JAGS 49:1493–1498, 2001© 2001 by the American Geriatrics Society 0002-8614/01/$15.00

R

ecent years have seen a rapid increase in attentionpaid to end-of-life care for older people. This interest

has produced important research that has advanced ourunderstanding of the challenges that exist for this popula-tion. Perhaps the most notable of these was the Study toUnderstand Prognoses and Preferences for Outcomes andRisks of Treatments study, which proved to be a thor-ough, and highly visible, chronicle of numerous opportu-nities to improve end-of-life care in a largely older popula-tion.

1,2

Indeed, it is becoming increasingly clear that thecurrent healthcare system often fails to promote a gooddeath, broadly defined as a safe and comfortable dying ex-perience, self-determined life closure, and effective griev-ing.

3

Although there are many opportunities to improveend-of-life care for all older adults, one group that has re-ceived growing attention are older people who reside innursing homes.

4

Data suggest that even basic needs forpain control may not be met for nursing home residents ingeneral,

5–7

and especially for those with cancer.

8

Morebroadly, there is growing evidence from the perspective ofresidents’ families that facilities are not meeting their ex-pectations for end-of-life care.

9

Observations about end-of-life care for older adultshave led to a variety of proposals and interventions. For in-stance, some have proposed an innovative expansion ofMedicare services to better meet the supportive care needs ofcommunity-dwelling older people in the Medicaring demon-stration project.

10

In addition, organizations such as the

Does Hospice Have a Role in Nursing Home Care at the End of Life?

David J. Casarett, MD, MA,*

†‡§

Karen B. Hirschman, MSW, PhD,

‡

and Michelle R. Henry, BA

§

OBJECTIVES:

To assess the possible benefits and chal-lenges of hospice involvement in nursing home care bycomparing the survival and needs for palliative care ofhospice patients in long-term care facilities with those liv-ing in the community.

DESIGN:

Retrospective review of computerized clinicalcare records.

SETTING:

A metropolitan nonprofit hospice.

PARTICIPANTS:

The records of 1,692 patients were searched,and 1,142 patients age 65 and older were identified. Of these,167 lived in nursing homes and 975 lived in the community.

MEASUREMENTS:

Patient characteristics, needs for pal-liative care, and survival.

RESULTS:

At the time of enrollment, nursing home resi-dents were more likely to have a Do Not Resuscitate order(90% vs 73%;

P

�

.001) and a durable power of attorneyfor health care (22% vs 10%;

P

�

.001) than were thoseliving in the community. Nursing home residents also haddifferent admitting diagnoses, most notably a lower preva-lence of cancer (44% vs 74%;

P

�

.032). Several needs forpalliative care were less common among nursing home res-idents, including constipation (1% vs 5%;

P

�

.02), pain(25% vs 41%;

P

�

.001), and anticipatory grief (1% vs9%;

P

�

.001). Overall, nursing home residents had fewerneeds for care (median 0, range 0–3 vs median 1, range 0–5;rank sum test

P

�

.001). Nursing home residents had a sig-nificantly shorter survival (median 11 vs 19 days; log ranktest of survivor functions

P

�

.001) and were less likely towithdraw from hospice voluntarily (8% vs 14%;

P

�

.03).However, there was no difference in the likelihood of be-coming ineligible during hospice enrollment (6% for bothgroups).

CONCLUSIONS:

These results suggest that hospices iden-tify needs for palliative care in a substantial proportion of

nursing home residents who are referred to hospice, al-though nursing home residents may have fewer identifiableneeds for care than do community-dwelling older people.However, the finding that nursing home residents’ survival isshorter may be of concern to hospices that are consideringpartnerships with nursing homes. An increased emphasis onhospice care in nursing homes should be accompanied bytargeted educational efforts to encourage early referral.

J AmGeriatr Soc 49:1493–1498, 2001.Key words: nursing homes; hospice; palliative care; pain;

older

From the *Department of Veterans Affairs, Philadelphia, Pennsylvania;

†

In-stitute on Aging;

‡

Division of Geriatric Medicine; and

§

Center for Bioethics, University of Pennsylvania, Philadelphia, Pennsylvania.

