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The opioid crisis has devastated the U.S. more than any other country, and the epidemic is getting worse. While opioid prescriptions have decreased by more than 40% from its peak in 2010, unfortunately, opioid-related overdose deaths have not declined but continued to increase. With greater scrutiny on prescription opioids, many users switched to the cheaper and more readily available heroin that drove up heroin-related overdose deaths from 2010 to peak in 2016, being overtaken by the spike in synthetic opioid (mostly fentanyl)-related overdose deaths. The surge in fentanyl-related overdose deaths since 2013 is alarming as fentanyl is more potent and deadly. One thing is certain the opioid crisis is not improving but has become dire with the surge in fentanyl-related overdose deaths. Evidence-based strategies have to be implemented in the U.S. to control this epidemic before it destroys more lives. Other countries, including European countries and Canada, have invested more in harm reduction strategies than the U.S. even though they (especially Europe) do not face anywhere near the level of crisis as the U.S. In the long-run, upstream measures (tackling the social determinants of health) are more effective public health strategies to control the epidemic. In the meantime, however, harm reduction strategies have to be employed to mitigate the harm from addiction and overdose deaths.

The purpose of this 3-month quasi-experimental pilot study was to examine the effect of a physical activity and dietary education program on body mass index (BMI) and resilience. Participants were given data-storing pedometers to record their physical activity, attended classes on healthy eating, and used portion control tools from http://ChooseMyPlate.gov . MyPlate usage and commissary purchases were collected weekly. BMI and resilience scores were measured at baseline, 6 weeks, and 12 weeks. Twenty-nine female prisoners completed the study. There was a statistically significant reduction in BMI after 12 weeks (χ

In 2011, 1.65 million individuals with terminal illnesses received hospice services, and 44.6% of all decedents in the United States had been under the care of a hospice.1 Hospice users and their primary caregivers are typically older adults. In 2013, an estimated 84% of hospice users were aged 65 and older and 41% were aged 85 and older.2 Primary caregivers, who help make decisions for terminally ill individuals, are most often their spouses or adult children who are aged 60 and older.3 Although most family members of individuals in hospice who die recover from initial reactions of acute grief and return to preloss functioning,4 an estimated 11% develop the mental health disorders of complicated grief (CG) and depression, with prevalence increasing slightly with increasing age.5–7 CG is characterized by symptoms of reactive distress to the death (e.g., disbelief or bitterness) and disruption in social relationships or identity.8 Criteria for major depressive disorder (depression) are well established,8 but diagnosis of depression after bereavement has recently undergone a significant change. The Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, allows diagnosis of depression within 2 weeks of bereavement, replacing the DSM, Fourth Edition, requirement that depression not be diagnosed until 2 months after bereavement.8 This change expands the population of individuals who might benefit from screening and treatment. In older adults, depression and CG are associated with greater risk of morbidity for most of the common diseases of later life, including chronic functional impairment, hypertension, sleep impairment, and suicidal ideation.9–18 For example, the risk of hypertension is 10 times as high in older widowed adults who meet consensus criteria for CG as in those who do not.19 As the U.S. population continues to age, it is likely that the impairment associated with depression and CG will create an even greater societal burden. Well-validated measures and effective individual and group psychotherapeutic treatments for CG and depression in older adults have been developed,20–22 yet older adults are less likely to seek bereavement support than younger adults,23 in part because of a cohort-specific stigma about the acceptability of using mental health care.24 Because hospices care for people before and during death, they are uniquely positioned to offer screening and referral services for CG and bereavement-related depression in older family caregivers. Receiving bereavement support in a setting to which older adults are already connected may make it use more likely.25 Moreover, Medicare, the primary payer for hospice care (providing coverage to 84% of people in hospice)1 requires that hospices offer bereavement services to family members for at least a year after the person in hospice dies in order to receive reimbursement under the Medicare Hospice Benefit.1 Although hospice provision of bereavement services has been described in detail,26–29 previous publications have not focused specifically on screening and referral practices for CG or depression. Accordingly, the current study used data from the National Hospice Survey to estimate the extent to which hospices nationally provide screening and referral services that address the mental health needs of family members of individuals who die in hospice. The associations between organizational and staff factors and the likelihood of offering screening and referral for CG and depression were also examined. Organizational theory posits that organizational structure can affect the type and quality of care provided.30 In this analysis, organizational factors considered included hospice profit status, chain affiliation, size, and geographical region. In keeping with previous work, it was hypothesized that larger hospice size would be associated with higher likelihood of conducting screening and referral.29 Because previous analyses did not find consistent associations between profit status, chain affiliation, region, and bereavement service intensity more generally,29 it was not expected to that any association would be found with these variables in the analyses. It was also hypothesized that the extent to which hospices provide screening and referral or bereavement-related mental health conditions would be associated with provider- level factors, such as level of provider training, volunteer availability, and interdisciplinary team meeting involvement. Consistent with theories that participation of and interactions among providers of a variety of backgrounds can enhance care,31–33 research has demonstrated that social worker and volunteer involvement, and interdisciplinary collaboration more broadly, are associated with better quality of care for people in hospice.22,34,35 Training requirements have also been associated with quality of bereavement care provision specifically,36 but these associations have not been adequately studied for hospice bereavement care. As previous findings and existing theory predicted, it was hypothesized that lengthier training requirements, interdisciplinary team attendance from a large range of providers, and a lower ratio of volunteer hours to number of individuals in hospice would be associated with higher likelihood of conducting CG and depression screening and referral. Findings from this study can provide a more-complete picture of how hospices may be screening for important bereavement-related mental health problems and helping family caregivers connect to appropriate care after the death. This information can inform future work to identify strategies to improve mental health screening or therapy in hospices, as well as in other settings with a large bereaved population.

