Predictors of six-month survival among patients with dementia: an evaluation of hospice Medicare guidelines

Prognostic models and factors identifying end-of-life in non-cancer chronic diseases: a systematic review

BACKGROUND

Precise prognostic information, if available, is very helpful for guiding treatment decisions and resource allocation in patients with non-cancer non-communicable chronic diseases (NCDs). This study aimed to systematically review the existing evidence, examining prognostic models and factors for identifying end-of-life non-cancer NCD patients.

METHODS

Electronic databases, including Medline, Embase, CINAHL, Cochrane Library, PsychINFO and other sources, were searched from the inception of these databases up until June 2023. Studies published in English with findings mentioning prognostic models or factors related to identifying end-of-life in non-cancer NCD patients were included. The quality of studies was assessed using the Quality in Prognosis Studies tool.

RESULTS

The analysis included data from 41 studies, with 16 focusing on chronic obstructive pulmonary diseases (COPD), 10 on dementia, 6 on heart failure and 9 on mixed NCDs. Traditional statistical modelling was predominantly used for the identified prognostic models. Common predictors in COPD models included dyspnoea, forced expiratory volume in 1 s, functional status, exacerbation history and body mass index. Models for dementia and heart failure frequently included comorbidity, age, gender, blood tests and nutritional status. Similarly, mixed NCD models commonly included functional status, age, dyspnoea, the presence of skin pressure ulcers, oral intake and level of consciousness. The identified prognostic models exhibited varying predictive accuracy, with the majority demonstrating weak to moderate discriminatory performance (area under the curve: 0.5-0.8). Additionally, most of these models lacked independent external validation, and only a few underwent internal validation.

CONCLUSION

Our review summarised the most relevant predictors for identifying end-of-life in non-cancer NCDs. However, the predictive accuracy of identified models was generally inconsistent and low, and lacked external validation. Although efforts to improve these prognostic models should continue, clinicians should recognise the possibility that disease heterogeneity may limit the utility of these models for individual prognostication; they may be more useful for population level health planning.

Feasibility of the Palliative Care Education in Assisted Living Intervention for Dementia Care Providers: A Cluster Randomized Trial

BACKGROUND AND OBJECTIVES

Alzheimer's disease and related dementia (ADRD) is a major cause of death in the United States. While effective interventions have been developed to deliver palliative care to nursing home residents with ADRD, little work has identified effective interventions to reach assisted living (AL) residents with dementia.

RESEARCH DESIGN AND METHODS

One hundred and eighteen AL residents with dementia from 10 different ALs in Florida participated. A pilot study using a cluster randomized trial was conducted, with 6 sites randomized to receive a palliative care educational intervention for staff (N = 23) to deliver care to residents; 4 sites were usual care. The feasibility of the intervention was assessed by examining recruitment, retention, and treatment fidelity at 6 months. Cohen's d statistic was used to calculate facility-level treatment effect sizes on key outcomes (documentation of advance care planning [ACP] discussions, hospice admission, and documentation of pain screening).

RESULTS

The intervention proved feasible with high ratings of treatment fidelity. The intervention also demonstrated preliminary evidence for efficacy of the intervention, with effect sizes for the treatment group over 0.80 for increases in documentation of ACP discussions compared to the control group. Hospice admissions had a smaller effect size (0.16) and documentation of pain screenings had no effect.

DISCUSSION AND IMPLICATIONS

The pilot results suggest that the intervention shows promise as a resource for educating and empowering AL staff on implementing person-centered palliative care delivery to persons with dementia in AL. A larger, fully powered randomized trial is needed to test for its efficacy.

Prediction of survival of persons with advanced dementia using the advanced dementia prognostic tool: A 2-year prospective study

BACKGROUND

In this prospective study, we evaluated the usefulness of the advanced dementia prognostic tool (ADEPT) for estimating the 2-year survival of persons with advanced dementia (AD) in China.

METHODS

The study predicted the 2-year mortality of 115 persons with AD using the ADEPT score.

RESULTS

In total, 115 persons with AD were included in the study. Of these persons, 48 died. The mean ADEPT score was 13.0. The AUROC for the prediction of the 2-year mortality rate using the ADEPT score was 0.62. The optimal threshold of the ADEPT score was 11.2, which had an AUROC of 0.63, specificity of 41.8, and sensitivity of 83.3.

CONCLUSIONS

The ADEPT score based on a threshold of 11.2 may serve as a prognostic tool to determine the 2-year survival rate of persons with AD in Chongqing, China. However, further studies are needed to explore the nature of this relationship.

Patterns of oral bisphosphonate deprescribing in older nursing home residents with dementia

In a national sample of Medicare nursing home residents with dementia treated with bisphosphonates, 20% had bisphosphonates deprescribed. Residents with clinical characteristics representing decreased likelihood for long-term benefit were more likely to have bisphosphonates deprescribed. Future studies are needed to evaluate outcomes of deprescribing bisphosphonates in this population.

INTRODUCTION

To determine incidence of deprescribing bisphosphonates among nursing home (NH) residents with dementia and identify factors associated with deprescribing.

METHODS

2015-2016 Medicare claims, Part D prescriptions, Minimum Data Set (MDS) 3.0, and Nursing Home Compare for non-skilled NH residents aged 65 + with dementia and prescriptions for oral bisphosphonates overlapping the first 14 days of the stay. Our primary definition for deprescribing was a 90-day gap in medication supply; we also explored the reliability of different deprescribing definitions (30-, 90-, 180-day gaps). We estimated associations of NH, provider, and resident characteristics with deprescribing bisphosphonates using competing risks regression models.

RESULTS

Most NH residents with dementia treated with bisphosphonates (n = 5312) were ≥ 80 years old (72%), white (81%), and female (90%); about half were dependent for transfers (50%) or mobility (45%). Using a 90-day gap in supply, the 180-day cumulative incidence of deprescribing bisphosphonates was 14.8%. This increased to 32.1% using a 30-day gap and decreased to 11.7% using a 180-day gap. Factors associated with increased likelihood for bisphosphonate deprescribing were age ≥ 90 years, newly admitted (vs. prevalent stay), dependent for mobility, swallowing difficulty, > 1 hospitalization in the prior year, CCRC facility, and nurse practitioner primary provider (vs. physician). Cancer and western geographic region were associated with reduced likelihood for deprescribing.