Dr. Casarett is supported by a Research Career Development Award from the Department of Veterans Affairs and by grants from the Greenwall Foun-dation, the Commonwealth Fund, and the VistaCare Foundation.

Address correspondence to David Casarett, MD, MA, Institute on Aging, University of Pennsylvania, 3615 Chestnut Street, Philadelphia, PA 19104.

1494

CASARETT ET AL.

NOVEMBER 2001–VOL. 49, NO. 11 JAGS

Robert Wood Johnson Foundation have also invested heavilyin efforts to improve end-of-life care in nursing homes.Other strategies have focused on developing accurate data-bases that would be readily available to coordinate end-of-life care for residents and have led to the development of apalliative care module that will be added to the MinimumData Set.

Although these and other strategies are essential, thereis another promising way to improve end-of-life care innursing homes that needs little development and is alreadyin place nationwide. Hospice has become the single mostwidely utilized provider of end-of-life care in the UnitedStates that is specifically designed for this purpose. Withover 3,139 hospice organizations across the country, hos-pice provides end-of-life care for over 700,000 people ev-ery year.

11

Over the past 20 years, hospice has proven tobe a popular and effective strategy for providing end-of-life care.

12–15

There are grounds for optimism, therefore,that a greater hospice presence in nursing homes, achievedthrough clinician education and hospice-facility partner-ships, can offer a rapid and effective way to improve end-of-life care.

However, before facilities and hospices proceed downthis path, three important questions need to be answered.First, it is not known whether hospice providers will beable to identify needs for care when they are asked to par-ticipate in the care of nursing home residents. In fact, be-cause nursing home residents already have a care team, in-cluding a nurse and a social worker, it is possible that allof a resident’s needs for care have already been identifiedand a care plan has been created. In this case the hospiceteam may find few unmet needs for care.

Second, it is not known whether hospices will havesufficient time to intervene to improve care. The medianlength of stay in hospice is already as low as 14 days insome organizations, which does not allow hospice teamsadequate time to identify needs for care, assemble re-sources, create a care plan, and intervene effectively.

16

Ifnursing home residents’ survival is even slightly shorterthan that of community-dwelling hospice patients, hos-pices will experience a significant disincentive to provideservices to nursing home patients.

Third, it is not known whether hospices’ involvementin nursing home care can improve residents’ care. It will bethe answer to this third question that will drive innovationand policy changes to promote better end-of-life care fornursing home residents. However, before this question canbe answered, it will first be essential to define nursinghome residents’ needs for palliative care and to determinewhether nursing home residents’ lengths of stay are longenough to permit hospices to meet those needs. Therefore,the goal of this study was to compare nursing home resi-dents with community-dwelling older patients in terms oftheir needs for palliative care at the time of hospice enroll-ment and their survival from the time of enrollment.

METHODS

This retrospective study was conducted at the nonprofit hos-pice affiliated with the University of Pennsylvania, whichprovides care to patients with Medicare, Medicaid, and pri-vate insurance and to those without insurance. This hospicehas a daily census of between 170 and 200 patients, of whom

approximately 10% are nursing home residents. This hospiceprovides care to residents in 32 nursing homes throughoutthe metropolitan area that range in size from 60 to 240 beds.These facilities are both nonprofit and for profit and encom-pass a range of Medicare/Medicaid case mixes. Five facilitieshave affiliations with academic medical centers.

This hospice was chosen for the present study becauseit maintains meticulous computerized records, includingclinical and demographic data, and extensive clinical notes.All records are used in daily patient care, which ensures ahigh degree of accuracy and completeness.

To control for the association of nursing home place-ment with age, analysis was limited to patients age 65 andolder. The sample was further limited to patients who wereenrolled in this hospice between January 1997 and January1999. All patients admitted during the study period eitherdied or had been discharged at the time of data analysis.

