects on patients and their family members. The aim of the present study was to characterize common experiences of patients and primary family caregivers as they transition to hospice, focusing on caregiver perceptions of factors that might contribute to delays in hospice enrollment.

Methods:We conducted in-depth interviews with a purposive sample of 12 caregivers selected from a population of primary family caregivers of patients with terminal cancer who enrolled with hospice in Connecticut between September 2000 and September 2001. Respondents represented different ages, genders, and kinship relationships with patients. Respondents were asked about the patient's care trajectory, how they first learned about hospice, and their experiences as they transitioned to hospice. NUD*IST software was used for qualitative data coding and analysis.

Results:Constant comparative analysis identified three themes common to the experience of transitioning to hospice: (1) caregivers' acceptance of the impending death, (2) challenges in negotiating the health care system across the continuum of care, and (3) changing patient–family dynamics.

Significance of results:Identification of these themes from the caregivers' perspective generates hypotheses about potential delays in hospice and may ultimately be useful in the design of interventions that are consistent with caregivers' needs.

Systematic review of the problems and issues of accessing specialist palliative care by patients, carers and health and social care professionals

OBJECTIVES

To determine the problems and issues of accessing specialist palliative care by patients, informal carers and health and social care professionals involved in their care in primary and secondary care settings.

DATA SOURCES

Eleven electronic databases (medical, health-related and social science) were searched from the beginning of 1997 to October 2003. Palliative Medicine (January 1997-October 2003) was also hand-searched.

STUDY SELECTION

Systematic search for studies, reports and policy papers written in English.

DATA EXTRACTION

Included papers were data-extracted and the quality of each included study was assessed using 10 questions on a 40-point scale.

RESULTS

The search resulted in 9921 hits. Two hundred and seven papers were directly concerned with symptoms or issues of access, referral or barriers and obstacles to receiving palliative care. Only 40 (19%) papers met the inclusion criteria. Several barriers to access and referral to palliative care were identified including lack of knowledge and education amongst health and social care professionals, and a lack of standardized referral criteria. Some groups of people failed to receive timely referrals e.g., those from minority ethnic communities, older people and patients with nonmalignant conditions as well as people that are socially excluded e.g., homeless people.

CONCLUSIONS

There is a need to improve education and knowledge about specialist palliative care and hospice care amongst health and social care professionals, patients and carers. Standardized referral criteria need to be developed. Further work is also needed to assess the needs of those not currently accessing palliative care services.

Access and referral to specialist palliative care: patients’ and professionals’ experiences

The aim of this study was to explore the reasons why patients and families are referred to specialist palliative care. Semi-structured interviews were undertaken with patients and professionals from primary care and specialist palliative care services in the north of England. A content analysis of the transcripts was undertaken, key issues were identified and common themes grouped. Twelve professionals working in specialist palliative care, three GPs, six community nurses and thirteen patients were interviewed (n = 34). Five key themes are reported: reasons why patients are referred to specialist palliative care; reasons why patients are not referred to specialist palliative care; timeliness of referrals; continuity of care; and use of referral criteria. It was found that the professionals in primary care would like more training and education about how to refer patients to specialist palliative care and how to deal with issues of death and dying. The patients were generally satisfied with the service but wanted to be able to be supported at home in their final days. Further training and education may improve the knowledge of professionals who refer patients to specialist palliative care. There are currently no standardized criteria in the UK to determine when a referral should be triggered. The development of a set of standardized referral criteria may be useful in aiding a referral decision.

Nurses' attitudes and practice related to hospice care

PURPOSE

To describe characteristics, attitudes, and communications of nurses regarding hospice and caring for terminally ill patients.

DESIGN

A cross-sectional study of randomly selected nurses (n = 180) from six randomly selected Connecticut community hospitals was conducted in 1998 and 1999.

METHODS

Hospice-related training, knowledge and attitudes, demographic and practice characteristics, and personal experience with hospice were assessed with a self-administered questionnaire (response rate = 82%). Logistic regression was used to model the effects of hospice-related training, knowledge, and attitudes on these outcomes, adjusting for personal experience and other characteristics of nurses.

FINDINGS

Characteristics associated with discussion of hospice with both patients and families included greater religiousness, having a close family member or friend who had used hospice, and reporting satisfaction with hospice caregivers. Greater self-rated knowledge was significantly associated with discussion of hospice with patients. Attitudinal scores indicating greater comfort with initiating discussion and greater perceived added benefit of hospice were significantly associated with discussion with patients' families.

