Health Care Worker Perceptions of Gaps and Opportunities to Improve Hospital-to-Hospice Transitions

Abstract

Background:

Care transitions from the hospital to hospice are a difficult time, and gaps during this transitions could cause poor care experiences and outcomes. However, little is known about what gaps exist in the hospital-to-hospice transition.

Objectives:

To understand the process of hospital-to-hospice transition and identify common gaps in the transition that result in unsafe or poor patient and family caregiver experiences.

Design:

We conducted a qualitative descriptive study using semistructured interviews with health care workers who are directly involved in hospital-to-hospice transitions. Participants were asked to describe the common practice of discharging patients to hospice or admitting patients from a hospital, and share their observations about hospital-to-hospice transition gaps.

Setting/Subjects:

Fifteen health care workers from three hospitals and three hospice programs in Portland, Oregon.

Measurements:

All interviews were audio recorded and analyzed using qualitative descriptive methods to describe current practices and identify gaps in hospital-to-hospice transitions.

Results:

Three areas of gaps in hospital-to-hospice transitions were identified: (1) low literacy about hospice care; (2) changes in medications; and (3) hand-off information related to daily care. Specific concerns included hospital providers giving inaccurate descriptions of hospice; discharge orders not including comfort medications for the transition and inadequate prescriptions to manage medications at home; and lack of information about daily care hindering smooth transition and continuity of care.

Conclusion:

Our findings identify gaps and suggest opportunities to improve hospital-to-hospice transitions that will serve as the basis for future interventions to design safe and high-quality hospital-to-hospice care transitions.

Introduction

Approximately 1.49 million US patients received hospice care in 2017, of which nearly 40% transition directly from an acute care hospital.¹ Transitions of care are known to increase risks of medical errors, disruptions in continuity of care, avoidable hospital admissions, and preventable adverse events.^2–4 However, little is known about hospital-to-hospice transitions.

Direct enrollment from a hospital to hospice requires patients and family caregivers to not only adapt to new health care services but also cope with a drastic shift in goals of care from cure to comfort and awareness of approaching death.^5–8 In a short period of time, patients and their families must make difficult decisions to forego curative treatments, physically transfer to a new care environment, and establish a relationship with a new hospice care team. Moreover, there is typically only one chance to make this transition right because it is likely the first and last transition into hospice service for many patients.^8,9 Small gaps in such care transitions can have devastating effects on patients' and family members' end-of-life experiences and quality of life.

While evidence-based interventions exist to improve care transition from hospital to home or to skilled nursing facilities,^10–13 few studies have examined hospital-to-hospice transitions. The purpose of this study was to describe the process of hospital-to-hospice transition and identify potential gaps and opportunities to improve these transitions.

Methods

Study design

We conducted a qualitative descriptive study using semistructured individual interviews of hospice and hospital care workers who were involved in the care for patients during the hospital-to-hospice transitions. The Oregon Health & Science University Institutional Review Board approved this study.

Setting and participants

We purposively sampled participants from three hospitals (one academic medical center and two, not-for-profit, community hospitals) and three hospice programs (two not-for-profit and one for-profit program) in Portland, Oregon metropolitan area. We contacted directors and managers in these organizations and asked them to identify persons who are frequently involved in the discharge or admission of patients from the hospital to the hospice program. We recruited identified health care workers and interviewed them after obtaining consent.

Data collection

Three investigators (S.I., J.P.F., and B.N.N.) conducted in-person interviews between June 2017 and January 2018 using a semistructured interview guide developed by the investigators. The interview guide included questions in three areas: (1) common practices during hospital-to-hospice transitions; (2) examples of when the hospital-to-hospice transition did not go well; and (3) common gaps and potential solutions to improve the transition. Each interview lasted ∼40 minutes and was audio recorded with the participant's permission.

Data analysis

We used a directed qualitative content analysis approach.¹⁴ The first author summarized common practices for the hospital-hospice transition by listening to audio recordings of each interview, then integrated them to illustrate a typical workflow of the transition. Portions of the audio recordings describing gaps during transitions were transcribed by the first investigator who also conducted primary coding to identify common gaps using the 8P Screening Tool developed by Project BOOST (www.hospitalmedicine.org/BOOST) as an initial framework. When gaps did not fit to the primary coding derived from the 8P Screening Tool, new codes were added or initial codes were modified. Two other investigators (B.N.N. and J.P.F.) reviewed the codes, and after discussion between the three investigators, the final set of codes emerged. The final areas and subgroups of gaps were reviewed by three additional authors (J.T., J.M., and J.B.) to ensure consistency with their clinical observations.