CONCLUSION

In a national sample of NH residents with dementia, bisphosphonate deprescribing was uncommon, and associated with clinical characteristics signifying poor prognosis and decreased likelihood for long-term benefit. Future studies should evaluate clinical outcomes of deprescribing bisphosphonates in this population.

The "Counseling+" Roles of the Speech-Language Pathologist Serving Older Adults With Mild Cognitive Impairment and Dementia From Alzheimer's Disease

Purpose

Persons with dementia and mild cognitive impairment (MCI) are major consumers of services provided by speech-language pathologists (SLPs). These services include not only direct assessment and treatment of communication and swallowing but also counseling, collaboration, prevention, and wellness. These "counseling+" activities can be especially challenging for SLPs to deliver because of the lack of evidence, as well as the complex nature of Alzheimer's disease (AD) and other conditions that cause MCI and dementia.

Method

This tutorial is written by a speech-language pathologist, a neuropsychologist, and a geriatric psychiatrist to provide education, resources, and recommendations for SLPs delivering counseling+ activities to patients with MCI and dementia from AD and related disorders.

Results and Conclusions

We describe counseling+ activities across the continuum of care ranging from educating and conducting cognitive screenings with adults experiencing age-related cognitive decline to supporting end-of-life wishes. Because of their expertise in communication, SLPs can provide an array of important leading and supporting services to patients, their family, and other health care professionals on the care team, such as providing patients with appropriate feedback following a cognitive screening and helping caregivers identify the communicative intent of a responsive behavior. The demand for SLP services for patients with MCI and dementia will grow significantly over the next few decades, necessitating more systematic research and clinical evidence in this area.

Caregiver-Reported Barriers to Quality End-of-Life Care in Dementia With Lewy Bodies: A Qualitative Analysis

OBJECTIVE

This study investigated barriers to quality end-of-life (EOL) care in the context of dementia with Lewy bodies (DLB), one of the most common degenerative dementias in the United States.

METHODS

The study consisted of telephone interviews with caregivers and family members of individuals who died with DLB in the last 5 years. Interviews used a semi-structured questionnaire. Investigators employed a qualitative descriptive approach to analyze interview transcripts and identify common barriers to quality EOL care.

RESULTS

Thirty participants completed interviews. Reported barriers to quality EOL experiences in DLB pertained to the DLB diagnosis itself and factors relating to the US health-care system, facilities, hospice, and health-care providers (physicians and staff). Commonly reported barriers included lack of recognition and knowledge of DLB, lack of education regarding what to expect, poor coordination of care and communication across health-care teams and circumstances, and difficulty accessing health-care resources including skilled nursing facility placement and hospice.

CONCLUSION

Many identified themes were consistent with published barriers to quality EOL care in dementia. However, DLB-specific EOL considerations included diagnostic challenges, lack of knowledge regarding DLB and resultant prescribing errors, difficulty accessing resources due to behavioral changes in DLB, and waiting to meet Medicare dementia hospice guidelines. Improving EOL experiences in DLB will require a multifaceted approach, starting with improving DLB recognition and provider knowledge. More research is needed to improve recognition of EOL in DLB and factors that drive quality EOL experiences.

The Accuracy of Imminent Death Diagnosis in a Palliative Care Setting

Background

Prognostication is important for patients and their family members as they need this information for the preparation and planning of their future. It is important for physicians as they desire to be accurate in their prognostication skills in order to plan and deliver better care to their patients; healthcare managers require it as they need this information for planning and distribution of hospital resources. We intended to study the accuracy of imminent death diagnosis (IDD) in a palliative care setting in all patients who died at the Palliative Care Unit (PCU) at King Fahad Medical City between December 2012 and December 2014.

Methods

We conducted a retrospective chart review of all consecutive patients who died in the PCU between 2012 and 2014. We studied the percentage of patients who were diagnosed with imminent death. We further looked at the accuracy of IDD by calculating the time between the diagnosis of imminent death and death. The primary outcomes were the percentage of patients who had an IDD and the proportion of those who died within 14 days of IDD. The secondary outcomes were the difference between patients who die after IDD and patients who die without imminent death diagnosis (NIDD) at the end of life interventions.

Results

During the period from December 2012 until December 2014, 48 patients died in the PCU. The majority of 28/48 (58%) died with IDD. However, 20/48 (42%) died NIDD. In the IDD group, 25/28 (89.3%) died within 14 days of diagnosis while 3/28 (10.3%) died after 14 days

Conclusions

IDD is a critical skill for palliative care physicians to make an advance care plan. Our study showed a high degree of accuracy of prediction of fourteen-day mortality in PCU patients. The median survival was two days. However, a large proportion of patients still died without a documented IDD. Multidisciplinary team input improves the accuracy of IDD. We recommend further studies be done to explore how IDD could improve care planning for dying patients and families.

Does Caregiving Strain Increase as Patients With and Without Dementia Approach the End of Life?

CONTEXT

Family caregivers play critical and demanding roles in the care of persons with dementia through the end of life.

OBJECTIVES

The objective of this study was to determine whether caregiving strain increases for dementia caregivers as older adults approach the end of life, and secondarily, whether this association differs for nondementia caregivers.

METHODS

Participants included a nationally representative sample of community-living older adults receiving help with self-care or indoor mobility and their primary caregivers (3422 dyads). Older adults' death within 12 months of survey was assessed from linked Medicare enrollment files. Multivariable logistic regression was used to assess the association between dementia and end-of-life status and a composite measure of caregiving strain (range: 0-9, using a cut point of 5 to define "high" strain) after comprehensively adjusting for other older adult and caregiver factors.

RESULTS

The prevalence of dementia in our sample was 30.1%; 13.2% of the sample died within 12 months. The proportion of caregivers who experienced high strain ranged from a low of 13.5% among nondementia, non-end-of-life caregivers to a high of 35.0% among dementia caregivers of older adults who died within 12 months. Among dementia caregivers, the odds of high caregiving strain were nearly twice as high (aOR = 1.94, 95% CI: 1.10-3.45) for those who were assisting older adults nearing end of life. Among nondementia caregivers, providing care near the end of life was not associated with high strain.

CONCLUSION

Increased strain toward the end of life is particularly notable for dementia caregivers. Interventions are needed to address the needs of this population.

The prognostic predictors of six-month mortality for residents with advanced dementia in long-term care facilities in Taiwan: A prospective cohort study

BACKGROUND

Although hospice or palliative care for patients with advanced dementia has been implemented for more than 30 years, few studies have investigated the prognostic predictors of 6-month mortality in these patients. Prognostication has been a major obstacle, and 6-month prognostic predictors for patients with advanced dementia are still considered elusive.

