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BACKGROUND: Antibiotics are frequently prescribed at the end of life, though the benefits and harms are not well understood. METHODS: We abstracted relevant findings from articles published in English in the past 25 years to answer questions generated by discussion among the authors and with stakeholders in Palliative Care and Infectious Diseases. FINDINGS: Prescribing practices vary based on individual situation and geographic location. Patients with cancer and those hospitalized receive more antibiotics than those enrolled in outpatient hospice. Urinary tract infections and pulmonary infections are the most common conditions treated with antibiotics at the end of life -most often with penicillin derivatives and vancomycin in the hospital, fluoroquinolones in outpatient, and cephalosporins in both settings. When asked, patients most often prefer limiting antibiotics to symptom management at the end of life. Physicians' over-estimation of patient preference for antibiotics and the increased probability of misdiagnosis increases antibiotic prescription rates. Antibiotics can improve symptoms when used for specific diseases at the cost of drug reactions, resistant organisms, and delayed discharge. Antibiotic use has variable results on survival duration. Antimicrobial stewardship exists in hospital and long-term care facilities, but not outpatient hospice groups. Stewardship interventions could increase proper use of antibiotics, but more information is needed to apply these interventions to hospice groups. CONCLUSIONS: Antibiotics at the end of life are impactful and efforts to educate patients and providers will be invaluable in optimizing care.

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BACKGROUND: Empathy is important in hospice nursing clinics and may influence nurses' professional quality of life (ProQOL). However, present studies ignoring each empathic dimension, and few researches have explored the correlation between empathy and ProQOL in hospice nurses in Asia. To better understand hospice nurses' empathy abilities in China and its relationship with ProQOL, the aim of this study was to identify the latent profiles and its influencing factors of hospice nurses' empathy ability, as well as differences in ProQOL across each latent profile. METHODS: A cross-sectional study was conducted from October 2021 to September 2022, and a total of 725 hospice nurses were recruited from different geographic regions in China. Participants completed the Empathy Ability Scale for Hospice Nurses and the Brief Professional Quality of Life Scale. Latent profile analysis (LPA) was employed to identify latent profiles of empathy ability among hospice nurses in China. The predictors of hospice nurses' empathy ability in different latent profiles were assessed using multinomial logistic regression analysis. One-way ANOVA test and the Kruskal-Wallis test were used to compare the ProQOL scores in each latent profile of nurses' empathy ability. RESULTS: This study identified three latent profiles of hospice nurses' empathy ability, and those profiles labelled "poor empathy ability-high surface empathy expression" (n = 216, 29.8%), "moderate empathy ability" (n = 359, 49.5%) and "high empathy ability-high deep empathy expression" (n = 150, 20.7%). Multinomial logistic regression analysis suggested that age, hospital level, whether income meets expectations, interests in hospice care work, hospice work experience, and receiving psychological counselling were predictors of hospice nurses' profile membership of empathy ability. The scores of compassion satisfaction (CS) and burnout (BO) in ProQOL were significantly different across each profile (P < 0.001), while scores of secondary traumatic stress (STS) in ProQOL were not different across each profile (P = 0.294). CONCLUSIONS: Hospice nurses' empathy ability was divided into three latent profiles, and enhancing empathy ability may be conducive to improving hospice nurses' CS, while reducing BO, thus fostering their overall quality of life. Nursing managers should identify hospice nurses at higher risk of BO and implement targeted interventions focused on enhancing nurse's empathy abilities.

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Hospice care is designed to support the medical and psychosocial needs of individuals with serious illness and their caregivers through the dying process. Some individuals, though, leave hospice prior to death, generally referred to as disenrollment or a "live discharge." Live discharge from hospice is a common and often distressing issue for hospice patients, their caregivers, and also for hospice professionals and agencies. This paper discusses common issues surrounding live discharge that clinicians and other healthcare professionals should consider when dealing with live discharge in their own clinical practices. Where applicable, we provide practical steps for hospice and palliative care clinicians to better support patients and families through this critical care transition. Further, we offer strategic directions interprofessional clinicians can take to affect systemic change to improve live discharge experiences.

