Factors Associated With Opinions About Hospice Among Older Adults: Race, Familiarity With Hospice, and Attitudes Matter

Enhancing End-of-Life Care Knowledge Among Older Spanish-Speaking Adults: Results From a Pilot Educational Intervention on Advance Care Planning and Care Options

BACKGROUND

Disparities in advance care planning (ACP) among older Latinos necessitate targeted interventions to enhance engagement and knowledge in end-of-life care. This study aimed to evaluate the effectiveness of a resource-efficient, culturally tailored educational intervention in improving ACP readiness and knowledge among older Latino adults in the community.

METHODS

A quasi-experimental pretest-posttest design was used to assess the impact of the intervention. The study involved community-dwelling older Latinos (aged 61-94) in the U.S. attending community wellness centers. Measures included participants' knowledge of ACP, care options, familiarity with hospice and palliative care, and attitudes toward hospice, assessed using pre- and post-intervention surveys.

RESULTS

Statistically significant improvements were observed in ACP knowledge, understanding of care options, and attitudes towards hospice and palliative care post-intervention. Demographic factors influenced knowledge scores, with no significant gender differences in the intervention's efficacy.

CONCLUSIONS

The educational intervention effectively enhanced end-of-life care planning readiness and knowledge among older Latinos. The study highlights the potential for sustainable, accessible, and culturally sensitive educational strategies to reduce disparities in ACP knowledge and possibly engagement.

Exploring Pediatric Code Status, Advance Care Planning, and Mode of Death Disparities at End of Life

CONTEXT

Children from marginalized groups are at risk for worse medical outcomes, yet little is known about their end of life experiences.

OBJECTIVE

We examine the characteristics of deceased children with a focus on race, ethnicity, and preferred language.

METHODS

We conducted a cross-sectional study of patients who died at Texas Children's Hospital from 2018 to 2019. Demographics, date of death, and final code status were extracted. Medical complexity prior to admission and mode of death were obtained from chart review.

RESULTS

We included 433 patients. Over one-third were Hispanic (39.3%) with 42.3% preferring Spanish. The majority were White (61.4%) or Black (21.0%). Most patients had significant medical complexity (52.0%) or were infants in their birth admission (29.4%). Half (52.4%) received palliative care; patients with increased medical complexity were more likely to have palliative care involved (P<0.001). There were no differences in palliative care, code status, or mode of death by race. Hispanic patients were less likely to have a full code status (OR 0.42, 95% CI: 0.25-0.73). Spanish-speaking patients were more likely to have palliative care involvement (OR 2.05, 95% CI: 1.21-3.46) and less likely full code orders (OR 0.24, 95% CI: 0.1-0.63).

CONCLUSION

Palliative care services are engaged with most children at end of life and is accessible to marginalized patient groups. Spanish-speaking patients have different code status orders and modes of death at end of life. Further studies are needed to elucidate explanatory factors for differences revealed and multicenter studies are needed to characterize more widespread experiences.

The Medicare Care Choices Model was associated with reductions in disparities in the use of hospice care for Medicare beneficiaries with terminal illness

OBJECTIVE

To assess the effects of the Medicare Care Choices Model (MCCM) on disparities in hospice use and quality of end-of-life care for Medicare beneficiaries from underserved groups-those from racial and ethnic minority groups, dually eligible for Medicare and Medicaid, or living in rural areas.

DATA SOURCES AND STUDY SETTING

Medicare enrollment and claims data from 2013 to 2021 for terminally ill Medicare fee-for-service beneficiaries nationwide.

STUDY DESIGN

Through MCCM, terminally ill enrolled Medicare beneficiaries received supportive and palliative care services from hospice providers concurrently with curative treatments. Using a matched comparison group, we estimated subgroup-specific effects on hospice use, days at home, and aggressive treatment and multiple emergency department visits in the last 30 days of life.

