Journal of palliative medicine
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The goal of the larger study was to explore physicians' emotional responses to the death of their patients; this study analyzed a subset of physician transcripts to elucidate the construct of questioning care, which emerged from the larger study. ⋯ A typology of questioning care emerged from these physicians' narratives that parallels and reflects recent and classic research on medical error and the culture of medicine. Physicians' questions about care can contribute to designing training experiences for residents and to improving the quality of systems that affect patients' experiences at life's end and physicians' experiences in caring for dying patients.
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Randomized Controlled Trial Clinical Trial
A quality improvement intervention to increase palliative care in nursing homes.
Death is common in nursing homes, but access to palliative care is limited. ⋯ A quality improvement intervention was effective in increasing hospice enrollment, pain assessment, nonpharmacologic pain treatment, and advance care planning discussions.
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Comparative Study
"Lost to follow-up": ethnic disparities in continuity of hospice care at the end of life.
Hospice has become the major provider of comprehensive end-of-life care in the United States, but is underutilized by African American patients. It is likely that whatever factors are responsible for lower rates of hospice utilization among African Americans also lead to lower rates of return to hospice after discharge, but this is not known. ⋯ Ethnic disparities in hospice utilization may extend even to those patients who do enroll in hospice. African Americans who leave hospice during their first admission and their families may be less likely to have access to the comprehensive services that hospice programs provide near the end of life, including intensive nursing care, pain and symptom management, and education.
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Hospices provide care to patients with a wide range of prognoses, and must develop care plans that anticipate each patient's likely illness trajectory. However, the tools available to guide prognostication and care planning in this population have limited data to support their use. For instance, one of the most widely-used prognostic tools, the Palliative Performance Scale (PPS), has been studied primarily in inpatient settings and in patients with cancer. Its prognostic value in a heterogeneous US hospice population is unknown. ⋯ The PPS performs well as a predictor of prognosis in a heterogeneous hospice population, and performs particularly well for nursing home residents and for patients with non-cancer diagnoses. The PPS should be useful in confirming hospice eligibility for reimbursement purposes and in guiding plans for hospice care.
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Patients typically receive hospice care only in the last days or weeks of life, and there is widespread agreement among experts that patients enroll in hospice too late. However, it is not known whether patients and their families believe that they are enrolling in hospice too late. ⋯ Despite late enrollment in hospice and very short lengths of stay, most patients and families believe that they are enrolling in hospice at the right time.