OBJECTIVES

To better understand the dying trajectories of patients with advanced dementia, we performed a longitudinal prospective cohort study to investigate the predictors of 6-month mortality for residents with advanced dementia in long-term care facilities in Taiwan.

DESIGN

Prospective cohort study.

SETTING

This study took place in 32 long-term care facilities selected from northern, central, and southern Taiwan.

PARTICIPANTS

The study included 320 residents with advanced dementia.

MEASUREMENTS

Measurements were obtained after determining study eligibility; the participants underwent follow-up assessments once every 3 months for 6 months or died during follow-up. The assessments included demographic characteristics, health and medical status characteristics, and death-related information. The Kaplan-Meier survival function estimation and the Cox proportional hazards model were used to estimate the survival rate and predict the prognostic factors.

RESULTS

Baseline data from 320 residents with advanced dementia in long-term care facilities were obtained. The mean age was 82.7 years and 61.6% were female. The 6-month survival rate was 78.1%. The major cause of death was multiple organ failure related to pneumonia. The 6-month prognostic predictors were pneumonia (adjusted hazard ratio, 5.56; 95% confidence interval, 2.46-12.6; p-value < .001), reduction in nutrient intake >25% (adjusted hazard ratio, 5.05; 95% confidence interval, 2.37-10.8; p-value < .001), oxygen dependency (adjusted hazard ratio, 2.58; 95% confidence interval, 1.51-4.39; p-value = .001), treatment for electrolyte abnormalities (adjusted hazard ratio, 2.14; 95% confidence interval, 1.10-4.14; p-value = .025), severe pressure injuries (adjusted hazard ratio, 2.04; 95% confidence interval, 1.13-3.67; p-value = .018), and long-term indwelling urinary catheters (adjusted hazard ratio, 1.80; 95% confidence interval, 1.09-2.96; p-value = .021).

CONCLUSION

Our results identified six prognostic predictors of 6-month mortality among residents with advanced dementia in Taiwan. These predictors may serve as risk assessment indicators for nursing staff who provide clinical care and can enable the identification of patients in recognized terminal decline, thereby allowing access to hospice palliative services.

Hospice Underutilization in the U.S.: The Misalignment of Regulatory Policy and Clinical Reality

After three and a half decades of experience with the Medicare hospice benefit in the U.S., despite excellent quality outcomes in symptom management, patient and family satisfaction, and reduction in health care costs, only 12%-15% of beneficiaries' days during the last year of life are spent being cared for within the highly cost-effective interdisciplinary coordinated advanced illness care model known as hospice. Although there are many reasons for this, including difficulties in acknowledging mortality among patients, their families, and physicians, a significant cause of low overall hospice utilization and intractably low median lengths of stay, reflective of late admissions, can be attributed to increasingly difficult and highly variable prognostic determinations for most of the leading causes of death among Medicare beneficiaries. Medicare is the payer for most hospice care in the U.S. and requires certification of a prognosis of six months or less for a beneficiary to access hospice support. At the time of admission to hospice, two physicians must predict that a patient is more likely to die in the next six months than survive, based on clinical status. In addition to prognostic uncertainty constituting a barrier to timely hospice referral, the Centers for Medicare and Medicaid Services and its payer contractors have developed a robust and expensive retrospective review process that penalizes hospices when patients outlive their expected prognosis. The administratively burdensome and financially punitive review practices further delay or limit access to care for eligible patients as certifying physicians and agencies, fearful of the financial and legal repercussions of reviews and audits, are hesitant to take patients under care unless they are clearly in the dying process. This article will review pertinent history and address the core problem of access to a health care benefit built on a policy that requires far greater prognostic certainty than any clinician can reasonably ascertain and fails to take into consideration the favorable impact hospice care has on terminally ill patients in improving prognosis. This clinical conundrum that limits access of seriously ill people to high-value quality care is of profound importance to the U.S. Medicare population and also one with potential relevance to all complex and regulated health systems and to other models of care whose eligibility criteria are based on prognostication.

Anticholinergic Burden in Hospice Patients With Dementia

BACKGROUND

End-of-life (EOL) patients with dementia have an increased risk for anticholinergic toxicities due to age-related pharmacokinetic and physiologic changes in conjunction with an increased susceptibility to drug-induced cognitive impairments. Despite this well-documented risk, the use of drugs with anticholinergic properties (DAPs) remains prevalent in EOL patients with dementia.

OBJECTIVE

The aims of this study were to describe prescribing patterns and characterize anticholinergic burden among hospice patients with dementia, as measured by the Anticholinergic Cognitive Burden (ACB) scale.

METHODS

This was a retrospective review of a national hospice patient information database. Patients included were admitted on January 1, 2016, discharged by death by December 31, 2016, and had a primary diagnosis of dementia. Patients' anticholinergic burden was calculated using ACB scores.

RESULTS

A total of 1283 patients met the inclusion criteria. Of those, 37.1% (n = 476) were prescribed at least 1 DAP. Specifically, 28.9% (n = 371) were prescribed 1 DAP, 6.6% (n = 84) were prescribed 2 DAPs, 1.6% (n = 20) were prescribed 3 DAPs, and 0.08% (n = 1) were prescribed 4 DAPs. The majority of patients prescribed a DAP had an ACB score of 3 (n = 359, 75.4%) and an average ACB score of 3.8. The most common DAPs prescribed in patients with an ACB score of 2 or higher were quetiapine (n = 202, 42.4%), atropine (n = 155, 32.6%), hyoscyamine (n = 61, 12.8%), olanzapine (n = 46, 9.6%), and scopolamine (n = 35, 7.4%).

CONCLUSION

Due to the limited benefit and increased harms with the use of DAPs, providers should aim to maximize nonpharmacologic options. By reducing the use of the top 5 DAPs identified in this study, the quality of life and care for EOL patients with dementia can potentially be improved.

Estimating the survival of elderly patients diagnosed with dementia in Taiwan: A longitudinal study

Background

Dementia is characterized by prolonged progressive disability. Therefore, predicting mortality is difficult. An accurate prediction tool may be useful to ensure that end-of-life patients with dementia receive timely palliative care.

Purpose

This study aims to establish a survival prediction model for elderly patients with dementia in Taiwan.