DATA COLLECTION/EXTRACTION METHODS

The sample included decedent Medicare beneficiaries enrolled in MCCM and a matched comparison group from the same geographic areas who met model eligibility criteria at time of enrollment: having a diagnosis of cancer, congestive heart failure, chronic obstructive pulmonary disease, or HIV/AIDS; living in the community; not enrolled in the Medicare hospice benefit in the previous 30 days; and having at least one hospital stay and three office visits in the previous 12 months.

PRINCIPAL FINDINGS

Eligible beneficiaries from underserved groups were underrepresented in MCCM. MCCM increased enrollees' hospice use and the number of days at home and reduced aggressive treatment among all subgroups analyzed. MCCM also reduced disparities in hospice use by race and ethnicity and dual eligibility by 4.1 (90% credible interval [CI]: 1.3-6.1) and 2.4 (90% CI: 0.6-4.4) percentage points, respectively. It also reduced disparities in having multiple emergency department visits for rural enrollees by 1.3 (90% CI: 0.1-2.7) percentage points.

CONCLUSIONS

MCCM increased hospice use and quality of end-of-life care for model enrollees from underserved groups and reduced disparities in hospice use and having multiple emergency department visits.

Close but Not Close Enough: How Distance Caregiving is Associated with Hospice Family Caregiver Hospice Communication Experiences

Half of hospice family caregivers report having unmet information needs, which can contribute to poor pain and symptom management, emergency department use, and hospice disenrollment for care-recipients and to caregiver strain and stress. Effective communication between hospice teams and family caregivers is critical yet communication inadequacies persist. Despite the growing prevalence of distance caregiving, including in hospice care, and the relationship between caregiver proximity and communication effectiveness, little is known about how caregiver proximity is associated with caregiver perceptions of hospice communication. In this secondary analysis of quantitative data from two multisite randomized clinical trials (NCT03712410 and NCT02929108) for hospice family caregivers (N = 525), multivariate linear models with demographic and contextual controls were used to analyze caregivers' perceptions of caregiver-centered communication with hospice providers based on caregiver proximity to the hospice care-recipient. In multivariate models, "local" hospice family caregivers who lived within 1 hour of the hospice care-recipient reported less effective communication with the hospice team than co-residing caregivers; and older caregivers rated communication more favorably than younger caregivers. To improve communication and collaboration between hospice teams and caregivers, regardless of proximity, distance communication training for hospice teams and interventions such as telehealth communication and virtual tools that enable triadic collaboration are recommended. Research is needed to understand why local caregivers, specifically, perceive communication quality less favorably and how hospice teams can better meet local and distance caregiver communication needs.

Hispanics and Hospice: A Systematic Literature Review

Background. Hospice has been shown to improve patient and family satisfaction with care, reduce hospitalizations and hospital costs, and reduce pain and symptoms. Despite more than 40 years of hospice care and related research in the U.S., few studies examining hospice experiences have included Hispanics. Thus, little is known about hospice barriers, facilitators, and outcomes among Hispanics.Aim. This systematic literature review aimed to provide a comprehensive overview of studies assessing knowledge of and attitudes toward hospice, barriers and facilitators to hospice use, utilization patterns, and hospice-related outcomes among Hispanics.Design. Between March 2019 and March 2020 we searched Ovid Medline (PubMed), EMBASE, and CINAHL, using search terms for hospice care, end-of-life care, Hispanics, and Latinos. All steps were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols. U.S. studies that examined Hispanics' knowledge and attitudes towards hospice, facilitators or barriers to hospice use, hospice use, and hospice-related outcomes were included. Qualitative studies and non-empirical work were excluded. Study quality was assessed using Hawker's quality criteria.Results. Of the 4,841 abstracts reviewed, 41 peer-reviewed articles met the inclusion criteria. These studies largely report lower hospice knowledge and awareness among Hispanics and mixed results around hospice use and outcomes in comparison to Whites.Conclusion. There has been relatively little research focused specifically on Hispanics' experience with hospice. Future research should focus on testing interventions for overcoming hospice-related disparities among Hispanics and on improving access to quality hospice care among terminally ill Hispanics.