All data described in this study were extracted fromcomputerized records using precoded data fields, whichobviated the need for chart review and abstraction. Pa-tients’ needs for care were identified by the categories ofproblems and interventions that are used to develop plansfor care. These needs are not equivalent to the presence ofa symptom or problem, rather they indicate the presenceof a problem for which an immediate intervention is re-quired of the care team. For instance, a patient would onlybe coded as having a need for pain management if achange in treatment were required. Similarly, anticipatorygrief is coded if an intervention is required for a familymember who demonstrates symptoms or behaviors typi-cally associated with grief, such as sadness or anxiety, thatoccur before the patient’s death.

17–19

It is important to note that the absence of a recordedneed does not mean that no services were provided. First,these codes reflect only needs at the time of enrollment.Many patients with no needs at enrollment developedneeds for care later in their illness course. Second, patientsfor whom no need for intervention was recorded still re-ceived a variety of other services. For instance, a chaplaincontact and home health aide services were provided tovirtually all patients in this sample.

These needs, and the other variables reported here,were defined at the time of the patient’s enrollment. Mostvariables were naturally coded in patient records as di-chotomous (e.g., the presence of a Do Not Resuscitate(DNR) order) or as ordinal (e.g., income ranges). Orienta-tion to person and place is assessed at the time of enroll-ment, and this field is coded if a patient is oriented to bothperson and place. Because patients in both groups had awide variety of primary diagnoses, these were combined incategories. A separate “other” category was created forthose diagnoses with fewer than four patients each.

Either an odds ratio or the rank sum test was used tocompare the characteristics and needs of nursing homeresidents with those of community-dwelling older people.Previous studies have shown that needs for care may be un-derrecognized in patients with cognitive impairment;

20–22

therefore, the number of needs noted for each patient wasadjusted for the presence or absence of orientation to per-son and place in a linear regression equation. To comparethe survival of the two groups, survival times were calcu-lated from the date of patients’ enrollment. Deaths were

JAGS NOVEMBER 2001–VOL. 49, NO. 11

HOSPICE IN NURSING HOMES

1495

ascertained using administrative records, and survival wascensored at the time of patients’ last contact with this hos-pice. Kaplan-Meier survival functions for nursing homeresidents and community-dwelling older people were esti-mated and compared using the log rank test. Stata soft-ware was used for all statistical analysis.

23

Both the hospice research committee and the Institu-tional Review Board of the University of Pennsylvania ap-proved this study.

Hospice focuses on maximizing quality of life but doesnot seek to prolong life. Patients referred to hospice must meeteligibility criteria defined in the Medicare hospice legislation

24

and by the Health Care Financing Administration as thefiscal intermediaries who reimburse hospice programs inter-pret them. Under Medicare hospice eligibility criteria, the pa-tient must be entitled to Part A of Medicare and must havewritten certification by two physicians that the patient has “alife expectancy of 6 months or less if the terminal illness runsits normal course.”

24

For patients with noncancer diagnoses, anumber of other specific requirements are applied.

Hospice teams consist of a nurse, social worker, chap-lain, and medical director, any of whom might call on theservices of a physical therapist, home health aide, occupa-tional therapist, or bereavement counselor. All members ofthe team except the medical director, who visits only as re-quested, typically visit the patient. If a patient at home re-quires inpatient or respite care while in hospice, the teamcontinues to be responsible for the patient’s plan of careand continues to visit. Home health aide services also con-tinue during respite stays. One year of bereavement care isoffered, with phone contacts, written materials, supportgroups, and individual counseling.

RESULTS

Over the study period, 1,142 patients age 65 and olderwere enrolled in this hospice program. Of these, 167 wereresidents of nursing homes and 975 lived in the commu-

nity. The sample of community-dwelling older patients in-cluded 24 in assisted living situations.

The vast majority of community-dwelling older pa-tients lived with family (890; 91%). However, 85 (9%)were initially enrolled in the hospice’s live-alone program,which provides additional support and services to help pa-tients remain independent as long as possible. All of thesepatients who lived alone had an identified caregiver wholived nearby.