Despite increased hospice use over the last decade, end-of-life care intensity continues to increase. To understand this puzzle, we sought to examine regional variation in intensive end-of-life care and determine its associations with hospice use patterns.Using Medicare claims for decedents aged 66 years and above in 2011, we assessed end-of-life care intensity in the last 6 months of life across hospital referral regions (HRRs) as measured by proportion of decedents per HRR experiencing hospitalization, emergency department use, intensive care unit (ICU) admission, and number of days spent in hospital (hospital-days) and ICU (ICU-days). Using hierarchical generalized linear models and adjusting for patient characteristics, we examined whether these measures were associated with overall hospice use, very short (≤7 d), medium (8-179 d), or very long (≥180 d) hospice enrollment, focusing on very short stay.End-of-life care intensity and hospice use patterns varied substantially across HRRs. Regional-level end-of-life care intensity was positively correlated with very short hospice enrollment. Comparing HRRs in the highest versus the lowest quintiles of intensity in end-of-life care, regions with more intensive care had higher rates of very short hospice enrollment, with adjusted odds ratios (AOR) 1.14 [99% confidence interval (CI), 1.04-1.25] for hospitalization; AOR, 1.23 (CI, 1.12-1.36) for emergency department use; AOR, 1.25 (CI, 1.14-1.38) for ICU admission; AOR, 1.10 (CI, 1.00-1.21) for hospital-days; and AOR, 1.20 (CI, 1.08-1.32) for ICU-days.At the regional level, increased end-of-life care intensity was consistently associated with very short hospice use.

Hospices are now mandated to perform routine quality assessment under the final Medicare Hospice Conditions of Participation, creating an opportunity to explore standardized approaches to monitoring hospice quality.We report hospice staff experiences using a standardized symptom assessment instrument, the Edmonton Symptom Assessment System (ESAS), in a pilot study designed to develop and test quality measures on symptom management. Use of the ESAS illustrates the benefits and challenges arising with standardized symptom assessment for quality monitoring in hospice.We interviewed 24 individuals representing 8 hospices involved with the National Association for Home CareHospice Quality Assessment Collaborative, which pilot tested the ESAS as a source of standardized data for quality assessment. Transcripts were analyzed using the constant comparative method.Participants reported benefits and challenges with the ESAS. Benefits were that the ESAS was a brief and easy tool that identified areas of concern, engaged patients in symptom assessment, and monitored symptom changes over time. Additionally, the ESAS was viewed as a useful teaching tool for less experienced staff. Challenges included lack of clarity about inclusion rules and frequency of assessments; difficulty interpreting the numeric symptom rating scale, difficulty incorporating patient preferences with symptoms, and a sense that the use of standard assessment instruments was "unnatural."Recommendations to promote effective use of ESAS data for quality monitoring of hospice care include standardizing implementation procedures, adding patients' preferences to the ESAS form, and staff education to enhance comfort with the instrument before implementation.

