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Background: Most prefer to die at home, but the Medicare Hospice Benefit does not cover custodial care, making it difficult for terminally ill patients with housing insecurity and/or caregiver instability to access hospice care at home., Objectives: To examine the characteristics of patients who received end-of-life care in community-run, residential care homes (RCHs) operating under the social model hospice., Methods: A retrospective chart review of 500 residents who were admitted to one of three RCHs in Upstate New York over a 15-year period (2004-2019)., Results: Patients served by the RCHs included 318 (63.6%) women and 182 (36.4%) men aged 34-101 (M = 77.8). The majority (94.9%) were Caucasian and most had cancer diagnoses (71.6%). Prior to admission, most (93%) patients resided in a private residence, and nearly half (47%) lived alone, but most (81.7%) had full- or part-time caregivers. Nearly all patients were admitted either directly from a hospital (47.5%) or private home (47.2%). Over half (52%) were admitted to RCHs within a month of hospice enrollment, and 20.1% enrolled concurrent with admission. While the average length of stay was 21 days, 50% died within 10 days of admission., Conclusions: Community-run RCHs represent a unique approach for improving access to hospice home care for patients with home insecurity and/or caregiver instability, yet most patients had prior caregiver coverage and were admitted from a hospital or home setting, suggesting there is a need for community care settings for patients unable to remain at home in the final weeks or days prior to death., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Antidepressants can be used to manage symptoms at the end of life, but the dying process can impact their use. Objectives: To examine the use of antidepressants during hospice patients' final months of home care. Methods: A retrospective case records review of 227 hospice patients in their last three months of care in a residential setting. Chart reviews were conducted of medication logs, hospice staff notes, and caregiver narratives to examine antidepressant use including types of medications prescribed and factors associated with medication maintenance. Results: Thirty percent of patients were prescribed at least 1 antidepressant for symptoms including depression, anxiety, pain, disturbances in sleep, and poor appetite. The majority (96.1%) of patients were not administered their antidepressant on the day of death, and more than half (61.8%) did not receive their antidepressant during their last 3 days of life. A quarter (25.5%) of patients on antidepressants did not receive medication 4-7 days prior to death while some (12.7%) went without their antidepressant for 8 or more days. Antidepressant use was discontinued by hospice staff or caregivers due to a variety of reasons including difficulty swallowing, minimal consciousness, confusion, nausea, or patient refusal. Conclusions: Antidepressants are prescribed to manage multiple symptoms at the end of life, but use is often disrupted during patients' final days. Tapering and other prescription adjustments may be warranted to avoid risk of antidepressant discontinuation syndrome (ADS).

Background : Hospice patients receiving care at home rely on caregivers to manage liquid morphine for pain and dyspnea during the dying process. Medication is prescribed under varying regimens, yet caregivers are not required to record when morphine is used. Therefore, it is not known whether morphine use varies by regimen for hospice patients dying at home. Design and methods A retrospective review of medication records from 227 deceased hospice patients who received routine home care in a residential setting in the U.S. Concentrated liquid morphine doses prescribed by hospice and doses administered by caregivers were calculated 7 days prior to death and on the day of death. Percent of maximum dose prescribed was determined by regimen type (scheduled, pro re nata, or combination) and by prescription flexibility (varied vs set doses/times). : A retrospective review of medication records from 227 deceased hospice patients who received routine home care in a residential setting in the U.S. Concentrated liquid morphine doses prescribed by hospice and doses administered by caregivers were calculated 7 days prior to death and on the day of death. Percent of maximum dose prescribed was determined by regimen type (scheduled, pro re nata, or combination) and by prescription flexibility (varied vs set doses/times). Results : Morphine was prescribed to 60.4% of patients a week prior to death and to 86.8% of patients on the day they died. Doses prescribed and percent morphine administered increased over the last week ( P Morphine was frequently prescribed in the last week of life, but administration rates by caregivers were low, especially with less structured regimens. Caregivers may need more guidance regarding morphine's use at home, especially with more flexible regimens.P < .01) with flexible prescriptions (21.84%) than with structured regimens (39.52%). Conclusion: Morphine was frequently prescribed in the last week of life, but administration rates by caregivers were low, especially with less structured regimens. Caregivers may need more guidance regarding morphine's use at home, especially with more flexible regimens.