Several differences in patient demographics were found(Table 1). For instance, nursing home residents were morelikely to be women (68% vs 55%;

P

�

.002) and were lesslikely to be married (22% vs 40%;

P

�

.001). Nursinghome residents also had lower incomes than did commu-nity-dwelling older patients and were more likely to havean income of less than $30,000 (53% vs 30%;

P

�

.001).At the time of enrollment, nursing home residents werealso more likely to have a DNR order (90% vs 73%;

P

�

.001), a living will (59% vs 43%;

P

�

.001), and a durablepower of attorney for health care (22% vs 10%;

P

�

.001). Nursing home residents were less likely to be re-ferred by a physician based at an academic medical center(defined as the primary teaching hospital of an allopathicmedical school or one of that school’s designated internalmedicine residency sites) (11% vs 18%;

P

�

.021).Several clinical differences between patients in the two

groups were noted as well. For instance, nursing home resi-dents were less likely to have a primary diagnosis of cancer(44% vs 74%;

P

�

.032) and more likely to have a diagnosisof failure to thrive (20% vs 3%;

P

�

.002) (Table 2). Alsonoteworthy is the finding that nursing home residents weremore likely to have a primary diagnosis of dementia (16% vs4%;

P

�

.052). Overall, only half of patients in either groupwere oriented to person and place (47%); nursing home res-idents were even less likely to be oriented than were commu-nity-dwelling older people (32% vs 50%;

P

�

.001).In general, the needs for care in the two groups were

similar (Table 3). However, several significant differences

Table 1. Patient Demographics

VariableNursing Home n

�

167 (%)Communityn

�

975 (%)Odds Ratio

95% Confidence Interval

P

-value

Sex (female) 113 (68) 537 (55) 1.71 1.21–2.41 .002Married 36 (22) 390 (40) 0.412 0.28–0.608

�

.001Caucasian 99 (61) 604 (63) 0.921 0.655–1.30 .637Income*$0–29,999 88 (53) 293 (30) — — —$30,000–50,000 43 (26) 524 (54) 0.273 0.185–0.404

�

$50,000 29 (17) 127 (13) 0.760 0.476–1.21Do not resuscitate

order151 (90) 714 (73) 3.45 2.03–5.85

�

.001

Living will 98 (59) 420 (43) 1.88 1.35–2.61

�

.001Durable power

of attorney 36 (22) 100 (10) 2.40 1.58–3.66

�

.001Oriented to

person, place 53 (32) 488 (50) 0.46 0.33–0.66

�

.001Academic medical

center 18 (11) 176 (18) 0.548 0.329–0.914 .021

*

Data were missing for 38 patients; analysis used case-wise deletion.

1496

CASARETT ET AL.

NOVEMBER 2001–VOL. 49, NO. 11 JAGS

were identified. Constipation was identified as a problemrequiring intervention (e.g., the addition of a bowel regi-men) less often among nursing home residents (1% vs 5%;

P

�

.024). A need for changes in pain management (e.g.,the addition of a new pain medication or an increase indose) was also less common in this group (25% vs 41%;

P

�

.001). In addition, hospice teams identified a need formanagement of anticipatory grief significantly less oftenamong nursing home residents (1% vs 9%;

P

�

.001).Typically, management of anticipatory grief in this hospiceconsists of life review by a social worker and sometimesadditional sessions with a bereavement counselor. Only aneed for feeding tube management was more commonamong nursing home residents (8% vs 4%;

P

�

.010).Overall, nursing home residents had fewer needs for

care (median 0, range 0–3 vs median 1, range 0–5; ranksum test

P

�

.001) and were more likely to have no needfor care (58% vs 36%;

P

�

.001). Because of the possibil-ity that needs for care were underrecognized in nursinghome residents, the needs for care in the two groups werecompared after adjustment for orientation in a linear re-gression model. In this equation, nursing home residenceremained a significant predictor of patients’ need for care(beta

�

�

0.35; 95% CI

�

�

0.48 to

�

0.22), whereas ori-entation was not (beta

�

�

0.05; 95% CI

�

�0.15–0.04).The date of death could be determined for 165 nurs-

ing home residents (99%) and 937 community-dwellingolder people (96%). Of these, nursing home residents hada significantly shorter survival (median 11 days, range 0–

312 vs median 19 days, range 0–570). When the survivorfunctions of these two groups were compared, with cen-soring of patients at their last contact, nursing home resi-dents’ survival remained significantly shorter (log rank testP � .001) (Figure 1). The proportions of outliers with asurvival greater than 6 months were not significantly dif-ferent (nursing home: 1/165, 0.6% vs community 28/937,3.0%; chi-square P � .078). It is important to note thatthese numbers describe survival and not length of stay inhospice for greater than 6 months. Nursing home residentswere less likely to withdraw from hospice voluntarily (8%vs 14%; P � .03). However, there was no difference in thelikelihood of becoming ineligible during hospice enroll-ment (6% for both groups).