Methods

Data from the 2001 to 2010 National Health Insurance Research Database in Taiwan were used to identify 37,289 patients with dementia aged ≥65 years for inclusion in this retrospective longitudinal study. Moreover, this study examined the mortality indicators for dementia among demographic characteristics, chronic physical comorbidities, and medical procedures. A Cox proportional hazards model with time-dependent covariates was used to estimate mortality risk, and risk score functions were formulated using a point system to establish a survival prediction model. The prediction model was then tested using the area under the receiver operating characteristic curve.

Results

Thirteen mortality risk factors were identified: age, sex, stroke, chronic renal failure, liver cirrhosis, cancer, pressure injury, and retrospectively retrieved factors occurring in the 6 months before death, including nasogastric tube placement, supplemental oxygen supply, ≥2 hospitalization, receiving ≥1 emergency services, ≥2 occurrences of cardiopulmonary resuscitation, and receiving ≥2 endotracheal intubations. The area under the receiver operating characteristic curves for this prediction model for mortality at 6 and 12 months were 0.726 and 0.733, respectively.

Conclusions

The survival prediction model demonstrated moderate accuracy for predicting mortality at 6 and 12 months before death in elderly patients with dementia. This tool may be valuable for helping health care providers and family caregivers to make end-of-life care decisions.

Palliative care in dementia: issues and evidence

Palliative care is an approach that stands well with the aims of person-centred dementia care. There is no doubt that the standards of care for many people with advanced dementia are poor. There is a lack of good-quality evidence, however, to support any particular approach for palliative care in dementia. Still, there are a number of areas in relation to caring for people with severe dementia where a palliative approach might be beneficial. In general, the relevant decisions have to be made on an individual basis but within a palliative framework. Advance care planning is likely to be crucial in encouraging this process. There is certainly a moral imperative behind the idea that care at the end of life for people with dementia should be improved.

Not Calm and Aminoff Suffering Syndrome in Advanced Alzheimer's Disease

We studied 183 patients with advanced dementia who had been admitted to the Geriatric-Internal Medicine Department of a general hospital, with a 1 year follow-up evaluated by Mini-Suffering State Examination (MSSE) scores on first days after admission. The not calm compared to calm patients with advanced dementia had a high suffering level (6.12 ± 2.16 versus 3.21 ± 1.71) with a statistically significant difference (P = 0.001). The not calm patients were sicker, a higher percentage had fever (P = 0.005), elevated levels of white blood cells WBC (P = 0.003) and C-reactive protein (CRP) (P = 0.020). The Kaplan-Meier function analysis showed a shorter survival of not calm versus calm advanced dementia patients, with a statistically significant difference (Log Rank [Mantel-Cox] P = 0.002). Not calm in advanced dementia patients is the first item of the MSSE and is a very important symptom of Aminoff Suffering Syndrome.

Evaluation and management of the elderly patient presenting with cognitive complaints

Cognitive complaints are common in the geriatric population. Older adults should routinely be asked about any concerns about their memory or thinking, and any cognitive complaint from the patient or an informant should be evaluated rather than be attributed to aging. Several screening instruments are available to document objective impairments and guide further evaluation. Management goals for patients with cognitive impairment are focused on maintaining function and independence, providing caregiver support, and advance care planning. There are currently no treatments to effectively prevent or treat dementia. Increasing appreciation of the heterogeneity of Alzheimer disease may lead to novel treatment approaches.

Prognosis of short survival in patients with advanced dementia as diagnosed by Aminoff suffering syndrome

On the first few days after admission to the Geriatric-Internal Medicine department, the suffering level of patients with advanced dementia (Mini-Mental State Examination 0 of 30) was evaluated according to the Mini-Suffering State Examination (MSSE). During hospitalization, 14.8% (27 of 183) of patients with advanced dementia were died with a mean survival rate of 19.86 ± 26.9 days. The MSSE scale score of died patients was 7.56 ± 1.71 during the first few days of admission which indicates high suffering levels. The MSSE scale score of survived patients with advanced dementia was 3.99 ± 2.10 which confirms their low level of suffering. There was a significant difference (P < .001) between the groups. Patients with dementia who died and were diagnosed as having Aminoff suffering syndrome during the first few days of admission had a high suffering level and short-survival time.

Predictors of six-month mortality among nursing home residents: diagnoses may be more predictive than functional disability

OBJECTIVE

Loss of daily living functions can be a marker for end of life and possible hospice eligibility. Unfortunately, data on patient's functional abilities is not available in all settings. In this study we compare predictive accuracy of two indices designed to predict 6-month mortality among nursing home residents. One is based on traditional measures of functional deterioration and the other on patients' diagnoses and demography.

METHODS

We created the Hospice ELigibility Prediction (HELP) Index by examining mortality of 140,699 Veterans Administration (VA) nursing home residents. For these nursing home residents, the available data on history of hospital admissions were divided into training (112,897 cases) and validation (27,832 cases) sets. The training data were used to estimate the parameters of the HELP Index based on (1) diagnoses, (2) age on admission, and (3) number of diagnoses at admission. The validation data were used to assess the accuracy of predictions of the HELP Index. The cross-validated accuracy of the HELP Index was compared with the Barthel Index (BI) of functional ability obtained from 296,052 VA nursing home residents. A receiver operating characteristic curve was used to examine sensitivity and specificity of the predicted odds of mortality.

RESULTS

The area under the curve (AUC) for the HELP Index was 0.838. This was significantly (α <0.01) higher than the AUC for the BI of 0.692.

CONCLUSIONS

For nursing home residents, comorbid diagnoses predict 6-month mortality more accurately than functional status. The HELP Index can be used to estimate 6-month mortality from hospital data and can guide prognostic discussions prior to and following nursing home admission.

Caregivers' experiences seeking hospice care for loved ones with dementia

As the prevalence of dementia continues to grow, informal caregivers face unique challenges as they approach the end of life, and access to support and palliative care is often limited. I used a phenomenological approach to explore the experiences of caregivers actively seeking formal end-of-life care, in particular hospice care, for a loved one with dementia. In-depth interviews with 11 caregivers about 14 patients revealed five themes, including: setting the stage for heartbreak, reaching the boiling point, getting through the front lines, settling for less, and welcoming death. Nurses must recognize the complex needs of caregivers, educate caregivers on the disease process, and adjust to palliative goals sooner to meet the needs of caregivers. Prevalence of these issues must be further examined through quantitative study to evaluate the need to reconsider current hospice eligibility criteria based on prognosis.

Patients surviving six months in hospice care: who are they?