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OBJECTIVES: Approximately 5.5% of the population live with serious mental illnesses (SMI). Older adults with SMI experience a high burden of serious medical illnesses and disparities in advance care planning, symptom management, and caregiver support. The objectives of this study are to explore interdisciplinary clinician perspectives on the palliative care needs of older adults with SMI and serious medical illnesses. DESIGN, SETTING, AND PARTICIPANTS: This qualitative study utilized thematic analysis of semi-structured interviews of interdisciplinary clinicians practicing palliative care, geriatrics, or geriatric/consultation-liaison psychiatry at four hospitals within an urban health system. MEASUREMENTS: Themes related to care of older adults with serious mental illness and serious medical illness with respect to clinician experiences, challenges in care, and opportunities to improve care. RESULTS: The authors interviewed 45 clinicians. Major themes identified were: (1) Current paradigms of palliative care do not meet the needs of patients with SMI; (2) Clinicians are motivated to care for this population but require more training and interdisciplinary practice; (3) There is a need for structural integration of psychiatric and palliative care services. CONCLUSIONS: The study underscores the inadequacy of current palliative care models in meeting the unique needs of older adults with SMI. Models of integrated psychiatric and serious illness care and enhanced training are needed to improve the delivery of palliative care. Integrated care models and workforce development at the interface of serious illness care and psychiatric have the potential to improve outcomes for this vulnerable population.

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PURPOSE: The Palliative Care Outcomes Collaboration (PCOC) aims to enhance patient outcomes systematically. However, identifying crucial items and accurately determining PCOC phases remain challenging. This study aims to identify essential PCOC data items and construct a prediction model to accurately classify PCOC phases in terminal patients. METHODS: A retrospective cohort study assessed PCOC data items across four PCOC phases: stable, unstable, deteriorating, and terminal. From July 2020 to March 2023, terminal patients were enrolled. A multinomial mixed-effect regression model was used for the analysis of multivariate PCOC repeated measurement data. RESULTS: The dataset comprised 1933 terminally ill patients from 4 different hospice service settings. A total of 13,219 phases of care were analyzed. There were significant differences in the symptom assessment scale, palliative care problem severity score, Australia-modified Karnofsky performance status, and resource utilization groups-activities of daily living among the four PCOC phases of care. Clinical needs, including pain and other symptoms, declined from unstable to terminal phases, while psychological/spiritual and functional status for bed mobility, eating, and transfers increased. A robust prediction model achieved areas under the curves (AUCs) of 0.94, 0.94, 0.920, and 0.96 for stable, unstable, deteriorating, and terminal phases, respectively. CONCLUSIONS: Critical PCOC items distinguishing between PCOC phases were identified, enabling the development of an accurate prediction model. This model enhances hospice care quality by facilitating timely interventions and adjustments based on patients' PCOC phases.

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Palliative care is a comprehensive approach aimed at improving the quality of life for patients and their families. The symptom burden and care needs of patients with end-stage, non-malignant diseases are similar to those experienced by patients with advanced cancer. Therefore, the World Health Organization (WHO) has recommended the expansion of palliative care to encompass a broad spectrum of diseases. However, in Korea, the adoption of palliative care for non-malignant conditions remains markedly low, presenting numerous challenges that differ from those associated with cancer. Key barriers to implementing hospice care for non-malignant diseases include the difficulty in predicting end-of-life and a general lack of awareness about hospice palliative care among healthcare providers, patients, and their families. Additionally, there is a risk that suggesting palliative care to patients with non-malignant diseases might be misinterpreted as an endorsement by healthcare providers to cease treatment or abandon the patient. This article explores strategies to broaden the scope of hospice and palliative care for patients with non-malignant diseases.

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BACKGROUND: Countries with formal policies for palliative care, and advanced and integrated practices in this field, such as Portugal, face challenges in achieving excellence in care, particularly in home-based assistance. Issues include care coordination among providers, confusion regarding the roles of each health care professional in the network, and a lack of monitoring and evaluation of actions. Our objective was to analyze the implementation of palliative care in primary health care in Portugal. METHODS: We conducted a qualitative, descriptive, and exploratory study in Portugal involving health care professionals with experience in palliative care. The data were collected through semistructured interviews and focus groups between March and October 2023. Eighteen health care professionals participated. We used the Alceste software for lexicographic analysis. The research was authorized by an Ethics Committee. RESULTS: Four classes were identified; classes 1 and 2, comprising 77% of the corpus, addressed the study objectives. Participants highlighted inequitable access, strategic development plans with unattainable short-term goals; and low literacy. They emphasized the importance of legislation, professional training initiatives for generalist palliative care at home, and early referral. Home-based challenges included professionals' lack of exclusive dedication, absence of 24/7 coverage, and unavailability of capable family caregivers. The networks' response to hospital admissions and patient transitions from hospital to home, with access to the specialized team, was also inadequate. CONCLUSIONS: Health care professionals aim to increase patients' time spent at home, reduce emergency department visits, and minimize hospitalizations by leveraging the resources of the national palliative care network. In addition to investments to sustain network implementation and legally guaranteed palliative care rights, the country must focus on measurable indicators for evaluating and monitoring actions, providing better guidance in the short, medium, and long term.