Objectives To characterize the number and types of care transitions in the last 6 months of life of individuals who used hospice and to examine factors associated with having multiple transitions in care. Design Retrospective cohort study. Setting One hundred percent fee-for-service Medicare decedent claims data. Participants Medicare beneficiaries aged 66 and older who died between July 1, 2011, and December 31, 2011, and were enrolled in hospice at some time during the last 6 months of life. Measurements Hierarchical generalized linear modeling was used to identify individual, hospice, and regional factors associated with transitions. The sequence of transitions across healthcare settings was described. Healthcare transitions after hospice enrollment included from and to the hospital, skilled nursing facility, home health agency program, hospice, or home without receiving any service in these four healthcare settings. Results Of 311,090 hospice decedents, 31,675 (10.2%) had at least one transition after hospice enrollment, and this varied substantially across the United States; 6.6% of all decedents had more than one transition in care after hospice enrollment (range 2–19 transitions). Of hospice users with transitions, 53.4% were admitted to hospitals, 17.7% were admitted to skilled nursing facilities, 9.6% used home health agencies, and 25.8% had transitions to home without receiving the services from the healthcare settings examined. In adjusted analyses, decedents who were younger, nonwhite, enrolled in a for-profit or small hospice program, or had less access to hospital-based palliative care had significantly higher odds of having at least one transition. Conclusion A notable proportion of hospice users experience at least one transition in care in the last 6 months of life, suggesting that further research on the effect of transitions on users and families is warranted.

Bereavement services are central to high-quality end-of-life care, however, little is known about how frequently and why such bereavement services are used and not used. We examined family caregiver reports about how often they used bereavement services, predictors of their use, and reported reasons for not using bereavement services.Prospective cohort study of family caregivers (n = 161) of patients with cancer enrolled with hospice between October 1999 and September 2001. We conducted bivariate and multivariable analyses to determine predictors of bereavement service use, adjusted for a broad range of factors including caregiving experiences, major depressive disorder (MDD), relationship with the deceased, and demographic factors. We used content analysis to summarize responses to open-ended questions concerning why individuals did not use bereavement services.We found that approximately 30% of family caregivers used bereavement services in the year postloss, and the majority of these caregivers used services in the first 6 months postloss. Even among bereaved caregivers with MDD, less than half (47.6%) used bereavement services. Factors associated with using bereavement services included being a spouse caregiver, younger age, having MDD at study enrollment, witnessing highly distressing events pertaining to the patient's death, having assisted the patient with more Instrumental Activities of Daily Living (IADLs) prior to the patient's death, having greater availability of instrumental support for oneself, and physician communication with the caregiver about the patient's prognosis before the patient's death. The most common given reason for nonuse was the perception that bereavement services were not needed or would not help.Addressing caregiver receptivity to bereavement services will be an important aspect of increasing appropriate use of such services. Future studies might examine specific interventions for reducing barriers and increasing receptivity to bereavement service use.

Little is known about state-level variation in patterns of hospice use, an important indicator of quality of care at the end of life. Findings may identify states where targeted efforts for improving end-of-life care may be warranted.Our aim was to characterize the state-level variation in patterns of hospice use among decedents and to examine state, county, and individual factors associated with these patterns.We conducted a retrospective analysis of Medicare fee-for-service decedents. The primary outcome measures were state-level hospice use during the last 6 months of life and the state's proportion of hospice users with very short hospice enrollment (≤7 days), very long hospice enrollment (≥180 days), and hospice disenrollment prior to death.In 2011, the percentage of decedents who used hospice in the last 6 months of life nationally was 47.1%, and varied across states from 20.3% in Alaska to 60.8% in Utah. Hospice utilization patterns also varied by state, with the percentage of hospice users with very short hospice enrollment ranging from 23.0% in the District of Columbia to 39.9% in Connecticut. The percentage of very long hospice use varied from 5.7% in Connecticut to 15.9% in Delaware. The percentage of hospice disenrollment ranged from 6.2% in Hawaii to 19.0% in the District of Columbia. Nationally, state-level hospice use among decedents was positively correlated with the percentage of potentially concerning patterns (including very short hospice enrollment, very long hospice enrollment, and hospice disenrollment) among hospice users (the Pearson correlation coefficient=0.52, p value0.001). Oregon was the only state in the highest quartile of hospice use and the lowest quartiles of both very short and very long hospice enrollment.The percentage of decedents who use hospice may mask important state-level variation in these patterns, including the timing of hospice enrollment, a potentially important component of the quality of end-of-life care.

Objective To examine the association between a multi-item measure of religiousness and major depressive disorder (MDD) in bereaved family caregivers of patients with cancer. Design A prospective longitudinal study of primary caregivers of consecutive patients (n=175) with cancer enrolled in the largest hospice in Connecticut. Results Caregivers with a high religiousness summary score were significantly less likely to have MDD at the 13–month follow-up interview (OR=0.79, 95% CI: 0.68–0.91). This finding remained significant (OR=0.74, 95% CI: 0.59–0.91) after adjustment for caregiver MDD at baseline, caregiver age, caregiver burden, and number of activities restricted due to caregiving roles. Conclusions Family caregivers who reported greater religiousness at baseline had lower rates of depression in the 13–month follow up after their loss. Collaboration with religious support groups or community groups during bereavement could offer an effective mechanism for speeding the process of recovery for some caregivers.