Results

Sixteen individuals were invited to participate in the interviews and all but one agreed. Hospital health care workers included a nurse care manager serving as a discharge planner (n = 1) and care coordinators (n = 2). Hospice health care workers included hospice admission nurses (n = 6), non-nurse hospice admission coordinators (n = 3), and hospice specialists (nonhealth care professional) who were employed by the hospice program and visit hospitals to provide information about their hospice services to hospital staff, patients, and families (n = 3) (Table 1).

Table 1.

Participant Characteristics

Roles and titles	Hospice (n = 12)
	Admission nurses (n = 6)
	Admission coordinators ( = 3)
	Hospice specialist^a (n = 3)
	Hospital (n = 3)
	Nurse care manager (n = 1)
	Hospice care coordinator (n = 2)
Years of experience	Mean 17.9 years (SD = 13.7; range 5–40)
Years in this position	Mean 4.17 years (SD = 4.19; range 0.04–14 years)

Non-RN that explains hospice to patients and family members.

RN, registered nurse; SD, standard deviation.

Gaps in the hospital-to-hospice transition

Analyses regarding difficulties in hospital-to-hospice transition revealed three common areas of gaps: (1) literacy about hospice services, (2) changes in medications, and (3) hand-off information related to daily care. Descriptions of each gap are provided below and additional illustrative quotations are shown in Table 2.

Table 2.

Gaps and Opportunities to Improve Hospital-to-Hospital Transitions

Gap or opportunity	Subgroups	Illustrative quotations
Hospice literacy	Expectation for 24/7 home care	Sometimes people are discharged so quickly; and all they heard [about hospice] was “this extra help.” They thought we are like a caregiving agency giving 24-hour help. Sometimes they hear what they want. When the patient gets home, they were like “What do you mean you are leaving? You are not going to be here all night to help me? What am I supposed to do?” (ID03 Hospice admission nurse)
	Awareness of terminal conditions	Hospital providers do not tell prognosis to patients. And that could be a barrier to prepare for hospice. (ID01 Hospice admission nurse) Some people come hospice with idea to die like this (snaps fingers); they do not understand some people graduate from hospice. (ID11 Hospice nurse) They (patients and families) think going to hospice means we (hospice nurses) will come in, medicate them, and kill them. (ID03 Hospice admission nurse)
	Foregoing curative treatment	Hospitals don't let patients and families know they cannot continue chemo and radiation while on hospice services. They (patients and families) are not well-educated … and they are overwhelmed. When they have time to think about it, they may say “we are not ready for this [hospice].”(ID03 Hospice admission nurse) When they come to hospice, they pick one doctor and the patient no longer sees specialists. Also, the focus of the treatment will be different: no more next chemo, clinical trial and so on. This type of change could be a deal breaker to make a hospice decision. (ID09 Hospice admission nurse) A patient said “If I knew I could not get that MRI in hospice, I would wait until I take the scan to enroll hospice.” (ID11 Hospice nurse)
Medication changes	Comfort medications during transition	The hospital usually prescribes three days of meds. But their goal is to prescribe minimally needed medications. Hospice pays for comfort meds, but hospice cannot write a prescription for comfort meds until the patient is formally admitted to the hospice. Hospice can ask the hospital to include some comfort meds for the transition in their discharge prescription, but need to consider who is paying for it. (ID04 Hospice admission coordinator) Patients rarely come home with comfort meds. It will be a problem if patients need hourly meds. (ID05 Hospice admission nurse)
	Inappropriate/incomplete prescriptions	In hospital, they usually start with faster, better, and new meds for patients rather than meds that is easier to have at home. Fentanyl patch for 78 lb patients does not work. Prescribers not seeing the bigger picture when they are prescribing meds. (ID01 Hospice admission nurse) Critical meds (controlled substance etc.) are usually fine; pharmacy will reject it if it is not complete. Typically, lower priority, less critical meds such as over the counter meds, stool softeners, and cream/lotions are incomplete and not much information. Cream/lotions; what is it for? Do they have a rash, where is it? Is it getting better? Adjuvant meds may be overlooked in discharge prescriptions. But it is important what has been working for the patient, and to make sure they are included and prescribed. (ID09 Hospice admission nurse)
	Poor communication regarding medication change	Once in a while, patients come with meds we don't cover; [a] blood thinner is common one. It would be scary for patients to stop meds for chronic illness. It is important for providers to explain and educate them for the risks, reasons, and hospice requirement. Patients may not understand or remember, but it should not be the first time the patient hears about the discontinuation of the meds in the hospice. (ID09 Hospice admission nurse)
Hand-off information relate to daily care	Information about daily care	We do not get enough report from hospital nurses. When was the latest pain meds, last bowel movement, are they walking or not? (ID05 Hospice admission nurse)
	Functional status and home environment	[The] patient was walking when he left his house, but he was in hospital for 2 weeks and now he cannot walk. But they sent him back home with his tiny 70 some years old wife. Nobody planned the discharge with him. [The] hospital called his wife and said “We are sending him home.” It was [a] late evening admission. I was able to place [the] order then, but it was late, so the meds and equipment need to wait to be delivered next day. (ID02 Hospice admission nurse)
	Discontinuation or changes in regular care	A patient was discharged to hospice with coumadin. We switched to aspirin over the course of admission, but the patient was still thinking to keep [having his] INR checked regularly. (ID01 Hospice admission nurse) When discharged to hospice, advance directives and POLST needs to be adjusted, but often it is left as loose end. POLST was not DNR, it is not appropriate for hospice patient at home. Physicians should have conversation with patients/family about prognosis and appropriate POLST before come home for hospice. (ID05 Hospice admission nurse)

