OBJECTIVE: The prevalence and mortality of chronic liver disease has risen significantly. In end stage liver disease (ESLD) the survival of patients is approximately 2 years. Despite the poor prognosis and high symptom burden of these patients, integration of palliative care is reduced. We aim to analyze the agreement between palliative care and hepatology physicians of clinical scenarios that could require palliative care intervention.
METHODS: A cross-sectional study was conducted. Palliative care and hepatology physicians were surveyed. Using a five-point Likert scale, their perceptions of palliative care in ESLD were rated. Their agreement in clinical scenarios that could require palliative care intervention were evaluated. Analyses were conducted to assess any differences by primary role (hepatology vs. palliative care) and length of practice (<10 years vs. 10 years).
RESULTS: A total of 123 responses were obtained: 52% from palliative care and 48% from hepatology. The majority (66.7%) work in the field for up to ten years. There was a great consensus in 4 of the 8 clinical scenarios. In scenarios with less consensus, the area of activity and length of practice influence the reliance of physicians on palliative care. Involvement of palliative care in ESLD was considered \"rare\" by 30% and 61% consider difficult to predict the prognosis. More than 90% support medical training in both areas of activity.
CONCLUSIONS: The current involvement of palliative care is considered low, but there are clinical conditions that reveal a clear consensus and there\'s a unanimous view of the relevance of training.

The aim of our article is to highlight the history of pain management. The multidisciplinary team (MDT) concept in confronting pain was first conceptualized by the Hippocratics, and has evolved through time and become a trend in medicine over recent decades. Documentary research was conducted to unveil the story of the evolution of MDTs. From the early 1950\'s the idea of an MDT approach to deal with various types of pain was sporadically introduced in medicine. Studies encouraged health institutions to support this concept by providing health professionals with training, alongside the necessary facilities and resources. Specialized care programs started with Dame Cicely Mary Strode Saunders as one of the pioneers. CONCLUSIONS: Team work and continuous interdisciplinary treatment of pain have rendered MDTs essential for health systems. Barriers in flexibility, information flow and personal issues give rise to the need for better organization and training. Pain and terminal disease palliation call for MDTs, and educated leaders to run them. Present and future health MDTs are considered necessary in all medical fields.

BACKGROUND: Advance Care Planning (ACP), as a process for expressing and recording patients\' preferences about end-of-life care, has received increasing attention in recent years. However, implementing ACP has been challenging in Iran.
OBJECTIVE: To assess the readiness for advance care planning and related factors in the general population of Iran.
METHODS: This cross-sectional study was conducted on the general population of Iran in 2022. The data was collected using demographic information questionnaire and The RACP Scale. The purpose and methodology of the research was explained to all participants, and upon their agreement an informed consent was obtained. Participants were invited to fill out the questionnaires wherever is more convenient for them, either alone or if needed, with the help of the researcher to protect their privacy. Chi-square, fisher exact test and multiple logistic Regression model were used to assess the effective factors on the RACP. The data were analyzed by SPSS software version 26.
RESULTS: A total of 641 people with an average age of 36.85 ± 12.05 years participated in this study. Of those, 377 (58.8%) had high RACP. The logistics model showed an association between the chance of readiness for receiving ACP with participants\' education level, such that the chance of readiness in those with Master\'s or Ph.D. degrees was three times higher than those with a diploma (p = 0.00, OR:3.178(1.672, 6.043)). However, the chances of readiness in those with bachelor\'s degrees was not significantly different from those with a diploma (p = 0.936, OR: 0.984 (0.654, 1.479)). Moreover, the chance of readiness was 1.5 higher in participants over 40 years of age compared with participants under the age of 40 (P = 0.01, OR: 1.571(1.10, 2.23)).
CONCLUSIONS: According to the findings of this study, it can be concluded that there is a relatively RACP among people in Iranian society. The readiness of individuals for ACP increases by their age and education level. Therefore, by holding appropriate training intervention, we can increase the readiness of the public for ACP to improve their end-of-life outcome.