Objective Although more people are using hospice than ever before, the average length of hospice enrollment is decreasing. Little is known about the effect of hospice length of enrollment on surviving family caregivers. The authors examine the association between patient length of hospice enrollment and major depressive disorder (MDD) among the surviving primary family caregivers 13 months after the patient's death. Methods The authors conducted a three-year longitudinal study of 175 primary family caregivers of patients with terminal cancer who consecutively enrolled in the participating hospice from October 1999 through September 2001. Interviews were conducted with the primary family caregiver when the patient first enrolled with hospice and again 13 months after the patient's death. The authors used multivariate logistic regression models to estimate caregivers' adjusted risk at 13 months postloss for MDD, assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). Results The effect of very short hospice length of enrollment (three days or less) compared with longer lengths of enrollment on caregiver MDD 13 months after their loss was nonsignificant in unadjusted analyses. The adjusted risk of MDD was significantly elevated for caregivers of patients who had very short hospice enrollments (adjusted odds ratio: 8.76, 95%confidence interval: 1.09–70.19) only after adjusting for baseline MDD, caregiver gender, caregiver age, kinship relationship to patient, caregiver education, caregiver chronic conditions, and caregiver burden. The adjustment for caregiver burden resulted in the greatest increase in odds ratio for very short hospice length of enrollment on risk of caregiver MDD 13 months after the loss. Conclusions This study identifies a potential target group of family caregivers, characterized by hospice length of enrollment and several caregiver features, who might be most in need of mental health interventions.

Few studies have examined physician-family caregiver communication at the end of life, despite the important role families have in end-of-life care decisions. We examined family caregiver reports of physician communication about incurable illness, life expectancy, and hospice; the timing of these discussions; and subsequent family understanding of these issues.Mixed methods study using a closed-ended survey of 206 family caregivers and open-ended, in-depth interviews with 12 additional family caregivers.Two hundred eighteen primary family caregivers of patients with cancer enrolled with hospice between October 1999 and June 2002.Family caregiver reports provided at the time of hospice enrollment of physician discussions of incurable illness, life expectancy, and hospice.Many family caregivers reported that a physician never told them the patient's illness could not be cured (20.8%), never provided life expectancy (40% of those reportedly told illness was incurable), and never discussed using hospice (32.2%). Caregivers reported the first discussion of the illness being incurable and of hospice as a possibility occurred within 1 month of the patient's death in many cases (23.5% and 41.1%, respectively). In open-ended interviews, however, family caregivers expressed ambivalence about what they wanted to know, and their difficulty comprehending and accepting "bad news" was apparent in both qualitative and quantitative data.Our findings suggest that ineffective communication about end-of-life issues likely results from both physician's lack of discussion and family caregiver's difficulty hearing the news. Future studies should examine strategies for optimal physician-family caregiver communication about incurable illness, so that families and patients can begin the physical, emotional, and spiritual work that can lead to acceptance of the irreversible condition.

Objective To identify factors associated with caregiver burden among those caring for terminally ill patients with cancer. Design Cross-sectional study of interviews with primary caregivers (n=206) of consecutive patients with cancer enrolled in the largest hospice in Connecticut. Methods Data were collected on the caregivers’ sociodemographic characteristics, social network index, and number of restrictions in their own activities due to their caregiving role. The outcome was a nine-item questionnaire adapted from the Zarit Burden Inventory. Results The highest burden was reported among caregivers with more limited social networks (OR 1.38, CI 1.02–1.87), more restrictions in their daily activities (OR 1.35, CI 1.13–1.61), and who were younger (OR 1.46, CI 1.10–1.93). Conclusions Variations exist in the intensity of caregiver burden based on subjective experiences and social support, rather than on the amount of assistance provided. Clinicians should consider factors such as these when targeting caregivers for interventions to alleviate burden.