POLST, portable orders for life-sustaining treatment.

Hospice literacy

A major gap that emerged was a lack of knowledge or misunderstanding about hospice services. Low hospice literacy was reported to cause difficulty or failed hospital-to-hospice transition resulting in revoking hospice enrollment and going back to the hospital.

Hospital providers have a lot of misinformation about what we (hospice) do and don't [do], and they share that [misinformation] with patients. When we meet with patients, we have to correct patients and that can be very disappointing [to them]. (ID11 Hospice admission nurse)

Expectation for 24/7 care

Participants described that patients and families often expected that hospice provides “24/7 home care.” Hospice staff is available 24/7 on-call, but not physically present at the patient bedside except rare occasions when patients require active and continuous symptom management.

All they [patients and families] heard [about hospice] was “this extra help.” They thought we are like a caregiving agency giving 24-hour help…. When the patient gets home, they were like “What do you mean you are leaving?” (ID03 Hospice admission nurse)

When hospice admission nurses described that they were not going to be there around the clock, families had to scramble to make other arrangements or might revoke hospice enrollment and go back to the hospital because they did not plan to, or were not able to, take care of the patient at home themselves.

Awareness of terminal conditions

Although all hospital participants said that they always describe hospice being for patients who have limited prognosis, some patients and family members seemed to be unaware of what they were told about the patient's terminal conditions.

Doctors have not been straightforward with them (patients and families) about their prognosis. They don't even say “terminal”…. Maybe they (patients and families) know it, but they say “nobody told me.” Maybe they did not hear it; maybe the doctor was not blatant enough. (ID05 Hospice admission nurse)

Enrolling in hospice without a clear understanding about the patient terminal condition makes it difficult to accept the hospice service, and affects their overall experiences of end-of-life care.

The opposite misunderstanding also could pose a challenge. Participants stated that some patients and family members believe that the patient would die soon after being admitted to hospice or hospice would medicate them to shorten their life. These families were not prepared to take care of the patient for weeks and months, and had to reconsider the care situation once the patient stabilized under hospice service.

Foregoing curative treatment

Another gap in the knowledge was about the hospice requirement to forego curative treatment. Many patients have lived with the illness for extended periods. Activities such as disease monitoring, taking medications, discussing next treatments, and calling emergency medical response (e.g., 911) and go to hospital when they have symptoms that have become part of their lifestyle. Therefore, hospice guidance to discontinue these activities catches many off-guard and may result in feeling lost and subsequently revoking the decision to enroll in hospice.

Hospitals don't let patients and families know they cannot continue chemo and radiation while in hospice.… When they have time to think about it, they may say “we are not ready for this [hospice].” (ID03 Hospice admission nurse)

Medication changes

Medication changes during care transitions are common, and care transition to hospice is not exception.¹⁵ However, hospital-to-hospice transitions may pose additional challenges due to changes in insurance coverage (i.e., from previous insurance to the Medicare Hospice Benefit) and the shift from curative to palliative treatments.