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Although many large Chinese cities have begun to implement hospice services, hospice care is still a relatively new concept in many parts of the country, especially in smaller cities. The purpose of this study was to gain a better understanding of health care providers' (physicians and nurses) perceptions of the facilitators and barriers to hospice care implementation in a fourth-tier city. Using a qualitative descriptive approach, semi-structured, open-ended interviews were conducted with 15 health care providers. Two major categories for developing hospice care were identified: (a) prospective facilitators and (b) perceived barriers. In addition, there is currently much ambiguity regarding what agency should oversee hospice services if implemented, who should be responsible for payment, the importance of developing interdisciplinary care teams and concerns about worker shortages. Future research is encouraged to investigate attitudes towards hospice care across various local healthcare systems and to promote the development of local hospice care support.

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Background: Paying attention to palliative care has accelerated in Iran in the last 10 years. Considering the trend of aging, increasing burden of chronic diseases and increasing health costs, planning and development of palliative care is necessary in the future. This study was conducted with the aim of explaining the alternative scenarios of palliative care in the health system of Iran until the horizon of 2030. Methods: This study was a multi-method scenario planning with a qualitative using multiple methods design, which was conducted in 3 phases in 2018-2020. In the first phase, a list of driving forces was extracted using qualitative interviews and literature review. In the second phase, all factors identified in the previous phase were examined in terms of degree of uncertainty and cross-impact analysis, and two key uncertainties were extracted. In the third phase, based on two key uncertainties, four future scenarios of palliative care were formulated, validated and scenario strategies were presented. Results: The results indicate two uncertainties, including "governance of palliative care in the health system" and "acceptance of palliative care by society," based on which, four scenarios with the names "climbing to the top," "excruciating climb," "edge of the abyss" and "The bottom of the valley" were compiled. Conclusion: The development of palliative care in health system of Iran is faced with serious uncertainties that it is necessary to focus the developmental activities of palliative care on the two axes of acceptance by society and need for coherent governance by considering all the dimensions and influential components by ministry of health. The application of the results of this research can provide reasonable options for effective interventions and implementation of this category of services to the beneficiaries of palliative care.

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BACKGROUND: While home is frequently expressed as the favorite place of death (PoD) among terminally ill cancer patients, various factors affect the fulfillment of this wish. The determinants of the PoD of cancer patients in countries without healthcare system-integrated palliative and supportive care have not been studied before. This study aimed at identifying the predictors of the PoD of patients who suffer from advanced cancer by developing a reliable predictive model among who received home-based palliative care in Iran as a representative of the countries with isolated provision of palliative care services. METHODS: In a cross-sectional study, electronic records of 4083 advanced cancer patients enrolled in the Iranian Cancer Control Center (MACSA) palliative homecare program, who died between February 2018 and February 2020 were retrieved. Multivariable binary logistic regression analysis as well as subgroup analyses (location, sex, marital status, and tumor topography) was performed to identify the predictors of PoD. RESULTS: Of the 2398 cases included (mean age (SD) = 64.17 (14.45) year, 1269 (%52.9) male), 1216 (50.7%) patients died at home. Older age, presence and intensity of medical homecare in the last two weeks and registration in the Tehran site of the program were associated with dying at home (P < 0.05). Gynecological or hematological cancers, presence and intensity of the calls received from the remote palliative care unit in the last two weeks were predictors of death at the hospital (p < 0.05). The model was internally and externally validated (AUC = 0.723 (95% CI = 0.702-0.745; P < 0.001) and AUC = 0.697 (95% CI = 0.631-0.763; P < 0.001) respectively). CONCLUSION: Our model highlights the demographic, illness-related and environmental determinants of the PoD in communities with patchy provision of palliative care. It also urges policymakers and service providers to identify and take the local determinant of the place of death into account to match the goals of palliative and supportive services with the patient preferences.

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Background: The majority of hospice patients are over the age of 65, and the majority of hospice deaths occur in private homes. As a hospice patient's disease progresses, death becomes imminent and family and friends gather around to say good-bye. These private vigils are the culmination of the hospice experience and reflect both the strengths and the challenges surrounding hospice care. The purpose of this study was to explore the stories and experiences of hospice staff with death vigils, unveiling the secrets of home deaths and identifying barriers to a good death. Methods: Qualitative analysis of interviews with 25 hospice staff representing 11 different hospice agencies explored the emotions and challenges of directing and managing the vigil experience. Based on Erving Goffman's dramaturgical model, the experience is explored in depth to unveil a private experience in hopes of enlightening the public on what death in the home looks and feels like. Co-coding of stories and validation of findings by hospice nurses and physicians assure the trustworthiness of the data. Results: Hospice staff share narratives related to family and caregiver burden, challenges with symptom management, frustrations with staffing shortages, and administrative burdens surrounding the experience of death vigils. Conclusions: The family and hospice clinician's experiences with the final act of dying at home are sometimes challenged by the intermittent nature of home care during the final days.