Purpose: To describe characteristics, attitudes, and communications of nurses regarding hospice and caring for terminally ill patients. Design: A cross-sectional study of randomly selected nurses (n=180) from six randomly selected Connecticut community hospitals was conducted in 1998 and 1999. Methods: Hospice-related training, knowledge and attitudes, demographic and practice characteristics, and personal experience with hospice were assessed with a self-administered questionnaire (response rate=82%). Logistic regression was used to model the effects of hospice-related training, knowledge, and attitudes on these outcomes, adjusting for personal experience and other characteristics of nurses. Findings: Characteristics associated with discussion of hospice with both patients and families included greater religiousness, having a close family member or friend who had used hospice, and reporting satisfaction with hospice caregivers. Greater self-rated knowledge was significantly associated with discussion of hospice with patients. Attitudinal scores indicating greater comfort with initiating discussion and greater perceived added benefit of hospice were significantly associated with discussion with patients' families. Conclusions: Nurses' discussion of hospice with terminally ill patients and their families are related to the potentially modifiable factors of self-rated knowledge and attitudes revealing comfort with discussion and perceived benefit of hospice care.

Purpose Health care institutions are examining ways to improve physicians' skills in the delivery of end-of-life (EOL) care. Experts have suggested that influencing physicians' knowledge and attitudes concerning EOL care can influence subsequent EOL practices, including hospice use for appropriate patients; yet few studies have examined empirically the influence of physicians' knowledge and attitudes on such practices. The authors assessed the influences of self-rated knowledge and attitudes on physicians' discussions and referrals for hospice care. Method In 1998 and 1999 the authors conducted a cross-sectional study of physicians affiliated with six randomly selected community hospitals in Connecticut with more than 200 licensed medical and surgical beds. Physicians completed a self-administered questionnaire (response rate 52.4%) that assessed self-rated knowledge of terminal care and hospice, a set of attitudinal items, and practices related to hospice discussion and referrals, as well as standard sociodemographic data. Bivariate and multivariate analyses were conducted. Results Self-rated knowledge was significantly associated with referral practices in unadjusted analyses (unadjusted odds ratio [OR]: 0.70; 95% confidence interval [CI]: 0.52, 0.95), although this association was attenuated in adjusted analyses by specialty and other physicians' characteristics (adjusted OR: 0.80; 95% CI: 0.55, 1.18). Attitudes representing support for hospice practices and philosophy were associated with referral practices in adjusted and unadjusted analyses (adjusted OR:0.52; 95% CI: 0.35, 0.77). Conclusions This study demonstrated that self-rated knowledge and attitudes may influence hospice referral. The results support current efforts to develop medical school curricula and continuing education programs that better cover the many aspects of caring for the dying, including hospice use.

Purpose Previous studies have suggested the importance of communicating with patients about prognosis at the end of life, yet the prevalence, content, and consequences of such communication have not been fully investigated. The purposes of this study were to estimate the proportion of terminally ill inpatients with documented discussions about prognosis, describe the nature and correlates of such discussions, and assess the association between documented discussions about prognosis and subsequent advance care planning. Subjects and methods Inpatients (n = 232) at least 65 years old who had brain, pancreas, liver, gall bladder, or inoperable lung cancer were randomly selected from six randomly chosen community hospitals in Connecticut. The presence and content of discussions about prognosis, advanced care planning efforts, and sociodemographic and clinical factors were ascertained by comprehensive review of medical records using a standardized abstraction form. Results Discussions about prognosis were documented in the medical records of 89 (38%) patients. Physicians and patients were both present during the discussion in 46 (52%) of these cases. Time until expected death was infrequently documented. Having a documented discussion about prognosis was associated with documented discussions of life-sustaining treatments (adjusted odds ratio [OR] = 5.8; 95% confidence interval [CI]: 2.8 to 12.0) and having a do-not-resuscitate order (adjusted OR=2.2; 95% CI: 1.1 to 4.2). Conclusions Among terminally ill patients with cancer, discussions about prognosis as documented in medical charts are infrequent and limited in scope. In some cases, such documented discussions may be important catalysts for subsequent discussions of patient and family preferences regarding treatment and future care.

Background Despite the central role of hospice in end-of-life care, little is known about the proportion of terminally ill patients referred for hospice and the physician factors associated with hospice referral. Methods Cross-sectional data from a self-administered survey of 231 physicians were used to estimate the proportion of terminally ill patients who were referred for hospice and to assess the independent effects of physician factors on hospice referral. Results On average, physicians reported referring about 55% of their terminally ill patients for hospice; 26.7% of the physicians referred less than one quarter of their terminally ill patients. Physician specialty, board certification, and physicians’ knowledge level about hospice were independently associated with the proportions of terminally ill patients referred for hospice. Conclusion Many terminally ill patients are not referred for hospice care and physician factors influence the use of hospice significantly. The study suggests effective factors and groups to target with interventions to enhance the appropriate use of hospice.

