title: Referral and timing of referral to hospice care in nursing homes: the significant role of staff members.
abstract: OBJECTIVE
  Given concerns about end-of-life care for many nursing home (NH) residents, this study sought to understand factors influencing hospice referral or nonreferral as well as timing of referral.
  
  
  METHODS
  We conducted semistructured interviews with personnel from seven participating NHs and two hospices. We interviewed NH directors of nursing regarding facility referral practices and conducted interviews with 34 NH nurses, 30 NH aides, and 17 hospice nurses knowledgeable about the factors that led to the hospice status of 32 NH decedents. Selected decedents varied by diagnosis and hospice status (received hospice for >7 days, <or=7 days, or not at all). We audiotaped, transcribed, and coded interviews for themes.
  
  
  RESULTS
  NH staff members' recognition of terminal decline, beliefs about hospice, and initiative significantly influenced hospice referral and timing of referral. Staff members' recognition of familiar signs of decline facilitated hospice referral; in contrast, a perception that death was unexpected impeded referral, and a perception of uncertain prognosis delayed referral. Staff members' beliefs that hospice does not add value to NH care or is for crises only impeded referral, and a belief that hospice is only for the "very end" delayed referral. Residents received hospice for longer periods when staff believed that hospice complemented NH care and when staff took the initiative in raising the option of hospice.
  
  
  CONCLUSIONS
  Enhanced training about recognizing terminal decline, hospice services in NHs, and the role of staff initiative would support NH staff in raising the option of hospice when appropriate.
authors: Department of Sociology and Criminal Justice Studies, Southern Illinois University Edwardsville, Edwardsville, IL 62026, USA. Lwelch@SIUE.edu
authors: Lisa C
authors: LC
authors: Welch
authors: Susan C
authors: SC
authors: Miller
authors: Edward W
authors: EW
authors: Martin
authors: Aman
authors: A
authors: Nanda
mesh_terms: D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000523:psychology*; D017051:Hospice Care / Q000523:psychology* / Q000706:statistics & numerical data; D006801:Humans; D007407:Interviews as Topic; D007902:Length of Stay; D008297:Male; D009726:Nurses / Q000523:psychology; D009728:Nursing Assistants; D009735:Nursing Homes; D012017:Referral and Consultation; D013997:Time Factors