DISCUSSIONThis study describes the needs for palliative care amongnursing home residents cared for by one hospice andshould be of considerable interest to clinicians, nursinghomes, and hospice organizations. In particular, it is note-worthy that these hospice teams often identified at leastone need that had not been addressed by the nursing homeresident’s care team. This finding should pave the way forfuture research to determine whether hospices are able tointervene effectively to meet these needs for care and, morebroadly, whether hospice involvement in the care of nurs-ing home residents offers added benefits.

This study also provides insights into how nursinghome residents’ needs for care compare with those of com-

Table 2. Diagnoses of Hospice Patients in Nursing Homes Versus Those Living at Home

Primary DiagnosisNursing Home n � 167 (%)

Communityn � 975 (%)

95% Confidence Interval

Odds Ratio P-value

Other 8 (5) 32 (3) — — —Cancer 74 (44) 717 (74) 0.183–0.929 0.413 .032Cardiovascular disease 9 (5) 58 (6) 0.218–1.77 0.621 .371Pulmonary 6 (4) 47 (5) 0.162–1.61 0.511 .252End stage renal disease 5 (3) 23 (2) 0.252–3.00 0.870 .825Dementia 26 (16) 42 (4) 0.991–6.19 2.48 .052Cirrhosis 2 (1) 7 (1) 0.198–6.59 1.14 .881Neurological disease 3 (2) 16 (2) 0.175–3.22 0.75 .699Failure to thrive 34 (20) 33 (3) 1.66–10.25 4.12 .002

Table 3. Nursing and Social Intervention

ComplaintNursing Home n � 167 (%)

Communityn � 975 (%)

95% ConfidenceInterval

Odds Ratio P-value

Dysphagia 6 (4) 23 (2) 0.636–3.75 1.54 .350Incontinence 10 (6) 90 (9) 0.323–1.22 0.626 .171Nausea/vomiting 2 (1) 34 (3) 0–1.28 0.335 .118Intravenous access 3 (2) 43 (4) 0.129–1.22 0.396 .112Edema 0 (0) 16 (2) 0–1.38 0 .096Dyspnea 20 (12) 175 (18) 0.381–1.02 0.622 .058Constipation 2 (1) 50 (5) 0–0.844 0.224 .024Feeding tube 14 (8) 38 (4) 1.21–4.23 2.26 .010Pain 42 (25) 400 (41) 0.333–0.700 0.483 �.001Management of anticipatory grief 2 (1) 89 (9) 0–0.450 0.121 �.001

JAGS NOVEMBER 2001–VOL. 49, NO. 11 HOSPICE IN NURSING HOMES 1497

munity-dwelling hospice patients in a similar age range atthe time of enrollment in hospice. These results demon-strate that, although nursing home residents have signifi-cant needs for care, they have fewer needs than do otherhospice patients. Although it cannot be determined fromthese results why this is so, one possible explanation isthat the care teams at these facilities had already begun toaddress residents’ palliative care needs before hospice be-came involved. Regardless of the reason for this difference,this finding should be reassuring to hospices that are con-sidering partnerships with nursing homes and should ame-liorate hospice concerns about excessive demands on stafftime.

However, it is important to note that these results donot portray an entirely optimistic circumstance of hospicepartnerships with nursing homes. In fact, this study’s find-ing that nursing home residents have a substantially shortersurvival than do community-dwelling older people will beof concern to hospice organizations. Hospices currentlyexperience overwhelming financial pressures to provideexcellent care within a fixed per diem of approximately$110, and they require longer lengths of stay to recoup theinitial costs of intake, needs assessment, and care plan-ning.16 A shorter survival among nursing home residentsmay provide a substantial disincentive to hospices to en-roll these patients.

