The relationship of caregiver self-efficacy to caregiver outcomes: a correlation and mediation analysis.

OBJECTIVES: Caregivers of individuals with Alzheimer's disease and related dementias experience significant burden and adverse outcomes. Enhancing caregiver self-efficacy has the potential to mitigate these negative impacts, yet little is known about its relationship with other aspects of caregiving. This study examined the relationship between self-efficacy and outcomes; identified factors associated with self-efficacy; examined the mediating role of self-efficacy; and analyzed whether there were racial/ethnic differences. METHODS: Data from caregivers (N = 243) were collected from the Caring for the Caregiver Network study. Participants' level of self-efficacy, depression, burden, and positive aspects of caregiving was assessed using validated measures. RESULTS: Two self-efficacy subscales predicted caregiver depression, burden, and positive aspects of caregiving. Being White, a spouse, or having a larger social network predicted lower self-efficacy for obtaining respite. Higher income and lower preparedness predicted lower self-efficacy for controlling upsetting thoughts and responding to disruptive behaviors. Self-efficacy for controlling upsetting thoughts mediated the relationship between preparedness and depression along with the relationship between preparedness and burden. Race/ethnicity did not improve model fit. CONCLUSION: Self-efficacy plays an important role in caregiver outcomes. These findings indicate that strategies to improve caregiver self-efficacy should be an integral component of caregiver interventions.

Which Pain Treatment Goals Are Important to Community-Dwelling Older Adults?

OBJECTIVE: In this cross-sectional study of 237 older adults, we ascertained the importance of seven pain treatment goals and identified factors associated with their perceived importance. METHODS: Participants (mean age = 72 years) ranked each goal (e.g., pain reduction; finding a cure) on a 1 (not at all important) to 10 (extremely important) scale. We used general linear models to identify sociodemographic and pain factors independently associated with the perceived importance of each goal and repeated measures mixed models to examine their relative importance. RESULTS: The goal with the lowest adjusted score was "minimize harmful side effects from pain medications" with a mean (standard error [SE]) of 6.75 (0.239), while the highest ranked goals, "finding a cure," and "reducing my pain" had mean scores of 8.06 (0.237) and 7.89 (0.235), respectively. Pain reduction did not differ significantly from the average of the other 6 goals (P = .072) but was significantly different when compared with the goals of minimizing side effects (P < .0001) and finding a cause for the pain (P = .047), and different from the average of the five other goals excluding finding a cure (P = .021). We did not identify differences in the importance of the seven goals by gender or race/ethnicity. Age was inversely associated with the goals of minimizing harmful side effects and decreasing pain's effects on everyday activities. Pain reduction was rated more important than all other goals but finding a cure. CONCLUSIONS: Future research is needed to establish the benefits of eliciting treatment goals when delivering pain care to older adults.

Linking Persistent Pain and Frailty in Older Adults.

OBJECTIVE: In older adults, the impact of persistent pain goes beyond simple discomfort, often contributing to worsening functional outcomes and ultimately frailty. Frailty is a geriatric syndrome that, like persistent pain, increases in prevalence with age and is characterized by a decreased ability to adapt to common stressors such as acute illness, thereby increasing risk for multiple adverse health outcomes. Evidence supports a relationship between persistent pain and both the incidence and progression of frailty, independent of health, social, and lifestyle confounders. DESIGN AND SETTING: In this article, we synthesize recent evidence linking persistent pain and frailty in an effort to clarify the nature of the relationship between these two commonly occurring geriatric syndromes. SETTING: We propose an integration of the frailty phenotype model by considering the impact of persistent pain on vulnerability toward external stressors, which can ultimately contribute to frailty in older adults. RESULTS AND CONCLUSIONS: Incorporating persistent pain into the frailty construct can help us better understand frailty and ultimately improve care for patients with, as well as those at increased risk for, pain and frailty.

Do Decision Aids Benefit Patients with Chronic Musculoskeletal Pain? A Systematic Review.

OBJECTIVE: To review the effect of patient decision aids for adults making treatment decisions regarding the management of chronic musculoskeletal pain. METHODS: We performed a systematic review of randomized controlled trials of adults using patient decision aids to make treatment decisions for chronic musculoskeletal pain in the outpatient setting. RESULTS: Of 477 records screened, 17 met the inclusion criteria. Chronic musculoskeletal pain conditions included osteoarthritis of the hip, knee, or trapeziometacarpal joint and back pain. Thirteen studies evaluated the use of a decision aid for deciding between surgical and nonsurgical management. The remaining four studies evaluated decision aids for nonsurgical treatment options. Outcomes included decision quality, pain, function, and surgery utilization. The effects of decision aids on decision-making outcomes were mixed. Comparing decision aids with usual care, all five studies that examined knowledge scores found improvement in patient knowledge. None of the four studies that evaluated satisfaction with the decision-making process found a difference with use of a decision aid. There was limited and inconsistent data on other decision-related outcomes. Of the eight studies that evaluated surgery utilization, seven found no difference in surgery rates with use of a decision aid. Five studies made comparisons between different types of decision aids, and there was no clearly superior format. CONCLUSIONS: Decision aids may improve patients' knowledge about treatment options for chronic musculoskeletal pain but largely did not impact other outcomes. Future efforts should focus on improving the effectiveness of decision aids and incorporating nonpharmacologic and nonsurgical management options.