Mental Health During the First Year of the COVID-19 Pandemic: A Review and Recommendations for Moving Forward

COVID-19 has infected millions of people and upended the lives of most humans on the planet. Researchers from across the psychological sciences have sought to document and investigate the impact of COVID-19 in myriad ways, causing an explosion of research that is broad in scope, varied in methods, and challenging to consolidate. Because policy and practice aimed at helping people live healthier and happier lives requires insight from robust patterns of evidence, this article provides a rapid and thorough summary of high-quality studies available through early 2021 examining the mental-health consequences of living through the COVID-19 pandemic. Our review of the evidence indicates that anxiety, depression, and distress increased in the early months of the pandemic. Meanwhile, suicide rates, life satisfaction, and loneliness remained largely stable throughout the first year of the pandemic. In response to these insights, we present seven recommendations (one urgent, two short-term, and four ongoing) to support mental health during the pandemic and beyond.

Factors Influencing the Willingness of Palliative Care Utilization among the Older Population with Active Cancers: A Case Study in Mandalay, Myanmar

Palliative care is an effective, multidisciplinary healthcare service to alleviate severe illness patients from physical, psychological, and spiritual pain. However, global palliative care has been underutilized, especially in developing countries. This cross-sectional survey aimed to examine the factors associated with older cancer patients’ willingness to utilize palliative care services in Myanmar. The final sample was composed of 141 older adults, 50-years of age and above who suffered from cancers at any stage. Simple random sampling was applied to choose the participants by purposively selecting three oncology clinics with daycare chemotherapy centers in Mandalay. We collected data using structured questionnaires composed of five sections. The sections include the participant’s socio-economic information, disease status, knowledge of palliative care, psychosocial and spiritual need, practical need, and willingness to utilize palliative care services. The study found that approximately 85% of older cancer patients are willing to receive palliative care services. The significant predictors of willingness to utilize palliative care services include place of living, better palliative care knowledge, more need for spiritual and psychosocial support, and practical support. This study can guide health policymakers in increasing the rate of palliative care utilization. The suggested policies include developing community-level palliative care services in Myanmar, especially in rural areas, promoting palliative care knowledge, applying appropriate religious and spiritual traditions at palliative treatment, and developing suitable medicines for the critically ill.

Diversity in Representations and Voices of Terminally Ill People in End-of-Life Documentaries

Background: The 21st century has seen a proliferation of end-of-life documentary films and television documentaries that contribute to building a public image of hospice and palliative care. The way in which terminally ill patients are represented in these documentaries creates impressions of who is welcomed to receive end-of-life care. These documentary representations have not been previously mapped. Methods: Using quantitative content analysis, I analyzed 35 contemporary Western documentaries and studied their diversity in the representations. I focused on terminally ill patients who are given time and space in the narration to voice their views about the end-of-life process. I paid attention to such elements as gender, race and ethnicity, age, class, religion and sexuality. Results: The documentaries welcomed the representations and voices of terminally ill people. Class, religion and sexuality often had a marginal role in narration. The gender diversity of the representations was quite balanced. Regarding age, the documentaries preferred stories about working age patients for dramatic purposes, yet all age groups were represented. However, the documentaries had an identifiable racial and ethnic bias. With a few exceptions, terminally ill who had a personal voice in the narrations were white. In comparison, racial and ethnic minorities were either absent from most of the documentaries, or their role was limited to illustrations of the general story. Conclusions: End-of-life documentaries provide identifiable access to the patients’ experiences and as such they provide emotionally and personally engaging knowledge about hospice and palliative care. While these representations are people-oriented, they include racial disparities and they focus mostly on the experiences of white terminally ill patients. This bias reinforces the misleading image of hospice and palliative care as a racialized healthcare service.

Evaluation of Racial Disparities in Hospice Use and End-of-Life Treatment Intensity in the REGARDS Cohort

Importance

Although hospice use is increasing and patients in the US are increasingly dying at home, racial disparities in treatment intensity at the end of life, including hospice use, remain.