Background: A growing number of informal caregivers (IFCs) manage hospice patients' anxiety by administering lorazepam (Ativan), yet little is known about prescribing practices in home care or the extent to which IFCs carry out regimens., Design and Methods: Data on hospice prescribed lorazepam was determined through a retrospective review of medication records from 216 deceased patients. The dose of lorazepam and type of regimen (i.e., scheduled, PRN, combination) as well as frequency with which it was administered by IFCs was calculated upon admission to a residential care home and on patients' day of death., Results: The majority (63.1%) of patients were prescribed lorazepam on admission to the home, and more (79.5%) were prescribed lorazepam on the day of death. While higher doses of lorazepam were prescribed and administered on the day of death, the percentage of medication consumed was low on admission (17%) and day of death (27%). Nearly all (92.8%) prescribed lorazepam on the day of death were allowed PRN medication. For PRN only regimens, less than a quarter (24.4%) of patients were given lorazepam on admission with less than half (40.4%) given it while dying. Highest lorazepam administration rates (91.2%) occurred on the day of death when lorazepam was prescribed under a combined regimen., Conclusion: The high frequency of PRN regimens reveal that IFCs are frequently tasked with making decisions about if and when to administer lorazepam. Low overall lorazepam administration suggests a closer monitoring of lorazepam use and enhanced support of IFCs may be needed.

Background: Health-care providers report a lack of training in end-of-life care and limited opportunities exist to learn about the dying process in home settings where most prefer to die., Aim: To evaluate the effectiveness of a Community Action, Research, and Education (CARE) program designed to promote empathy and self-efficacy communicating with and caring for terminally ill patients., Methods: This mixed-methods study collected pre-post data from 18 undergraduates (7 men≤ 11 women) in a 8-week immersive program where they served as primary caregivers in residential homes for the dying providing 200 hours of bedside care to hospice patients during their final days. Quantitative measures assessed empathy using the Jefferson Scale of Empathy-Health Professions (JSE-HPS) version and self-efficacy using a 20-question palliative care skill assessment. Qualitative analyses were conducted on reflective journals to further assess knowledge, skill, and value development., Results: Paired t tests revealed significant increases in empathy ( P < .05) and self-efficacy ( P < .001) to provide end-of-life care. Thematic analysis of reflective journals further demonstrated specific instances of empathy and self-efficacy., Conclusions: Community-run residential homes for the dying offer a unique opportunity for skills training in end-of-life care. The opportunity to serve as a caregiver for the dying improved students' confidence and ability to provide empathic patient- and family-centered end-of-life care to hospice patients in their final days.

Background: There is a growing need for home-based palliative care services, especially for seriously ill individuals who want to avoid hospitalizations and remain with their regular outside care providers., Aim: To evaluate the effectiveness of Care Choices, a new in-home palliative care program provided by the Visiting Nurse Services of Northeastern New York and Ellis Medicine's community hospital serving New York's Capital District., Methods: This prospective cohort study assessed patient outcomes over the course of 1 year for 123 patients (49 men and 74 women) with serious illnesses who were new enrollees in the program. Quality of life was assessed at baseline and after 1 month on service. Satisfaction with care was measured after 1 and 3 months on service. The number of emergency department visits and inpatient hospitalizations pre- and postenrollment was measured for all enrollees., Results: Patients were highly satisfied (72.7%-100%) with their initial care and reported greater satisfaction ( P < .05) and stable symptom management over time. Fewer emergency department ( P < .001) and inpatient hospital admissions ( P < .001) occurred among enrollees while on the palliative care service., Conclusion: An in-home palliative care program offered jointly through a visiting nurse service and community hospital may be a successful model for providing quality care that satisfies chronically ill patients' desire to remain at home and avoid hospital admissions.