BACKGROUND: This study aimed to investigate the trends of aggressive care at the end-of-life (EoL) for patients with advanced cancer in Korea and to identify factors affecting such care analyzing nationwide data between 2012 to 2018.
METHODS: This was a population-based, retrospective nationwide study. We used administrative data from the National Health Insurance Service and the Korea Central Cancer Registry to analyze 125,350 patients aged 20 years and above who died within one year of a stage IV cancer diagnosis between 2012 and 2018.
RESULTS: The overall aggressiveness of EoL care decreased between 2012 and 2018. In patients\' last month of life, chemotherapy use (37.1% to 32.3%; p < 0.05), cardiopulmonary resuscitation (13.2% to 10.4%; p < 0.05), and intensive care unit admission (15.2% to 11.1%; p < 0.05) decreased during the study period, although no significant trend was noted in the number of emergency room visits. A steep increase was seen in inpatient hospice use in the last month of life (8.6% to 26.6%; p < 0.05), while downward trends were observed for hospice admission within three days prior to death (13.9% to 11%; p < 0.05). Patients were more likely to receive aggressive EoL care if they were younger, women, had treatment in tertiary hospitals, or had hematologic malignancies. In the subgroup analysis, the overall trend of aggressive EoL care decreased for all five major cancer types.
CONCLUSIONS: The aggressiveness of EoL care in stage IV cancer patients showed an overall decrease during 2012-2018 in Korea.

Hospices in California have undergone significant and complicated ownership changes in recent years. Little is known about the impact of these ownership changes on hospices. The purpose of our longitudinal, retrospective descriptive study was to describe the ownership changes impacting hospices 2018 to 2021 in California. Using descriptive statistics, we measured characteristics of hospices with and without ownership changes employing public data from the California Home Health Agencies and Hospice Annual Utilization Report. Ownership change characteristics were measured via publicly available hospice provider and facility data. Spatial characteristics were additionally measured via latitude and longitude publicly available data. Our findings showed that ownership changes were significant and complicated. An influx of for-profit organizations into the California market was primarily responsible for these changes. Additionally, lack of corporate financial public disclosure and voluntary hospice accreditation, certification, and reporting result in a lack of free, publicly available, definitive comprehensive data on for-profit hospice ownership. This hinders information gathering on and provider/familial choice-making regarding hospices. Our study provides critical insight into the impact of ownership changes and lack of definitive, free, publicly available information on adult hospices in California caring for children and has important clinical, research, and policy implications.

OBJECTIVE: To document how dementia diagnoses appear in hospice claims, and how these different presentations reflect different hospice utilization. The reliance in the hospice literature on primary diagnosis, in addition to the focus on decedents, may underestimate the true presence of dementia in hospice, and little is known about the health care utilization of hospice patients with dementia as a secondary or not present diagnosis.
METHODS: Secondary data analysis of Medicare claims.
METHODS: Medicare beneficiaries with 2 or more dementia diagnoses from 2016 to 2018 electing hospice in 2018.
METHODS: Beneficiaries were classified based on the presence and position of dementia on their subset of hospice claims: primary diagnosis, secondary diagnosis, and not present. We then compared the demographics and utilization of the 3 claim-based categories of dementia beneficiaries in hospice in 2018.
RESULTS: Fewer than half of beneficiaries with a dementia diagnosis in all of their Medicare claims have dementia indicated as the primary diagnosis associated with their hospice claims, and 30% of beneficiaries did not have their diagnosed dementia appear at all on their hospice claims. Hospice length of stay and other utilization characteristics varied markedly across the 3 claim-based categories of dementia beneficiaries in hospice in 2018.
CONCLUSIONS: Collectively, International Classification of Diseases, Tenth Revision (ICD-10) coding and sequencing conventions, coding practices, and research methods related to hospice claim diagnoses may unintentionally underestimate and oversimplify how dementia manifests in hospice utilization.