Therefore, future research is needed to replicate thisstudy. If further studies provide evidence that nursinghome residents have a shorter survival after enrollment,hospices and nursing homes may wish to reevaluate theircontractual relationships to ensure that partnerships are fi-nancially feasible. Hospices and nursing homes might alsowork to encourage staff and clinicians to refer nursinghome residents sooner. For instance, a nursing home andhospice could collaborate in developing staff educationalprograms that are designed to increase awareness of hos-pice and hospice services. In fact, the hospice in which thisstudy was conducted has begun to offer special programsand continuing education to the staff of area nursinghomes. Although such educational programs can be con-ducted at any time, the upcoming introduction of the re-vised Minimum Data Set, which will include a palliativecare module, will be an excellent time to enhance aware-ness of hospice as one way to provide palliative care.

This study has several limitations. First, it did not as-sess whether hospice was able to meet the needs for pallia-tive care that were identified. Given the relatively short sur-vival of nursing home residents, it is not clear whetherhospices are able to meet nursing home residents’ needs forcare in a short period of time. Therefore, it is importantthat future prospective studies determine whether hospicesare able to meet nursing home residents’ needs for care andwhether the shorter survival of nursing home residents lim-its hospice’s effectiveness. Future studies should use strate-gies that are adapted to the challenges of assessment inolder people in general and in nursing home residents withcognitive impairment in particular.20–22 Nevertheless, theseresults identify those needs for care that are most commonamong nursing home residents, which should be very use-ful in guiding the design of future studies.

Second, it is possible that the prevalence of cognitiveimpairment in both nursing home residents and commu-nity-dwelling older people made the detection of needs forcare more difficult and resulted in underestimates.20–22 Ifcognitive impairment were more common among nursinghome residents, the resulting ascertainment bias could ex-plain the finding that nursing home residents had fewerneeds for care. However, two points mitigate the potentialimpact of this limitation. First, the difference in need forcare remained after adjustment for orientation, which wasitself not a significant predictor of patient need for care.Of course, orientation is only a rough proxy measure ofcognitive status, and it is possible that an effect wouldhave been found if a more sensitive measure, such as thefull Mini-Mental State Examination,25 had been used.Nevertheless, this finding suggests that cognitive impair-ment may not explain all of the differences in needs re-ported here. Second, the goal of this study was to defineneed for care in clinical terms, from the perspective of hos-pice providers. Therefore, even though the needs reportedhere may not represent “true” estimates of patients’ needs,they offer an important description of the needs that hos-pice providers are likely to find in long-term-care facilitiesand in the community, within the limits imposed by thepresence of cognitive impairment.

Third, this study describes only those needs that werepresent at the time of hospice referral. Need for care maychange rapidly near the end of life, and it is likely that newsymptoms or needs for care appeared during these pa-tients’ enrollment in hospice. Therefore future research isneeded to assess these changes over time in nursing homeand community settings and to compare the relative costand cost effectiveness of various strategies designed tomeet these needs. Nevertheless, these data provide usefulinsights into the needs that are present in these popula-tions at the critical time of hospice enrollment.

In summary, this study offers valuable preliminarydata that should be influential in guiding future advancesin end-of-life care in nursing homes. Specifically, it sug-gests that hospices can identify need for care in a substan-tial proportion of nursing home patients. However, thisstudy also suggests that hospices and nursing homes shoulddevelop collaborations carefully, with attention to the chal-lenges that hospices face in developing and implementing acare plan for patients with a very limited prognosis. Nev-ertheless, hospice care offers one important avenue for im-

Figure 1. Kaplan-Meier survival estimates.

1498 CASARETT ET AL. NOVEMBER 2001–VOL. 49, NO. 11 JAGS

proved end-of-life care for older people, and further re-search can make a valuable contribution to optimize thebenefits of this resource.

ACKNOWLEDGMENTSThe authors would like to thank Maryanna Phinn, KelliePreston, Dr. Janet Abrahm, and the staff and patients ofWissahickon Hospice.