Several initiatives to improve care at the end of life involve educational programs to influence clinicians’ attitudes about care for patients with terminal illnesses. The objective of this research was to develop and test a short and easily administered instrument for measuring physicians’ and nurses’ attitudes towards care at the end of life. The instrument was tested using a cross-sectional study of 50 clinicians (25 physicians and 25 nurses) from general medicine, cardiology, oncology, and geriatric medicine. Both reliability and validity were assessed, and the instrument was found to have acceptable test-retest reliability and construct validity. Such an assessment instrument may be useful in evaluating the impact of initiatives to modify attitudes towards terminal care and in improving the quality of care at the end of life.

Forests in northern Michigan will be affected directly and indirectly by a changing climate during the next 100 years. This assessment evaluates the vulnerability of forest ecosystems in Michigan's eastern Upper Peninsula and northern Lower Peninsula to a range of future climates. Information on current forest conditions, observed climate trends, projected climate changes, and impacts to forest ecosystems was considered in order to draw conclusions on climate change vulnerability. Upland spruce-fir forests were determined to be the most vulnerable, whereas oak associations and barrens were determined to be less vulnerable to projected changes in climate. Projected changes in climate and the associated ecosystem impacts and vulnerabilities will have important implications for economically valuable timber species, forest-dependent wildlife and plants, recreation, and long-range planning.

Reduction of blood pressure (BP) after stroke or TIA decreases stroke recurrence and is a major goal ofsecondary Stroke Prevention Clinics (SPCs). Health care providers need effective screening processes to identify those clients at highest risk of not achieving BP targets and those clients at highest risk ofnon-adherence to medication.This multicentred, randomized controlled study used a screening process to identify SPC patients with psychosocial/cognitive deficits (e.g., lack of confidence in the utility of medications, poor memory, mild cognitive impairment) who were experiencing difficulty managing their BP to target values and evaluated whether a model of nurse-led case management program (monthly telephone calls, motivational interviewingfor lifestyle change, plus home BP monitoring and use ofdosettes for medication administration) would improve BP measures and adherence to medications.Both intervention (n=29) and usual care groups (n=27) showed a trend-for'reduced BP at six months (Median ql-q3, Systolic BR p=0.46; Diastolic BR p=0.37). Diabetic patients, irrespective of the group to which they were randomized, were less likely to meet Best Practice Guideline targets than those without diabetes (Chi Square test, p=0.0001).Stroke and TIA patients with diabetes may require additional resources and support in order to reach BP target values.

BACKGROUND Shortcomings in the quality of care of hospitalized patients at the end of life are well documented. Although hospitalists and residents are often involved in the care of hospitalized patients with terminal illness, little is known about their knowledge and beliefs concerning terminal illness, despite the importance of such physicians to the quality of care at the end of life. DESIGN In 2006 we conducted an exploratory study at a large academic medical center to examine the knowledge, attitudes, and practices of hospitalists and residents (n = 52, response rate = 85.2%) about the care of terminally ill patients. Data were collected using a 22-item survey instrument adapted from previously published instruments. RESULTS Several common myths about treating terminally ill patients were identified. These myths pertained to essential aspects of end-of-life care including pain and symptom control, indications for various medications, and eligibility for hospice. Physicians reported positive attitudes about hospice care as well as the belief that many patients who would benefit from hospice do not receive hospice at all or only late in the course of their illness. CONCLUSIONS Our findings identified misunderstandings that hospitalists and residents commonly have, including about facts essential to know in order to provide appropriate pain and symptom management. Future interventions to improve knowledge need to focus on specific clinical knowledge about opioid therapy, as well as information about eligibility rules for hospice. Journal of Hospital Medicine 2007;2:357–365. © 2007 Society of Hospital Medicine.

To examine the association between a multi-item measure of religiousness and major depressive disorder (MDD) in bereaved family caregivers of patients with cancer.A prospective longitudinal study of primary caregivers of consecutive patients (n = 175) with cancer enrolled in the largest hospice in Connecticut.Caregivers with a high religiousness summary score were significantly less likely to have MDD at the 13-month follow-up interview (OR = 0.79, 95% CI: 0.68-0.91). This finding remained significant (OR = 0.74, 95% CI: 0.59-0.91) after adjustment for caregiver MDD at baseline, caregiver age, caregiver burden, and number of activities restricted due to caregiving roles.Family caregivers who reported greater religiousness at baseline had lower rates of depression in the 13-month follow up after their loss. Collaboration with religious support groups or community groups during bereavement could offer an effective mechanism for speeding the process of recovery for some caregivers.

