Improving Hospice Outcomes Through Systematic Assessment

A Clinical Trial

Susan C. McMillan, PhD, ARNP, FAAN; Brent J. Small, PhD; William E. Haley, PhD


Cancer Nurs. 2011;34(2):89-97. 

In This Article

Abstract and Introduction


Background: Systematic assessment is vital to palliative care, but documentation confirming completion of systematic assessment in hospice settings is often inadequate or absent.
Objective: The objective of the study was to determine the efficacy of systematic feedback from standardized assessment tools for hospice patient-caregiver dyads in improving hospice outcomes compared with the usual clinical practice.
Interventions/Methods: The sample of patients (n = 709) newly admitted to hospice home care in 2 hospices had designated family caregivers. The interdisciplinary teams (IDTs) caring for these dyads were randomly assigned to either experimental (n = 338) or control (n = 371) conditions. Data were collected from both groups of dyads using standardized assessments on admission and 1 week after each of the first 2 IDT meetings in which these dyads were discussed. The experimental intervention consisted of reporting data from the standardized assessments to the IDTs.
Results: Results showed improved patient depression (P < .001) as a result of the intervention and improvement in both groups in patients' quality of life (P < .001). No other patient outcomes (symptom distress, spiritual needs) or caregiver outcomes (depression, support, spiritual needs) were significantly different.
Conclusions: Assessment of depression added to usual care probably had an effect because it is not normally a focus of hospice staff. Hospice care was so good during the study that overall quality of life improved as a result of standard care and left little room for improvement in other variables.
Implications for Practice: Systematic assessment of depression is needed in hospice patients. No caregiver variables changed, which may indicate a need for a focus on caregivers.


Patients near the end of life experience a variety of symptoms that cause distress, and family caregivers also are distressed and at risk for depression. Systematic assessment is a vital part of palliative care, but documentation confirming completion of systematic assessment in oncology and hospice settings is often inadequate or absent.[1–6] Studies with cancer patients have demonstrated that improving assessment can improve pain outcomes,[7–9] but these studies have not been conducted in hospice or palliative care settings and have focused only on pain.

Depression is common in cancer and underdiagnosed by health care providers, including in hospice.[10,11] Providing feedback to professionals from standardized depression scales improves such detection.[10] Although there is little research about assessing depression in hospice patients, we have found in our local hospice that psychosocial assessments were missing the check-offs for depression about 75% of the time.

Attempts have been made to change care provider assessment behaviors, with mixed results. Traditional methods such as providing practice guidelines for physicians and physician conferences are generally ineffective in changing provider behavior without additional incentives or practice change interventions.[11–16] One important component of effective clinical change models is providing quantitative data on important outcomes.[2,4,6,17–20]

We provided an add-on to usual hospice care system assessment in an effort to enhance the usual process of care while not disrupting this care. The purpose of this study was to determine the efficacy of providing systematic feedback from standardized assessment tools for hospice patients and caregivers in improving hospice outcomes compared with the usual clinical practice. We hypothesized that patients and family caregivers who were cared for by members of interdisciplinary teams (IDTs) who received an enhanced assessment intervention would have significantly better outcomes compared with dyads from the teams that received only usual care.


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