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Private equity ownership across the US health care system is rapidly increasing, yet ownership structures are complex and opaque. We used an economic data set tracking mergers and acquisitions linked to Medicare data to identify private equity hospice acquisitions. Given the influence of for-profit ownership on hospice quality, transparent data on private equity investment are fundamental to ensuring high-quality end-of-life care.

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BACKGROUND: Nurse-patient relationships are an integral component of person-centred palliative care. Greater understanding of how nurse-patient relationships are fostered and perceived by patients and nurses can be used to inform nursing practice. AIM: To systematically identify and synthesise how nurse-patient relationships are fostered in specialist inpatient palliative care settings, and how nurse-patient relationships were perceived by patients and nurses. DESIGN: Integrative review with narrative synthesis. The review protocol was registered with PROSPERO (CRD42022336148, updated April, 2023). DATA SOURCES: Five electronic databases (PubMed, CINAHL Complete, Medline, Web of Science and PsycINFO) were searched for articles published from their inception to December 2023. Studies were included if they (i) examined nurse and/or patient perspectives and experiences of nurse-patient relationships in specialist inpatient palliative care, (ii) were published in English in a (iii) peer-reviewed journal. The Mixed Methods Appraisal Tool was used to evaluate study quality. Data were synthesised using narrative synthesis. RESULTS: Thirty-four papers from 31 studies were included in this review. Studies were mostly qualitative and were of high methodological quality. Four themes were identified: (a) creating connections; (b) fostering meaningful patient engagement; (c) negotiating choices and (d) building trust. CONCLUSIONS: Nurses and patients are invested in the nurse-patient relationship, benefitting when it is positive, therapeutic and both parties are valued partners in the care. Key elements of fostering the nurse-patient relationship in palliative care were revealed, however, the dominance of the nurses' perspectives signifies that the nature and impact of these relationships may not be well understood.

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CONTEXT: For many, the perception of "hospice" is synonymous with "death." Even clinicians struggle to have conversations that distinguish between hospice and palliative care for fear that discussing hospice may diminish hope. To date, there are no existing measurement tools to evaluate patient and family perceptions of hospice care. OBJECTIVE: This research aimed to develop a Hospice Perceptions Instrument (HPI) to capture these perceptions among diverse patients and families. METHODS: Building on previous studies and literature, 79 potential items were drafted for the instrument. Our interprofessional team independently and collectively evaluated these, resulting in 36 items rated on a 5-point Likert scale. Overarching domains include (1) hospice philosophy and definitions; (2) hospice services; (3) values; and (4) counter-perceptions. Sixteen national subject matter experts from various professions and roles were invited to participate in the content-validity index and five hospice caregivers were invited to participate in face validity. RESULTS: Fourteen experts responded, with ten meeting inclusion criteria: one physician, four nurses, three social workers, and two chaplains. Six of the ten identified as Black. Three items were removed (I-CVI ranged from 0.5-06), and nine items were revised (I-CVI ranged from 0.6-07). The overall Content Validity Index (CVI) was 0.83, indicating excellent content validity. After revisions, five hospice caregivers assessed face validity and no changes were made based on feedback. CONCLUSION: Results reveal a disconnect between professional expertise and patient/family voices related to hospice perceptions. Development of this instrument invites a better understanding of perceptions leading to new opportunities for patient/family engagement.

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Background: Patients with cancer use the internet to inform medical decision making. Objective: To examine the content of ChatGPT responses to a hypothetical patient question about decision making in advanced cancer. Design: We developed a medical advice-seeking vignette in English about a patient with metastatic melanoma. When inputting this vignette, we varied five characteristics (patient age, race, ethnicity, insurance status, and preexisting recommendation of hospice/the opinion of an adult daughter regarding the recommendation). ChatGPT responses (N = 96) were coded for mentions of: hospice care, palliative care, financial implications of treatment, second opinions, clinical trials, discussing the decision with loved ones, and discussing the decision with care providers. We conducted additional analyses to understand how ChatGPT described hospice and referenced the adult daughter. Data were analyzed using descriptive statistics and chi-square analysis. Results: Responses more frequently mentioned clinical trials for vignettes describing 45-year-old patients compared with 65- and 85-year-old patients. When vignettes mentioned a preexisting recommendation for hospice, responses more frequently mentioned seeking a second opinion and hospice care. ChatGPT's descriptions of hospice focused primarily on its ability to provide comfort and support. When vignettes referenced the daughter's opinion on the hospice recommendation, approximately one third of responses also referenced this, stating the importance of talking to her about treatment preferences and values. Conclusion: ChatGPT responses to questions about advanced cancer decision making can be heterogeneous based on demographic and clinical characteristics. Findings underscore the possible impact of this heterogeneity on treatment decision making in patients with cancer.