Comfort medications during transition

Participants described that hospital health care providers typically prescribe a few days of medications when they discharge patients to hospice, and that hospice providers prescribe medications on hospice admission, which is usually the same day as the hospital discharge. However, there is a disconnect regarding the perceived prescribing responsibilities of hospital providers who tend to prescribe minimally needed medications and sometimes do not prescribe comfort medications for the transition. This practice can be problematic if patients develop uncontrolled symptoms during the transition. Patients might have been receiving hourly pain medication while in the hospital; however, transfer from the hospital to home could take several hours or much longer if the patient is transferring long distance. Changes in environment or transportation by an ambulance could exhaust patients and worsen symptoms. If patients arrive home late in the evening, hospice admission nurse may not be there to prescribe medications immediately, and the delivery of prescriptions may have to wait until the next morning.

Inappropriate or incomplete prescriptions

Participants described that some hospital discharge prescriptions are either incomplete or inappropriate for patients at home. Examples of these prescriptions included intravenous medications and fentanyl patches for emaciated patients. Participants described that hospital providers may be in the habit of omitting details when writing prescriptions in the hospital. Yet, for patients and those who care for them to be able to manage medications at home or for hospice nurses to reconcile them with hospice prescriptions, incomplete prescriptions can cause confusion, delay, and contribute to poor symptom management.

Physicians write discharge orders, but the medications they put on order are incomplete. The order may say “take by mouth,” no frequency, duration, [the prescription] would say as needed but no indication. That creates a lot more work for us. (ID09 Hospice admission nurse)

Some participants noted that incomplete prescriptions are common for noncritical, low-priority medications such as over-the-counter medications. Although these medications may not be an urgent priority during the transition, information regarding these medications is important for continuity of care.

Poor communication regarding medication changes

Medicare reimbursement for hospice requires that the patients forego curative treatment once they transition to hospice care. Participants described “angst” among patients when having to stop medications they have been taking for long time and emphasized the importance of explaining the medication changes in hospice and discussing potential risks and benefits when exploring hospice options.

Meds can be a big one…. We [hospice] do not come in and change everything at once. But within a few weeks, we change one med or [tell patients] “we do not cover this medication,” and it can create angst and anxiety. (ID11 Hospice admission nurse)

Hand-off information related to daily care

Another gap that emerged from our interviews was related to daily care.

Information about daily care

Hospice admission nurses in the study stated that information about daily care is often missing in the hospital discharge summary. Information such as the last time the patient had pain medication or a bowel movement or types of medical devices patients may have and how to manage them are critical to maintain continuity of care through transition. Yet, this information is rarely communicated to hospice staff, and patients and family members often cannot provide this information. As a result, hospice admission nurses frequently must contact the hospital or determine for themselves, which delays care.

We need more detail and specific information. For example, type of catheter the patient uses: if it is the wrong kind or our nurses did not know patient has catheter, there is no time to come back and get these to visit patients again. (ID11 Hospice admission nurse)

Functional status and home environment

Information about patient's functional status and home environment are also essential to admit the patient to home hospice. Whether the patient can stand/walk or use stairs/bathroom, combined with the home environment such as stairs to go to bedroom/bathroom, heater/air conditioner, electricity, and if there is a person who can assist the patients determine whether patients can enroll in home hospice or not. Hospital staff often does not ask patients and family members about their home environment and do not think through if the patient will be safe at home with hospice services. If the home environment is not prepared and safe for the patient, hospice admission nurses may be compelled to send the patient back to hospital.

The patient could not ambulate at all. I and his son moved him to living area on a chair, not a wheel chair! His bedroom and bathroom was upstairs…. The son could not stay with him….It was not safe for him to stay by himself. [The] patient went back to the hospital. (ID01 Hospice admission nurse)

Discontinuation or changes in regular care

Another type of information often lost in the transition is regarding their routine health care. Many patients admitted to hospice had lived with their illness for a long time. As they enrolled in hospice care, some treatments and other routine care may need to be discontinued or reevaluated for its needs and priorities. Patients often assumed to continue these routine cares, then later found out they had to cancel standing appointments with health care providers they have known for years without closure. Hospice participants described that they rarely receive this information about patients' routine care and other care providers involved.