BACKGROUND

On January 1, 2011, the Centers for Medicare and Medicaid Services (CMS) began requiring U.S. hospices to conduct a "face-to-face" (F2F) assessment of eligibility for continued hospice care with patients entering their third certification period (180 days after initial enrollment). Understanding which patient populations require F2F assessment is important for evaluating the impact of the CMS regulation and gauging the appropriateness of the 6-month prognosis criteria for different patient groups.

METHODS

Retrospective program records were obtained for patients enrolled in a large hospice 6 months prior to implementation of the CMS regulation (N=375). Patients who remained in hospice and received a F2F (n=140) were compared to patients who were no longer in hospice (n=235) on demographics, terminal condition (categorized as debility/dementia, cancer, or other), presence of serious comorbidity, length of stay, setting of care prior to admission, and hospice outcome using bivariate statistics. Predictors of F2F recertification were examined using a multivariable logistic regression model controlling for demographics, setting of care prior to admission, comorbidity, and primary terminal diagnosis.

RESULTS

At the bivariate level, patients who received an F2F were older (p<0.001), and more likely to have lived in a facility care setting prior to hospice admission (p<0.001) than their non-F2F counterparts. Findings from the logistic regression analysis indicate that initial setting of care (odds ratio [OR] for inpatient versus home=0.20; p=0.01), presence of serious comorbidity (OR=2.84; p<0.001), and primary diagnosis (OR for debility/dementia versus cancer=3.35; p<0.001) were significant predictors of F2F recertification.

CONCLUSIONS

Unlike hospice patients with cancer, patients with a primary diagnosis of dementia or debility are more likely to remain in hospice care beyond 6 months and require F2F recertification. Still, these patients need the services provided by hospice care and may be limited by the 6-month recertification criteria.

Risk of death or hospital admission among community-dwelling older adults living with dementia in Australia

Background

Older people living with dementia prefer to stay at home to receive support. But they are at high risk of death and/or hospital admissions. This study primarily aimed to determine risk factors for time to death or hospital admission (combined) in a sample of community-dwelling older people living with dementia in Australia. As a secondary study purpose, risk factors for time to death were also examined.

Methods

This study used the data of a previous project which had been implemented during September 2007 and February 2009. The original project had recruited 354 eligible clients (aged 70 and over, and living with dementia) for Extended Aged Care At home Dementia program services during September 2007 and 2008. Client information and carer stress had been collected from their case managers through a baseline survey and three-monthly follow-up surveys (up to four in total). The principal data collection tools included Global Deterioration Scale, Modified Barthel Index, Instrumental-Dependency OARS, Adapted Cohen-Mansfield Agitation Inventory, as well as measures of clients’ socio-demographic characteristics, service use and diseases diagnoses. The sample of our study included 284 clients with at least one follow-up survey. The outcome variable was death or hospital admission, and death during six, nine and 16-month study periods. Stepwise backwards multivariate Cox proportional hazards analysis was employed, and Kaplan-Meier survival analysis using censored data was displayed.

Results

Having previous hospital admissions was a consistent risk factor for time to death or hospital admission (six-month: HR = 3.12; nine-month: HR = 2.80; 16-month: HR = 2.93) and for time to death (six-month: HR = 2.27; 16-month: HR = 2.12) over time. Previously worse cognitive status was a consistent risk factor over time (six- and nine-month: HR = 0.58; 16-month: HR = 0.65), but no previous use of community care was only a short-term risk factor (six-month: HR = 0.42) for time to death or hospital admission.

Conclusions

Previous hospital admissions and previously worse cognitive status are target intervention areas for reducing dementia clients’ risk of time to death or hospital admission, and/or death. Having previous use of community care as a short-term protective factor for dementia clients’ time to death or hospital admission is noteworthy.

Prognostic indicators of 6-month mortality in elderly people with advanced dementia: a systematic review

BACKGROUND

For end-of-life dementia patients, palliative care offers a better quality of life than continued aggressive or burdensome medical interventions. To provide the best care options to dementia sufferers, validated, reliable, sensitive, and accurate prognostic tools to identify end-of-life dementia stages are necessary.

AIM

To identify accurate prognosticators of mortality in elderly advanced dementia patients consistently reported in the literature.

DESIGN

Systematic literature review.

DATA SOURCES

PubMed, Embase, and PsycINFO databases were searched up to September 2012. Reference lists of included studies were also searched. Inclusion criteria were studies measuring factors specifically related to 6-month outcome in patients diagnosed with dementia in any residential or health-care setting.

RESULTS

Seven studies met the inclusion criteria, five of which were set in the United States and two in Israel. Methodology and prognostic outcomes varied greatly between the studies. All but one study found that Functional Assessment Staging phase 7c, currently widely used to assess hospice admission eligibility in the United States, was not a reliable predictor of 6-month mortality. The most common prognostic variables identified related to nutrition/nourishment, or eating habits, followed by increased risk on dementia severity scales and comorbidities.

CONCLUSIONS

Although the majority of studies agreed that the Functional Assessment Staging 7c criterion was not a reliable predictor of 6-month mortality, we found a lack of prognosticator concordance across the literature. Further studies are essential to identify reliable, sensitive, and specific prognosticators, which can be applied to the clinical setting and allow increased availability of palliative care to dementia patients.

Diagnosis and management of Alzheimer's disease: past, present and future ethical issues

There is great interest in the ethical issues associated with Alzheimer's disease (AD) and related dementias given the prevalence of AD and the evolving neuroscience landscape in matters of diagnoses and therapeutics. Much of the ethics discussion arises in the tension between the principle of not doing harm (principle of non-maleficence) in this vulnerable population and the development of effective treatments (principle of beneficence). Autonomy and capacity issues are also numerous, wide-ranging, and concern (1) day to day affairs such as driving safely and spending money wisely, (2) life-time events such as designating a legal representative in case of incapacity, making a will, (3) consenting to treatment and diagnostic procedures, (4) participating in research. The latter issue is particularly thorny and illustrates well the complexity of tackling concerns related to capacity. The impetus to protect AD patients has partly led to ethics regulation and policies making research on inapt patients more difficult because of stringent requirements for signed informed consent or for showing the value of the research to this specific patient population. New issues are arising that relate to earlier diagnosis using biomarkers and (possibly soon) the use of drugs that modify disease progression. We here summarize and discuss the different ethical issues associated with AD from a historical perspective, with emphasis on diagnostic and treatments issues.

