title: At the crossroads: making the transition to hospice.
abstract: OBJECTIVE
  Previous studies reveal that many terminally ill patients never receive hospice care. Among those who do receive hospice, many enroll very close to the time of death. Nationally, between 1992 and 1998, the median length of stay at hospice declined 27%, from 26 to 19 days. In our prior study of 206 patients diagnosed with terminal cancer and using hospice, we found that one-third enrolled with hospice within 1 week prior to death. Late hospice enrollment can have deleterious effects on patients and their family members. The aim of the present study was to characterize common experiences of patients and primary family caregivers as they transition to hospice, focusing on caregiver perceptions of factors that might contribute to delays in hospice enrollment.
  
  
  METHODS
  We conducted in-depth interviews with a purposive sample of 12 caregivers selected from a population of primary family caregivers of patients with terminal cancer who enrolled with hospice in Connecticut between September 2000 and September 2001. Respondents represented different ages, genders, and kinship relationships with patients. Respondents were asked about the patient's care trajectory, how they first learned about hospice, and their experiences as they transitioned to hospice. NUD*IST software was used for qualitative data coding and analysis.
  
  
  RESULTS
  Constant comparative analysis identified three themes common to the experience of transitioning to hospice: (1) caregivers' acceptance of the impending death, (2) challenges in negotiating the health care system across the continuum of care, and (3) changing patient-family dynamics.
  
  
  CONCLUSIONS
  Identification of these themes from the caregivers' perspective generates hypotheses about potential delays in hospice and may ultimately be useful in the design of interventions that are consistent with caregivers' needs.
authors.affiliation: School of Nursing, Center for Excellence in Chronic Illness Care, Yale University, New Haven, Connecticut, USA.
authors.forename: Dena
authors.initials: D
authors.lastname: Schulman-Green
authors.forename: Ruth
authors.initials: R
authors.lastname: McCorkle
authors.forename: Leslie
authors.initials: L
authors.lastname: Curry
authors.forename: Emily
authors.initials: E
authors.lastname: Cherlin
authors.forename: R
authors.initials: R
authors.lastname: Johnson-Hurzeler
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Bradley
mesh_terms: D000328:Adult; D000368:Aged; D017028:Caregivers / Q000523:psychology*; D003237:Connecticut; D003657:Decision Making; D005195:Family Relations; D005260:Female; D017051:Hospice Care / Q000523:psychology*; D006801:Humans; D007398:Interpersonal Relations; D008297:Male; D008875:Middle Aged; D033262:Narration; D009369:Neoplasms / Q000451:nursing; D010166:Palliative Care / Q000523:psychology*; D010287:Parent-Child Relations; D011795:Surveys and Questionnaires