Patients are discharged with all follow-up appointments and tests scheduled, so patients and families believing they still have to do all of them. (ID01 Hospice admission nurse)

As patients enroll in hospice, their code status, portable orders for life sustaining treatment, and/or advance directives often need to be changed, but this information also is not communicated routinely between hospital and hospice. Hospital staff may not have all the information regarding the patient's routine health care outside of the hospital. However, starting this conversation in the hospital and informing patients about these forthcoming changes and transferring patient information to hospice staff may improve hospital-to-hospice transitions.

Discussion

We interviewed health care workers on both ends of the hospital-to-hospice transition. Findings from these interviews identified common gaps in these transitions, including lack of hospice literacy, changes in medications, and information around daily care.

Misunderstanding or lack of knowledge about hospice care exacerbates the already difficult transition.^16,17 Participants in our study indicated that patients and their family caregivers who received incorrect or inadequate information about hospice from hospital providers later withdrew from the hospice because it was not what they expected. It is critical for hospital health care workers to provide accurate information to assist patients to make informed hospice decisions. Two of the hospice programs included in our study use hospice liaisons/specialists stationed within affiliated hospitals. They described that their role was to serve as a resource to educate hospital staff about hospice care and also to talk to patients and their family members when requested by hospital staff. These hospice liaisons and palliative care teams are knowledgeable to provide accurate hospice information, and often have communication skills to assist with hospice decision making.^7,18 Better integration and effective use of these resources should be considered to overcome the gap due to hospice literacy.

To make informed decisions regarding hospice enrollment, patients and family caregivers must understand the patient's prognosis. Our data suggest that some patients and family caregivers may not have this understanding before their decision. Hospital health care workers often do not want to talk about prognosis.^19,20 Even when hospital providers discuss the patients' prognosis, patients and family caregivers may be overwhelmed and unable to understand the meaning or not remember what they were told. This may be especially true if they were rushed to make the hospice decision in one to two days of their hospital stay.^21,22 In the current health care system, hospital discharge is often rushed and resulting in poor patient and caregiver outcomes.^10,16 Given the difficult decision to enroll in hospice, our data support the use of a process approach²² initiating the conversations about prognosis and potential benefits of hospice early and over several conversations allowing time for patients and family members to think through.

Medication changes through the hospital-to-hospice transition require additional considerations. Recommendations for a standard set of comfort medications for transition and a documentation template to list all medications used in the hospital and its indications may be useful tools to reduce gaps in the transition. An additional form communicating information about patient's daily care, functional status, home environment, and appointments and relevant medical orders may be helpful to maintain continuity of care throughout the transition.

This study had several limitations. Hospitals and hospice programs included in this study were limited to a defined geographic area and may not be representative of all facilities. The number of participants was small, although we are confident that the sample size was adequate given the high information power of our data.²³ Furthermore, we are confident that we achieved data saturation before concluding recruitment. Fewer hospital health care workers were available and participated in the study indicating the limited expertise or interest in hospice discharge in hospital settings. Furthermore, hospice participants provided more qualitatively-rich data, while hospital participant data were limited indicating a lack of awareness of potential gaps in these transitions. It is reasonable to assume that the hospice providers would provide more rich information regarding the gaps in the transition because they are in the position to observe the outcomes of the transition. Thus, our analysis relied heavily on data from hospice participants. However, interview data from hospital workers were still essential and useful to clarify where in transition gaps may exist. In future studies, more data collection regarding hospice decision making and discharge planning in hospital settings would add knowledge to build useful hospital-to-hospice transition tools.

Conclusions

The need for care coordination during health care transitions is well documented and hospital-to-hospice transitions are no exception. However, there are currently no specific tools or programs to assist in the coordination of hospital-to-hospice transitions. The gaps identified in this study point us to the opportunities to improve these transitions. Further studies aim to develop and test a toolkit to ensure seamless and safe transitions from the hospital to hospice care.

Footnotes

Funding Information

No funding was received for this article.

Author Disclosure Statement

J.P.F. has received consultant fees from Merck & Co. and Shionogi & Co., Ltd. and research funding from Merck & Co. J.T. has received consultant fees from CVS Health.

These data were presented, in part, at the American Geriatrics Society 2019 Annual Meeting, May 2019, Portland, OR.