CONCLUSIONS

Nurses' discussion of hospice with terminally ill patients and their families are related to the potentially modifiable factors of self-rated knowledge and attitudes revealing comfort with discussion and perceived benefit of hospice care.

The effect of inpatient hospice units on hospice use post-admission

The objective of this study was to determine whether having a hospice unit within the hospital increases the proportion of terminally ill patients who use hospice services (including home, nursing home, or inpatient hospice) post-admission. Using medical record data abstracted for 232 randomly selected patients with terminal cancer admitted to six community hospitals in Connecticut, we found that patients admitted to a hospital with a hospice unit were more likely to use hospice services (i.e., home hospice, nursing home hospice, or inpatient hospice) post-admission than patients admitted to a hospital without a hospice unit (unadjusted OR 5.7, 95% CI 3.1, 10.6). This effect persisted after adjusting for patient age, gender, marital status, documented discussions of prognosis, prior hospice use, and type of cancer.

Prognosis in advanced cancer

When considered with other parameters, prognostic factors of survival in far advanced cancer patients are necessary to enable the doctor, the patient, and his or her relative to choose the most suitable clinical management and care setting. Original studies and literature reviews, albeit with methodologic difficulties, have identified the most important prognostic factors as being: CPS, KPS, signs and symptoms relating to nutritional status (i.e., weight loss, anorexia, dysphagia, xerostomia), other symptoms (dyspnea, cognitive failure) and some simple biologic parameters (serum albumin level, number of white blood cells and lymphocyte ratio). Some authors have weighed the different impact of the most important prognostic factors and have integrated them into prognostic scores for clinical use. Despite the usefulness of these instruments, however, the communication of a poor prognosis is one of the most difficult moments to face in the relationship between doctor and patient.

Physicians' ratings of their knowledge, attitudes, and end-of-life-care practices

PURPOSE

Health care institutions are examining ways to improve physicians' skills in the delivery of end-of-life (EOL) care. Experts have suggested that influencing physicians' knowledge and attitudes concerning EOL care can influence subsequent EOL practices, including hospice use for appropriate patients; yet few studies have examined empirically the influence of physicians' knowledge and attitudes on such practices. The authors assessed the influences of self-rated knowledge and attitudes on physicians' discussions and referrals for hospice care.

METHOD

In 1998 and 1999 the authors conducted a cross-sectional study of physicians affiliated with six randomly selected community hospitals in Connecticut with more than 200 licensed medical and surgical beds. Physicians completed a self-administered questionnaire (response rate 52.4%) that assessed self-rated knowledge of terminal care and hospice, a set of attitudinal items, and practices related to hospice discussion and referrals, as well as standard sociodemographic data. Bivariate and multivariate analyses were conducted.

RESULTS

Self-rated knowledge was significantly associated with referral practices in unadjusted analyses (unadjusted odds ratio [OR]: 0.70; 95% confidence interval [CI]: 0.52, 0.95), although this association was attenuated in adjusted analyses by specialty and other physicians' characteristics (adjusted OR: 0.80; 95% CI: 0.55, 1.18). Attitudes representing support for hospice practices and philosophy were associated with referral practices in adjusted and unadjusted analyses (adjusted OR:0.52; 95% CI: 0.35, 0.77).

CONCLUSIONS

This study demonstrated that self-rated knowledge and attitudes may influence hospice referral. The results support current efforts to develop medical school curricula and continuing education programs that better cover the many aspects of caring for the dying, including hospice use.

Nurses' use of palliative care practices in the acute care setting

This study examines the reported use of palliative care practices by nurses caring for terminally ill patients in the acute care setting. Randomly selected nurses (n = 180) from six randomly selected hospitals in Connecticut completed a self-administered questionnaire. Factors associated with use of palliative care practices were examined by using bivariate and multivariate analyses. Most nurses surveyed (88.5%) reported using palliative care practices when caring for their terminally ill patients. Factors associated with greater use included greater knowledge about hospice, having practiced nursing for less than 10 years, and having had hospice training in the past 5 years. A substantial proportion of nurses reported that they never discuss hospice (51.7 per cent of nurses) and prognosis (26.6 per cent of nurses) with their terminally ill patients. Educational preparation (bachelor's degree versus less education) was not associated with greater use of palliative care practices. Palliative care practices are commonly used by nurses in the acute care setting. However, many report having limited training and substantial gaps in knowledge about hospice among this group of nurses, suggesting greater attention to palliative care and hospice may be warranted in nursing educational programs.