Background: An essential component of residential hospice care is the provision of high quality palliative care. The perspectives of quality of care from palliative care patients and bereaved caregivers have increasingly been studied to guide quality improvements. Aim: The study aimed to explore the experiences and perceptions of bereaved caregivers of patients who died in residential hospice during the coronavirus disease-19 (COVID-19) pandemic to determine perceptions of quality of care, caregiver grief and bereavement, and the impact of the COVID-19 pandemic. Design: Qualitative exploratory study using secure, web-based semistructured interviews. Data were analyzed using thematic analysis. Setting/Participants: A total of 15 bereaved caregiver participants were recruited from two residential hospice sites in Ottawa, Ontario. Results: Participants identified several factors that impacted the quality of care in residential hospice, including the impact of the COVID-19 pandemic itself. The findings are presented in three main themes: (1) quality of residential hospice end-of-life care; (2) caregiver perceptions of their grief and bereavement; and (3) impact of the COVID-19 pandemic on hospice quality of care and caregiver bereavement. Conclusions: The COVID-19 pandemic had a significant impact on the patient and caregivers experience of hospice, including perception of quality of care and caregiver experience of grief and bereavement.

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BACKGROUND: Hospice care leads to improved patient and family outcomes. Hospice use among older adults with end-stage kidney disease (ESKD) is markedly lower than among older adults with other serious illnesses, and the majority of those with ESKD who use hospice enroll in the last days of life. Here, our aim was to explore barriers to timely receipt of high-quality hospice care for older adults with ESKD.
METHODS: Utilizing a qualitative study design, we conducted a secondary analysis focused on hospice, a theme that we identified in our larger overarching study that involved semi-structured interviews with 20 nephrologists in the United States focused on treatment decision-making in older adults with advanced chronic kidney disease. We analyzed the interview transcripts using emergent thematic analysis to develop an understanding of barriers to high-quality hospice.
RESULTS: With a couple notable exceptions, nephrologists voiced general support for the concept of hospice, but few recalled patients of theirs who had received hospice. Nephrologists\' interviews revealed two interrelated contributors to the lack of timely access to high-quality hospice care for seriously ill older adults with ESKD: (1) nephrologists view dialysis and hospice as mutually exclusive models of care; (2) nephrologists feel unsure who should manage hospice care for patients with ESKD. The first contributor was rooted in nephrologists\' narrow vision of when to consider hospice (informed, in part, by policy barriers) and, in a couple of cases, strong discomfort with hospice. The second stemmed from nephrologists\' belief that neither they nor hospice are adequately prepared to provide hospice care for ESKD.
CONCLUSIONS: Our findings suggest that, in addition to Medicare policy change, nephrologists need to receive more training in primary palliative care skills including in indications for hospice, initiating conversations about hospice with patients, and collaborating with hospice clinicians to care for these vulnerable patients.

UNASSIGNED: Delirium is a serious neuropsychiatric syndrome with adverse outcomes, which is common but often undiagnosed in terminally ill people. The 4 \'A\'s test or 4AT (www.the4AT.com), a brief delirium detection tool, is widely used in general settings, but validation studies in terminally ill people are lacking.
UNASSIGNED: To determine the diagnostic accuracy of the 4AT in detecting delirium in terminally ill people, who are hospice inpatients.
UNASSIGNED: A diagnostic test accuracy study in which participants underwent the 4AT and a reference standard based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The reference standard was informed by Delirium Rating Scale Revised-98 and tests assessing arousal and attention. Assessments were conducted in random order by pairs of independent raters, blinded to the results of the other assessment.
UNASSIGNED: Two hospice inpatient units in Scotland, UK. Participants were 148 hospice inpatients aged ⩾18 years.
UNASSIGNED: A total of 137 participants completed both assessments. Three participants had an indeterminate reference standard diagnosis and were excluded, yielding a final sample of 134. Mean age was 70.3 (SD = 10.6) years. About 33% (44/134) had reference standard delirium. The 4AT had a sensitivity of 89% (95% CI 79%-98%) and a specificity of 94% (95% CI 90%-99%). The area under the receiver operating characteristic curve was 0.97 (95% CI 0.94-1).
UNASSIGNED: The results of this validation study support use of the 4AT as a delirium detection tool in hospice inpatients, and add to the literature evaluating methods of delirium detection in palliative care settings.
UNASSIGNED: ISCRTN 97417474.