Characteristics and outcomes of hospice enrollees with dementia discharged alive

OBJECTIVES

To examine the characteristics of hospice enrollees with dementia who were discharged alive because their condition stabilized or improved and predictors of death in the year after discharge.

DESIGN

Cross-sectional analysis of clinical and administrative data.

SETTING

For-profit hospice provider.

PARTICIPANTS

Hospice enrollees aged 65 and older with an admission diagnosis of dementia who died or were discharged alive because their condition stabilized or improved between January 1, 1999, and December 31, 2003.

MEASUREMENTS

Demographic variables and hospice length of stay; data did not include functional status or comorbidities.

RESULTS

Of 24,111 enrollees with dementia, 1,204 (5.0%) were discharged alive because their condition stabilized or improved; the remainder died while receiving hospice. The median length of stay for those who died was 12 versus 236 days for those discharged alive. Those discharged alive were more likely to be female or have a length of stay exceeding 180 days and less likely to be in the oldest age group (≥ 85), be African American, or reside in a nursing home. In a subgroup of 303 patients discharged alive, 75.5% were still alive at 1 year; none of the demographic variables were associated with death after hospice discharge.

CONCLUSION

A small proportion of hospice enrollees with dementia was discharged alive. Most died shortly after enrollment. Future research should examine other factors that may predict which hospice enrollees with dementia are likely to be discharged alive and their subsequent trajectory, such as functional status, comorbidities, and preferences for care.

Do Community and Caregiver Factors Influence Hospice Use at the End of Life Among Older Adults With Alzheimer Disease?

Hospice is an underused service among people with Alzheimer disease. This study used the Hospice Use Model to examine community, care recipient, and caregiver characteristics associated with hospice use before death among 145 community-dwelling care recipients with Alzheimer disease and their caregivers. Secondary analysis using logistic regression modeling indicated that older age, male gender, black race, and better functional health of care recipients with Alzheimer disease were associated with a decreased likelihood of using hospice (model χ25 = 23.5, P = .0003). Moreover, care recipients recruited from an Alzheimer clinic were more likely to use hospice than those recruited from adult day-care centers. Caregiver factors were not independent predictors of hospice use. However, there was a significant interaction between hours of care provided each week and recruitment site. Among care recipients from the Alzheimer clinic, the probability of hospice use increased as caregiving intensity increased. This relationship was reversed in care recipients from day-care centers. Results suggest that adult day-care centers need to partner with hospice programs in the community. In conclusion, care recipient and community service factors influence hospice use in individuals with Alzheimer disease.

Development of a prognostic model for six-month mortality in older adults with declining health

CONTEXT

Estimation of six-month prognosis is essential in hospice referral decisions, but accurate, evidence-based tools to assist in this task are lacking.

OBJECTIVES

To develop a new prognostic model, the Patient-Reported Outcome Mortality Prediction Tool (PROMPT), for six-month mortality in community-dwelling elderly patients.

METHODS

We used data from the Medicare Health Outcomes Survey linked to vital status information. Respondents were 65 years old or older, with self-reported declining health over the past year (n=21,870), identified from four Medicare Health Outcomes Survey cohorts (1998-2000, 1999-2001, 2000-2002, and 2001-2003). A logistic regression model was derived to predict six-month mortality, using sociodemographic characteristics, comorbidities, and health-related quality of life (HRQOL), ascertained by measures of activities of daily living and the Medical Outcomes Study Short Form-36 Health Survey; k-fold cross-validation was used to evaluate model performance, which was compared with existing prognostic tools.

RESULTS

The PROMPT incorporated 11 variables, including four HRQOL domains: general health perceptions, activities of daily living, social functioning, and energy/fatigue. The model demonstrated good discrimination (c-statistic=0.75) and calibration. Overall diagnostic accuracy was superior to existing tools. At cut points of 10%-70%, estimated six-month mortality risk sensitivity and specificity ranged from 0.8% to 83.4% and 51.1% to 99.9%, respectively, and positive likelihood ratios at all mortality risk cut points ≥40% exceeded 5.0. Corresponding positive and negative predictive values were 23.1%-64.1% and 85.3%-94.5%. Over 50% of patients with estimated six-month mortality risk ≥30% died within 12 months.

CONCLUSION

The PROMPT, a new prognostic model incorporating HRQOL, demonstrates promising performance and potential value for hospice referral decisions. More work is needed to evaluate the model.

In-hospital mortality in patients older than 60 years with very low albumin levels

CONTEXT

Low albumin levels have been associated with increased mortality, but few studies have looked at the mortality rates of patients with very low albumin levels.

OBJECTIVES

The objective of this study was to determine the in-hospital mortality rates for patients older than 60 years with albumin levels <2.0 g/dL.

METHODS

This was a retrospective study of 543 consecutive patients older than the age of 60 who had an albumin level <2.0 g/dL while admitted to Summa Akron City Hospital between July and November 2008. Data were obtained from hospital databases. Mortality rates were calculated for each albumin level and compared with the overall inpatient mortality for patients older than 60 years. Rates of discharge to home were calculated by albumin level. Cross-tabulations and correlations were conducted to determine the association between albumin level and mortality, and to assess the independent effects of total parenteral nutrition, dialysis, cancer, and end-stage renal disease.

RESULTS

Patients with albumin levels between 1.0 and 1.4 had a 41% in-hospital mortality rate, with only 16% of the patients being discharged to home. Patients with albumin levels between 1.5 and 1.9 had a 21% mortality rate, with 33% of patients discharged to home. Overall hospital mortality for patients older than 60 years was 6% during the study period. Total parenteral nutrition, cancer, dialysis, and end-stage renal disease were not independent risk factors for mortality in this study.

CONCLUSION

An albumin level is readily obtained across all areas of the hospital and provides a simple and useful aid in identifying patients at high risk of a poor hospital outcome.

Palliative care for advanced dementia: a pilot project in 2 nursing homes

This article describes a pilot project involving training, case consultations, and administrative coaching over a period of 1 year aimed at introducing palliative care in 2 nursing homes among 31 residents with advanced dementia. Resident outcomes that examined numerous clinical measures were assessed at 3 points in time. Changes in the knowledge and attitudes of 80 staff members and 33 family members who participated in the multimodal intervention were also assessed at 3 points in time. Limited improvements were demonstrated on measures for residents, staff members, and family members at the first nursing home (site 1) and significant improvements were demonstrated at the other nursing home (site 2). Top leadership turned over 3 times at site 1 which limited the integration of palliative care, whereas leadership of site 2 remained stable. Implications for implementing a program of palliative care in nursing homes are discussed.