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Context: The time-variable, competency-based mid-career fellowship in Hospice and Palliative Medicine (HPM) is a multicenter pilot program for physicians who want to train in HPM part-time. Objectives: This study describes the experience of the early cohort of mid-career fellows. Methods: Fellows at the seven sites were surveyed about their perceptions of the program and their confidence in subspecialty skills. Results: Surveys were sent to 13 fellows and completed by 8. All reported positive experiences with curricula, direct observation, feedback, and cross-site case reviews. Most responses were positive regarding individualized learning plans and case-stimulated reviews. Respondents reported high confidence in 9 of the 13 specialty-specific skills, including communication, caring for dying patients, and pain management. They reported less confidence with psychological and non-pain symptoms, spirituality, and prognostication. Fewer than half indicated that the process for graduation was clear. Conclusion: Physicians in the competency-based HPM fellowship report a positive experience and high confidence in subspecialty skills.

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BACKGROUND: Numerous studies have demonstrated that hospice palliative care interventions for cancer patients can reduce health care utilzation. In Taiwan, 20-25% of patients who require mechanical ventilation are using prolonged mechanical ventilation (PMV); however, only a limited number of studies have addressed the effectiveness of hospice palliative care for these patients. This study investigated the impact of hospice palliative care utilization on medical utilization among subjects using PMV. METHODS: By using the health insurance database of a nationwide population-based study, we identified subjects who had been on mechanical ventilation for > 21 d, were age ≥18 y between 2009 and 2017, and had received hospice palliative care. The control group was formed through 1:1 matching by using propensity scoring after excluding patients who had participated in palliative care for <15 d or for >181 d. Furthermore, we used a conditional logistic regression analysis to investigate the incidence of ICU admission, emergency department presentation, and cardiopulmonary resuscitation within 14 d before death. RESULTS: A total of 186,533 new subjects receiving PMV age ≥ 18 y were admitted between 2009 and 2017. In addition, the number of subjects receiving palliative care increased annually, rising from 0.6% in 2009 to 41.33% in 2017. The emergency department visits (odds ratio [OR] 0.68, 95% CI 0.63-0.74), ICU admission (OR 0.59, 95% CI 0.53-0.66), cardiopulmonary resuscitation (OR 0.40, 95% CI 0.35-0.46), and total hospitalization cost ($1,319.91 ± $1,821.66 versus $1,544.37 ± $2,309.27 [$USD], P < .001) were significant lower in the palliative care group. CONCLUSIONS: Subjects undergoing PMV while receiving hospice palliative care experienced significant reductions in total hospitalization costs, ICU admissions, cardiopulmonary resuscitation, and medical expenses within 14 d before death.

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CONTEXT: Spiritual care is recognition of patient and caregiver spiritual/religious needs and attention to those needs. Caregivers of African American hospice patients are more likely to report worse emotional/religious support. Yet, spiritual care delivery and roles of community clergy and chaplains for African American hospice patients are not well understood. OBJECTIVES: Examine who provides spiritual care to African American hospice patients and caregivers. METHODS: Partnering with large, urban/suburban community hospice, we interviewed caregivers of deceased African American hospice patients (n = 12), their clergy (n = 3) and chaplains (n = 5). Using a phenomenological qualitative study design, we coded transcripts and deceased patient chart data and conducted thematic analysis to identify themes. RESULTS: Community clergy and chaplains tend to not interact and provide different aspects of emotional, religious and spiritual support to hospice patients and families. Clergy and chaplains agreed that rapport and openness of the patient were main factors in meeting spiritual care needs. Clergy provided interaction with a trusted person and connection to church, congregational support, religious beliefs/theology, and practices. Chaplains focused on present needs and issues of death and dying. CONCLUSION: Clergy and chaplains have distinct, complementary roles in providing spiritual care to African American hospice patients and families. Both are needed to provide desired spiritual care for African American hospice patients and their caregivers. Robust spiritual care programs need to ensure chaplains have sufficient time to spend with patients and families and incorporate collaboration, handoffs and integrated processes for clergy and chaplains. Research is needed on effectively including clergy in hospice spiritual care delivery.