The purpose of this qualitative study was to uncover patterns across nurse practitioner (NP) experiences that contribute to understanding their perceptions of managed care, how it affects daily practice, and how NPs respond to a changing managed care workplace. In-depth interviews were conducted with 14 NPs representing primary care, specialty, and independent practices. Over an 18-month period, data collection and analysis occurred simultaneously using standard methods of purposive sampling, constant comparison, memoing, and member checks. This study illuminates the tension NPs experience between a business and a professional ethic and the strategies they use to reconcile this difference with core nursing values. Type of setting, workplace dynamics, and length of time in practice contributed to variation in NP perspectives. Keywords: values; dual agency; nurse-patient relationship; work environment; nurse practitioners Over the past 10 to 15 years, managed care has seen increased growth in the United States health care delivery system. Market penetration of this form of care varies regionally; 74% of Americans employed by firms with more than 200 workers now belong to managed care health plans (Gaffney, 1997). Nurse practitioners (NPs) have expanded their numbers significantly since the 1980s, the same time period when managed care began to dominate health care. The well-documented positive outcomes of NP care in the primary care setting, along with less costly salaries in comparison to physicians, make NPs attractive to managed care administrators. The literature on managed care speaks from business, social science, and health care perspectives and raises structural, socio-political, and ethical concerns. Communication and dialog on these issues of managed care are essential to establishing the NP's place in this system. MANAGED CARE AND NP PRACTICE Research on the effect of managed care on NP practice is limited. In a Delphi survey to explore perceptions of NPs and clinical nurse specialists (CNSs) regarding the influence of managed care on their practice, Harrison (1999) found that increased autonomy may diminish NPs' perceived threats from managed care; however, NPs viewed resource issues as affecting the quality of patient care. The expansion of the NP role to extend beyond primary care was viewed positively, but encroachment upon NP practice by other disciplines, employers, and managed care administrators indicated a need for vigilance. Exclusion of NPs on managed care organization (MCO) provider panels has been discussed as a barrier to NP practice. A survey on the credentialing of NPs by MCOs found that a large percentage of NPs had never applied for MCO panel status (Mason et al., 1999). This decision was influenced by the behavior of employers or administrators. The presence or absence of support from coworkers or superiors was also a major finding influencing NP role performance regardless of setting in a study conducted by Hupcey (1993) 6 years earlier. Ethical issues related to managed care are cited frequently in the theoretical literature (Pellegrino, 1999; Randel, Pearson, Sabin, Hyams, & Emanuel, 2001; Wurzbach, 1998). A survey to explore whether managed care raised ethical conflicts for NPs in the delivery of patient care (Ulrich, Soeken, & Miller, 2003) found that the majority of NPs reported moderate to extreme concerns with managed care and 80% reported bending the rules to benefit patient care. Interestingly NPs in HMOs had significantly lower ethical concern scores and perceived more favorably the ethical climate at the worksite than NPs in other types of practice settings. On the other hand, physicians who practiced in higher HMO penetration areas had decreased their stance of undivided loyalty to the patient (Sulmasy, Bloche, Mitchell, & Hadley, 2000). Results of these studies lend support to the premise that differences in state policy as well as administrator and employer support may influence managed care arrangements with NPs. …

Many terminally ill patients enroll in a hospice late in their illness, and recent data indicate decreasing lengths of hospice enrollment, yet we know little about the impact of hospice enrollment length on surviving caregivers. This is the first study the authors know of that examines the association between hospice enrollment length and subsequent major depressive disorder among surviving caregivers.The authors conducted a prospective cohort study with 174 primary family caregivers of consecutively enrolled hospice patients with cancer between October 1999 and September 2001. Using data from in-person interviews at the time of enrollment and 6-8 months after the patient's death, they estimated with logistic regression the adjusted risk of major depressive disorder with the Structured Clinical Interview for the DSM-IV axis I modules based on the number of days of hospice care before death.Caregivers of patients enrolled with hospice for 3 or fewer days were significantly more likely to have major depressive disorder at the follow-up interview than caregivers of those with longer hospice enrollment (24.1% versus 9.0%, respectively), adjusted for baseline major depressive disorder and other potential confounders.The findings identify a target group for whom bereavement services might be most needed. The authors also suggest that earlier hospice enrollment may help reduce the risk of major depressive disorder during the first 6-8 months of bereavement, which raises concerns about recent trends toward decreasing lengths of hospice enrollment before death.