References

National Hospice and Palliative Care Organization. NHPCO facts and figures: Hospice care in America. National Hospice and Palliative Care Organization. https://www.nhpco.org/wp-content/uploads/2019/07/2018_NHPCC_Facts_Figures.pdf (Last accessed July 1, 2019).

Hesselink

, Flink

, Olsson

, et al.: Are patients discharged with care? A qualitative study of perceptions and experiences of patients, family members and care providers. BMJ Qual Saf, 2012; 21 Suppl 1:i39–i49.

Kripalani

, Jackson

, Schnipper

, Coleman

: Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. J Hosp Med, 2007; 2:314–323.

Rennke

, Nguyen

, Shoeb

, et al.: Hospital-initiated transitional care interventions as a patient safety strategy: A systematic review. Ann Intern Med, 2013; 158(5 Pt 2):433–440.

Casarett

, Crowley

, Stevenson

, et al.: Making difficult decisions about hospice enrollment: What do patients and families want to know?. J Am Geriatr Soc, 2005; 53:249–254.

Casarett

, Fishman

, Lu

, et al. The terrible choice: Re-evluating hospice eligibility criteria for cancer. J Clin Oncol, 2008; 27:953–959.

Candrian

, Tate

, Broadfoot

, et al.: Designing effective interactions for concordance around end-of-life care decisions: Lessons from Hospice Admission Nurses. Behav Sci (Basel), 2017; 7:22.

Ellington

, Cloyes

, Berry

, et al.: Complexities for hospice nurses in supporting family caregivers: Opinions from U.S. thought leaders. J Palliat Med, 2013; 16:1013–1019.

Aldridge

, Canavan

, Cherlin

, Bradley

: Has hospice use changed? 2000–2010 Utilization patterns. Med Care, 2015; 53:95–101.

10.

Gadbois

, Tyler

, Shield

, et al.: Lost in transition: A qualitative study of patients discharged from hospital to skilled nursing facility. J Gen Intern Med, 2019; 34:102–109.

11.

Hansen

, Greenwald

, Budnitz

, et al.: Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med, 2013; 8:421–427.

12.

Parry

, Min

S-J

, Chugh

, et al.: Further application of the care transitions intervention: Results of a randomized controlled trial conducted in a fee-for-service setting. Home Health Care Serv Q, 2009; 28:84–99.

13.

Naylor

, Bowles

, McCauley

, et al.: High-value transitional care: Translation of research into practice. J Eval Clin Pract, 2013; 19:727–733.

14.

Hsieh

H-F

, Shannon

: Three approaches to qualitative content analysis. Qual Health Res, 2005; 15:1277–1288.

15.

Kadoyama

, Noble

, Izumi

, et al.: Frequency and documentation of medication decisions on discharge from the hospital to hospice care. J Am Geriatr Soc, 2019; 67:1258–1262.

16.

Phongtankuel

, Scherban

, Reid

, et al.: Why do home hospice patients return to the hospital? A study of hospice provider perspectives. J Palliat Med, 2016; 19:51–56.

17.

Phongtankuel

, Paustian

, Reid

, et al.: Events leading to hospital-related disenrollment of home hospice patients: A study of primary caregivers' perspectives. J Palliat Med, 2016; 20:260–265.

18.

Lally

, Rochon

, Roberts

, McCutcheon Adams

: The “Conversation Nurse” Model: An innovation to increase palliative care capacity. J Hosp Palliat Nurs, 2016; 18:556–563.

19.

Walczak

, Butow

, Bu

, Clayton

: A systematic review of evidence for end-of-life communication interventions: Who do they target, how are they structured and do they work?. Patient Educ Couns, 2016; 99:3–16.

20.

Isaacson

, Minton

, DaRosa

, Harming

: Nurse comfort with palliative and end-of-life communication: A rural and urban comparison. J Hosp Palliat Nurs, 2019; 21:38–45.

21.

Wallace

: Examining hospice enrollment through a novel lens: Decision time. Palliat Support Care, 2017; 15:168–175.

22.

Romo

, Wallhagen

, Smith

: Viewing hospice decision making as a process. Am J Hosp Palliat Care, 2016; 33:503–510.

23.

Malterud

, Siersma

, Duassora

: Sample size in qualitative interview sudies: Guided by information power. Qual Health Res, 2016; 16:1753–1760.