Advanced dementia: state of the art and priorities for the next decade

Dementia is a leading cause of death in the United States. This article outlines the current understanding of advanced dementia and identifies research priorities for the next decade. Research over the past 25 years has largely focused on describing the experience of patients with advanced dementia. This work has delineated abundant opportunities for improvement, including greater recognition of advanced dementia as a terminal illness, better treatment of distressing symptoms, increased access to hospice and palliative care services, and less use of costly and aggressive treatments that may be of limited clinical benefit. Addressing those opportunities must be the overarching objective for the field in the coming decade. Priority areas include designing and testing interventions that promote high-quality, goal-directed care; health policy research to identify strategies that incentivize cost-effective and evidence-based care; implementation studies of promising interventions and policies; and further development of disease-specific outcome measures. There is great need and opportunity to improve outcomes, contain expenditures, reduce disparities, and better coordinate care for the millions of persons in the United States who have advanced dementia.

Advanced dementia: state of the art and priorities for the next decade

Dementia is a leading cause of death in the United States. This article outlines the current understanding of advanced dementia and identifies research priorities for the next decade. Research over the past 25 years has largely focused on describing the experience of patients with advanced dementia. This work has delineated abundant opportunities for improvement, including greater recognition of advanced dementia as a terminal illness, better treatment of distressing symptoms, increased access to hospice and palliative care services, and less use of costly and aggressive treatments that may be of limited clinical benefit. Addressing those opportunities must be the overarching objective for the field in the coming decade. Priority areas include designing and testing interventions that promote high-quality, goal-directed care; health policy research to identify strategies that incentivize cost-effective and evidence-based care; implementation studies of promising interventions and policies; and further development of disease-specific outcome measures. There is great need and opportunity to improve outcomes, contain expenditures, reduce disparities, and better coordinate care for the millions of persons in the United States who have advanced dementia.

Tightening the Regulatory Knot: Hospice Regulatory and Health Care Legislative Reform Converge on Hospice Clinical Management

Hospices have been implementing various approaches to cope with the increased regulatory scrutiny in the last 3 years, prompted by concern about costs and outcomes. Medicare, through its fiscal intermediaries, has issued increasingly more restrictive local coverage determination (LCD) guidelines for initial and ongoing qualifying criteria. The regulatory focus has been intensified and extended by the 2010 federal health care reform legislation. The article examines how one hospice clinical management team is managing the convergence of the increased regulation and the new federal health care reform requirements.

Hospice care for persons with dementia: The growth of access in US nursing homes

BACKGROUND/RATIONALE

Persons with dementia often die in nursing homes (NHs); however, concerns exist about their low use of Medicare hospice.

METHODS

For 1999 through 2006 in all US states and DC we merged NH resident assessment data with Medicare claims and enrollment data to identify NH decedents with dementia and hospice use. We studied two groups, those with advanced dementia and those with mild-to-moderately severe dementia.

RESULTS

Across study years, 22.2% of all NH decedents had mild-to-moderately severe dementia and 19.6% had advanced dementia. In 1999, 14.5% of decedents with advanced and 13.2% with mild-to-moderately severe dementia accessed hospice, increasing to 42.5% and 37.9% respectively in 2006. Between 1999 and 2006, mean days of hospice stays increased from 46 to 118 for advanced dementia and from 39 to 79 for mild-to-moderately severe dementia. These mean length of stay differences resulted from a relatively lower proportion of short hospice stays (≤ 7 days) together with higher proportions of longer stays (≥ 181 days) among advanced versus mild-to-moderately severe dementia decedents. Hospice access and lengths of stay among US states varied widely.

CONCLUSIONS

Over 40% of US NH decedents have mild-to-moderately severe or advanced dementia. For these NH decedents, access to and duration of Medicare hospice has increased. However, there is considerable variation in hospice use across US states.

Prediction of 6-month survival of nursing home residents with advanced dementia using ADEPT vs hospice eligibility guidelines

CONTEXT

Estimating life expectancy is challenging in advanced dementia, potentially limiting the use of hospice care in these patients.

OBJECTIVE

To prospectively validate and compare the performance of the Advanced Dementia Prognostic Tool (ADEPT) and hospice eligibility guidelines to estimate 6-month survival in nursing home residents with advanced dementia.

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort study conducted in 21 nursing homes in Boston, Massachusetts, of 606 residents with advanced dementia who were recruited between November 1, 2007, and July 30, 2009. Data were ascertained at baseline to determine the residents' ADEPT score (range, 1.0-32.5; higher scores indicate worse prognosis) and whether they met Medicare hospice eligibility guidelines. Survival was followed up to 6 months.

MAIN OUTCOME MEASURES

Assessment and comparison of the performance of the ADEPT score and hospice guidelines to predict 6-month survival using sensitivity, specificity, and the area under the receiver operating characteristic (AUROC) curve.

RESULTS

At baseline, the residents' mean (SD) ADEPT score was 10.1 (3.1) points and 65 residents (10.7%) met hospice eligibility guidelines. Over 6 months, 111 residents (18.3%) died. The AUROC for the ADEPT score's prediction of 6-month mortality as a continuous variable was 0.67 (95% confidence interval [CI], 0.62-0.72). The AUROC for Medicare hospice eligibility guidelines was 0.55 (95% CI, 0.51-0.59), the specificity was 0.89 (95% CI, 0.86-0.92), and the sensitivity was 0.20 (95% CI, 0.13-0.28). Using a cutoff of 13.5 on the ADEPT score, which also had specificity of 0.89, the AUROC was 0.58 (95% CI, 0.54-0.63) and the sensitivity was 0.27 (95% CI, 0.19-0.36).

CONCLUSIONS

When prospectively validated at the bedside and used as a continuous measure, the ability of the ADEPT score to identify nursing home residents with advanced dementia at high risk of death within 6 months was modest, albeit better than hospice eligibility guidelines. Care provided to these residents should be guided by their goals of care rather than estimated life expectancy.

Palliative care for patients with dementia: a national survey

OBJECTIVES

To determine the extent to which hospice and nonhospice palliative care (PC) programs provide services to patients with dementia and to describe barriers and facilitators to providing nonhospice PC.

DESIGN

Telephone and Web-based surveys.

SETTING

U.S. hospice and PC programs from the National Hospice and Palliative Care Organization's program list.