REFERENCES1. Lynn J, Teno JM, Phillips RS et al. Perceptions by family members of the dy-

ing experience of older and seriously ill patients. SUPPORT Investigators.Study to Understand Prognoses and Preferences for Outcomes and Risks ofTreatments. Ann Intern Med 1997;126:97–106.

2. Teno JM, Hakim RB, Knaus WA et al. Preferences for cardiopulmonaryresuscitation: Physician-patient agreement and hospital resource use. TheSUPPORT Investigators. J Gen Intern Med 1995;10:179–186.

3. Standards and Accreditation Committee 1995–6. A Pathway for Patients andFamilies Facing Terminal Illness. Arlington, VA: National Hospice Organiza-tion, 1997.

4. Keay T, Fredman L, Taler G et al. Indicators of quality medical care for theterminally ill in nursing homes. J Am Geriatr Soc 1994;42:853–860.

5. Stein W, Ferrell B. Pain in the nursing home. Clin Geriatr Med 1992;12:601–613.

6. Sengstaken EA, King SA. The problems of pain and its detection among geri-atric nursing home residents. J Am Geriatr Soc 1993;41:541–544.

7. Won A, Lapane K, Gambassi G et al. Correlates and management of nonma-lignant pain in the nursing home. J Am Geriatr Soc 1999;47:936–942.

8. Bernabei R, Gambassi G, Lapane K et al. Management of pain in elderly pa-tients with cancer. JAMA 1998;279:1877–1882.

9. Hanson L, Danis M, Garrett J. What is wrong with end-of-life care? Opin-ions of bereaved family members. J Am Geriatr Soc 1997;45:1339–1344.

10. Lynn J, Wilkinson AM. Quality end of life care: The case for a MediCaringdemonstration. Hospice J 1998;13:151–163.

11. National Hospice Organization Fact Sheet [On-line]. Available: 2000:http://www.nho.org/facts.htm.

12. Kane RL, Berstein L, Wales J et al. Hospice effectiveness in controlling pain.JAMA 1985;253:2683–2686.

13. Longman AJ. Effectiveness of a hospice community bereavement program.Omega 1994;27:163–175.

14. Wales J, Kane R, Robbins S et al. UCLA hospice evaluation study. Methodol-ogy and instrumentation. Med Care 1983;21:734–744.

15. Lattanzi-Licht M, Mahoney JJ, Miller GW. The Hospice Choice. In Pursuitof a Peaceful Death. New York: Simon and Schuster, 1998.

16. Byock IR, Forman WB, Appleton M. Academy of hospice physicians’ posi-tion statement on access to hospice and palliative care. J Pain Sympt Manage1996;11:69–70.

17. Walker RJ, Pomeroy EC, McNeil JS et al. Anticipatory grief and AIDS: Strat-egies for intervening with caregivers. Health Soc Work 1996;21:49–57.

18. Theut SK, Jordan L, Ross LA et al. Caregivers’ anticipatory grief in dementia:A pilot study. Intl J Aging Human Dev 1991;33:113–118.

19. Casarett D, Kutner J, Abrahm J. for the American College of Physicians Endof Life Task Force. Life after death: A practical approach to grief and be-reavement. American College of Physicians Consensus Paper. Ann InternMed 2001; 134:208–215.

20. Parmelee PA, Smith B, Katz IR. Pain complaints and cognitive status amongelderly institution residents. J Am Geriatr Soc 1993;41:517–522.

21. Parmelee PA. Pain in cognitively impaired older persons. Clin Geriat Med1996;12:473–487.

22. Ferrell BA, Ferrell BR, Rivera L. Pain in cognitively impaired nursing homepatients. J Pain Sympt Manage 1995;10:591–598.

23. Stata for Windows, Version 5.0. College Station, TX: Stata Co., 2000.24. 42 Code of Federal Regulations, Part 418. Medicare Hospice Regulations.

Washington, DC: Government Printing Office, 1996.25. Folstein MF, Folstein F, McHugh PR. “Mini-mental state”: A practical

method for grading the cognitive state of patients for the clinician. J PsychRes 1975;12:189–198.