Objective

To examine differences between Black and White patients in end-of-life care in a population sample with well-characterized causes of death.

Design, Setting, and Participants

This study used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, an ongoing population-based cohort study with enrollment between January 25, 2003, and October 3, 2007, with linkage to Medicare claims data. Multivariable logistic regression models were used to examine racial and regional differences in end-of-life outcomes and in stroke mortality among 1212 participants with fee-for-service Medicare who died between January 1, 2013, and December 31, 2015, owing to natural causes and excluding sudden death, with oversampling of Black individuals and residents of Southeastern states in the United States. Initial analyses were conducted in March 2019, and final primary analyses were conducted in February 2020.

Main Outcomes and Measures

The primary outcomes of interest were hospice use of 3 or more days in the last 6 months of life derived from Medicare claims files. Other outcomes included multiple hospitalizations, emergency department visits, and use of intensive procedures in the last 6 months of life. Cause of death was adjudicated by an expert panel of clinicians using death certificates, proxy interviews, autopsy reports, and medical records.

Results

The sample consisted of 1212 participants (630 men [52.0%]; 378 Black individuals [31.2%]; mean [SD] age at death, 81.0 [8.6] years) of 2542 total deaths. Black decedents were less likely than White decedents to use hospice for 3 or more days (132 of 378 [34.9%] vs 385 of 834 [46.2%]; P < .001). After stratification by cause of death, substantial racial differences in treatment intensity and service use were found among persons who died of cardiovascular disease but not among patients who died of cancer. In analyses adjusted for cause of death (dementia, cancer, cardiovascular disease, and other) and clinical and demographic variables, Black decedents were significantly less likely to use 3 or more days of hospice (odds ratio [OR], 0.72; 95% CI, 0.54-0.96) and were more likely to have multiple emergency department visits (OR, 1.35; 95% CI, 1.01-1.80) and hospitalizations (OR, 1.39; 95% CI, 1.02-1.89) and undergo intensive treatment (OR, 1.94; 95% CI, 1.40-2.70) in the last 6 months of life compared with White decedents.

Conclusions and Relevance

Despite the increase in the use of hospice care in recent decades, racial disparities in the use of hospice remain, especially for noncancer deaths. More research is required to better understand racial disparities in access to and quality of end-of-life care.

Sociocultural Factors Associated with Awareness of Palliative Care and Advanced Care Planning among Asian Populations

Objective

Underutilization of palliative care (PC) among racial/ethnic minorities remains consistent despite projected demand. The purpose of this study was to examine knowledge of palliative care and advanced care planning (ACP) and potential variations among subgroups of Asian Americans.

Design

A survey was conducted to collect information about awareness, knowledge, and perspective of PC and ACP in the southwestern region of the United States, from October 2018 to February 2019. A total of 212 surveys were collected from the general public at such places as health fairs, New Year celebration events, church, and community centers; 154 surveys were included in the descriptive and multivariate data analysis.

Results

About 46.1% and 40.3% participants reported having heard of palliative care and advanced care planning, respectively. The average score of the Knowledge of Care Options Instrument (KOCO) was 6.03 out of 11 and the average score of the Palliative Care Knowledge Scale (PaCKS) was 4.38 out of 13. Among those who have heard of PC, both Chinese (odds ratio (OR) .19 [CI, .05, .73]) and Vietnamese (.22 [.06, .84]) were less likely to have heard of palliative care compared with Filipinos (1.00). Among those who have ever heard of advanced care planning, age (.60 [.43, .84]) was negatively and education level (1.91 [1.18, 3.08]) was positively associated with awareness about advanced care planning. The majority of survey participants preferred family members to serve as their power attorneys.

Conclusion

The low levels of palliative care and advanced care planning awareness and knowledge in the diverse Asian groups living in the United States raise concerns and shed light on the critical need for culturally appropriate education programs.