PARTICIPANTS

Executive directors of 240 hospice programs, 173 programs providing hospice and nonhospice PC, and 13 programs providing nonhospice PC.

MEASUREMENTS

A telephone survey of hospice and PC providers followed by an online survey of programs providing nonhospice PC.

RESULTS

Ninety-four percent of hospices and 72% of PC programs had served at least one patient with a primary diagnosis of dementia within the past year. Based on 80 responses to the online survey, the most highly rated barriers to providing PC were lack of awareness of PC by families and referring providers, need for respite services, and reimbursement policies. Highly rated needs were family information, assistance with caregiver burden, and behavioral symptoms. Strategies critical for success were an interdisciplinary team, collaboration with community organizations, and alternatives to aggressive end-of-life care.

CONCLUSION

Almost all hospices and a majority of nonhospice PC programs serve patients with dementia. Education and policy efforts should focus on education for families and providers, support for caregivers, and reforming reimbursement structures to provide coverage for interdisciplinary PC earlier in the disease, when patients have high needs but are not hospice eligible.

The advanced dementia prognostic tool: a risk score to estimate survival in nursing home residents with advanced dementia

CONTEXT

Estimating life expectancy is challenging in advanced dementia.

OBJECTIVES

To create a risk score to estimate survival in nursing home (NH) residents with advanced dementia.

METHODS

This was a retrospective cohort study performed in the setting of all licensed U.S. NHs. Residents with advanced dementia living in U.S. NHs in 2002 were identified using Minimum Data Set (MDS) assessments. Mortality data from Medicare files were used to determine 12-month survival. Independent variables were selected from the MDS. Cox proportional hazards regression was used to model survival. The accuracy of the final model was assessed using the area under the receiver operating characteristic curve (AUROC). To develop a risk score, points were assigned to variables in the final model based on parameter estimates. Residents meeting hospice eligibility guidelines for dementia, based on MDS data, were identified. The AUROC assessed the accuracy of hospice guidelines to predict six-month survival.

RESULTS

Over 12 months, 40.6% of residents with advanced dementia (n=22,405) died. Twelve variables best predicted survival: length of stay, age, male, dyspnea, pressure ulcers, total functional dependence, bedfast, insufficient intake, bowel incontinence, body mass index, weight loss, and congestive heart failure. The AUROC for the final model was 0.68. The risk score ranged from 1 to 32.5 points (higher scores indicate worse survival). Only 15.9% of residents met hospice eligibility guidelines for which the AUROC predicting six-month survival was 0.53.

CONCLUSION

A mortality risk score derived from MDS data predicted six-month survival in advanced dementia with moderate accuracy. The predictive ability of hospice guidelines, simulated with MDS data, was poor.

Predictors of mortality in nursing home residents with advanced dementia

This analysis uses data from the Care of Nursing Home Residents with Advanced Dementia (CareAD) study to investigate which factors increase the risk of death in patients who are in the advanced stages of dementia. The hypothesis of this analysis was that specific illnesses with known high mortality would be associated with increased risk of death in the population of nursing home residents with advanced dementia, after controlling for demographic variables and disease-stage variables. Baseline data on 123 end-stage dementia nursing home residents were analyzed with a Cox proportional hazards regression. Of the comorbidities studied, pneumonia was the only illness significantly associated with shortened survival. This information can help health care professionals assist surrogate decision makers in making medical decisions regarding the treatment of comorbid medical illness in persons with advanced dementia.

Challenges to improving end of life care of people with advanced dementia in the UK

The end of life care received by patients with advanced dementia and their carers is of increasing importance as the incidence of dementia is set to rise in the next 30 years. Currently, inappropriate admissions to hospital are common in the UK and patients are less likely to be referred to palliative care services, receive less pain control but undergo more invasive interventions compared to their cognitively intact counterparts. Patients and families are seldom informed of the terminal nature of dementia and advance care planning discussions are rare. The aim of this study was to improve the understanding of end of life care needs for this patient group and their carers, and to use this information to devise an intervention to improve care. Qualitative data were obtained from relatives of 20 patients with advanced dementia admitted to an inner London teaching hospital acute National Health Service (NHS) Trust and 21 health care professionals involved in their care. Framework analysis was used to analyse the transcripts. The results showed that participants’ understanding of dementia and its likely progress was poor. Provision of information regarding the future was rare despite high information needs. Attitudes regarding end of life care were often driven by the participant’s illness awareness. These attitudes served to guide the decision making process and appear to be a major barrier to the provision of more appropriate care. Implications for patient care are discussed and suggestions for future interventions are made.

End of life care for community dwelling older people with dementia: an integrated review

OBJECTIVE

To review the evidence for end-of-life care for community dwelling older people with dementia (including those resident in care homes).

DESIGN

An integrated review synthesised the qualitative and quantitative evidence on end-of-life care for community dwelling older people with dementia. English language studies that focused on prognostic indicators for end-of-life care, assessment, support/relief, respite and educational interventions for community dwelling older people with dementia were included. A user representative group informed decisions on the breadth of literature used. Each study selected was screened independently by two reviewers using a standardised check list.

RESULTS

Sixty eight papers were included. Only 17% (12) exclusively concerned living and dying with dementia at home. Six studies included direct evidence from people with dementia. The studies grouped into four broad categories: Dementia care towards the end of life, palliative symptom management for people with dementia, predicting the approach of death for people with dementia and decision-making. The majority of studies were descriptive. The few studies that developed dementia specific tools to guide end of life care and outcome measures specific to improve comfort and communication, demonstrated what could be achieved, and how much more needs to be done.

CONCLUSIONS

Research on end-of-life care for people with dementia has yet to develop interventions that address the particular challenges that dying with dementia poses. There is a need for investigation of interventions and outcome measures for providing end-of-life care in the settings where the majority of this population live and die.

Using Evidence-Based Instruments to Document Eligibility and Improve Quality of Life of Hospice Patients

Hospices have been implementing various approaches to cope with the increased regulatory scrutiny in the past 3 years, prompted by concern about costs and outcomes. Medicare, through its fiscal intermediaries, has issued increasingly more restrictive local coverage determination guidelines for initial and ongoing qualifying criteria. The article examines how one hospice, United Hospice of Rockland, Inc. (UHR, New City, NY), designed multifaceted program to simultaneously improve regulatory compliance and improve quality of life. This article presents how the six scales (i.e., pain-verbal and non-verbal, breathing, functional decline-PPS and Fast, and anxiety) were developed and implemented, and also presents the preliminary evaluation of successful results.