To identify factors associated with caregiver burden among those caring for terminally ill patients with cancer.Cross-sectional study of interviews with primary caregivers (n = 206) of consecutive patients with cancer enrolled in the largest hospice in Connecticut.Data were collected on the caregivers' sociodemographic characteristics, social network index, and number of restrictions in their own activities due to their caregiving role. The outcome was a nine-item questionnaire adapted from the Zarit Burden Inventory.The highest burden was reported among caregivers with more limited social networks (OR 1.38, Cl 1.02-1.87), more restrictions in their daily activities (OR 1.35, Cl 1.13-1.61), and who were younger (OR 1.46, Cl 1.10-1.93).Variations exist in the intensity of caregiver burden based on subjective experiences and social support, rather than on the amount of assistance provided. Clinicians should consider factors such as these when targeting caregivers for interventions to alleviate burden.

The objective of this study was to determine whether having a hospice unit within the hospital increases the proportion of terminally ill patients who use hospice services (including home, nursing home, or inpatient hospice) post-admission. Using medical record data abstracted for 232 randomly selected patients with terminal cancer admitted to six community hospitals in Connecticut, we found that patients admitted to a hospital with a hospice unit were more likely to use hospice services (i.e., home hospice, nursing home hospice, or inpatient hospice) post-admission than patients admitted to a hospital without a hospice unit (unadjusted OR 5.7, 95% CI 3.1, 10.6). This effect persisted after adjusting for patient age, gender, marital status, documented discussions of prognosis, prior hospice use, and type of cancer.

This study examines the reported use of palliative care practices by nurses caring for terminally ill patients in the acute care setting. Randomly selected nurses (n = 180) from six randomly selected hospitals in Connecticut completed a self-administered questionnaire. Factors associated with use of palliative care practices were examined by using bivariate and multivariate analyses. Most nurses surveyed (88.5%) reported using palliative care practices when caring for their terminally ill patients. Factors associated with greater use included greater knowledge about hospice, having practiced nursing for less than 10 years, and having had hospice training in the past 5 years. A substantial proportion of nurses reported that they never discuss hospice (51.7 per cent of nurses) and prognosis (26.6 per cent of nurses) with their terminally ill patients. Educational preparation (bachelor's degree versus less education) was not associated with greater use of palliative care practices. Palliative care practices are commonly used by nurses in the acute care setting. However, many report having limited training and substantial gaps in knowledge about hospice among this group of nurses, suggesting greater attention to palliative care and hospice may be warranted in nursing educational programs. J Prof Nurs 17:14-22, 2001. Copyright © 2001 by W.B. Saunders Company

Interdisciplinary care is fundamental to the hospice philosophy and is a key component of high-quality hospice care. However, little is known about how hospices differ in their interdisciplinary staffing patterns, particularly across nonprofit and for-profit hospices. The purpose of this study was to examine potential differences in the staffing patterns of for-profit and nonprofit hospices.Using the 2006 Medicare Provider of Services (POS) survey, we conducted a cross-sectional analysis of staffing patterns within Medicare-certified hospices operating in the United States in 2006. In bivariate and multivariable analyses, we examined differences in staffing patterns measured by the existence of a full range of interdisciplinary staff (defined as having at least 1 full-time equivalent (FTE) staff in each of 4 disciplines ascertained by the survey: physician, nursing, psychosocial, and home health aide) and by the professional mix of staff within each discipline.For-profit hospices had a winder range of paid staff but there were no differences by ownerships when volunteer staff were included. For-profit hospices had significantly fewer registered nurse FTEs as a proportion of nursing staff, fewer medical social worker FTEs as a proportion of psychosocial staff, and fewer clinician FTEs as a proportion of total staff (p values0.05). Compared to nonprofit hospices, for-profit and government-owned hospices also used proportionally fewer volunteer FTEs.Hospice staffing patterns differed significantly by ownership type. Future research should evaluate the impact of these differences on quality of care and satisfaction among patients and families using hospice.

A qualitative research design (grounded theory) was used to analyse the experiences of dieters attending a weight loss programme. Two hundred hours of observations at a nationally known weight reduction centre, a review of selected documents from the organization and multiple in-depth interviews with 13 informants were the data sources for this study. Data generation took place over a 21-month period. A substantive theory of restructuring identified three stages in the process of losing weight. These stages and key elements of the weight loss process are presented.

An investigation was conducted in January, 1975, to explore the attitudes and practices of counselors in private employment agencies in Dallas, Texas, toward the physically handicapped person in a wheelchair applying for the position of receptionist-typist. The finding of significant discrimination suggests that continuing attention should be given by the rehabilitation field toward removing architectural barriers, modifying attitudinal resistance on the part of employers, attacking the myth of increased costs, and exploring more ways of locating those companies willing to hire the handicapped.