Mobile health technology and home hospice care: promise and pitfalls.

With the increasing use of mobile devices (e.g., smart phones, tablets) in our everyday lives, people have the ability to communicate and share information faster than ever before. This has led to the development of promising applications aimed at improving health and healthcare delivery for those with limited access. Hospice care, which is commonly provided at home, may particularly benefit from the use of this technology platform. This commentary outlines several potential benefits and pitfalls of incorporating mobile health (mHealth) applications into existing home hospice care while highlighting some of the relevant telemedicine work being done in the palliative and End-of-Life care fields.

The Impact of Older Parents' Pain Symptoms on Adult Children.

OBJECTIVE: Not only is persistent pain a debilitating health problem for older adults, it also may have negative effects on family relationships. Studies have documented the effects of pain on spouses and on parents of young children. However, research has not extended this line of inquiry to later life, and specifically to the impact of older parents' pain symptoms on adult children. This study addresses the question: Does older mothers' pain affect the quality of relations with offspring? SUBJECTS AND DESIGN: Using data from a survey of 678 adult children of older mothers, this article presents two analyses examining the impact of mothers' self-reported pain on emotional closeness and on tension in the adult child-parent relationship. RESULTS: Contrary to research conducted on younger families, multilevel models showed no effects on emotional closeness or tension in relationships with adult children when mothers experienced higher levels of persistent pain. This surprising finding suggests that mechanisms may exist that protect adult child caregivers from stressors that result from a relative's chronic pain. CONCLUSIONS: Based on the findings of this article, further exploration of the impact of chronic pain on relations between adult children and their parents is justified. Of interest is exploration of factors that may insulate later-life intergenerational relationships from the effects of pain.

Is geographic variation within species related to macroevolutionary patterns between species?

The relationship between microevolution and macroevolution is a central topic in evolutionary biology. An aspect of this relationship that remains very poorly studied in modern evolutionary biology is the relationship between within-species geographic variation and among-species patterns of trait variation. Here, we tested the relationship between climate and morphology among and within species in the salamander genus Plethodon. We focus on a discrete colour polymorphism (presence and absence of a red dorsal stripe) that appears to be related to climatic distributions in a common, wide-ranging species (Plethodon cinereus). We find that this trait has been variable among (and possibly within) species for >40 million years. Furthermore, we find a strong relationship among species between climatic variation and within-species morph frequencies. These between-species patterns are similar (but not identical) to those in the broadly distributed Plethodon cinereus. Surprisingly, there are no significant climate-morphology relationships within most other polymorphic species, despite the strong between-species patterns. Overall, our study provides an initial exploration of how within-species geographic variation and large-scale macroevolutionary patterns of trait variation may be related.

Practice-Based Research Priorities for Palliative Care: Results From a Research-to-Practice Consensus Workshop.

We employed the research-to-practice consensus workshop (RTP; workshops held in New York City and Tompkins County, New York, in 2013) model to merge researcher and practitioner views of translational research priorities in palliative care. In the RTP approach, a diverse group of frontline providers generates a research agenda for palliative care in collaboration with researchers. We have presented the major workshop recommendations and contrasted the practice-based research priorities with those of previous consensus efforts. We uncovered notable differences and found that the RTP model can produce unique insights into research priorities. Integrating practitioner-identified needs into research priorities for palliative care can contribute to addressing palliative care more effectively as a public health issue.

Identifying Key Priorities for Future Palliative Care Research Using an Innovative Analytic Approach.

Using an innovative approach, we identified research priorities in palliative care to guide future research initiatives. We searched 7 databases (2005-2012) for review articles published on the topics of palliative and hospice-end-of-life care. The identified research recommendations (n = 648) fell into 2 distinct categories: (1) ways to improve methodological approaches and (2) specific topic areas in need of future study. The most commonly cited priority within the theme of methodological approaches was the need for enhanced rigor. Specific topics in need of future study included perspectives and needs of patients, relatives, and providers; underrepresented populations; decision-making; cost-effectiveness; provider education; spirituality; service use; and interdisciplinary approaches to delivering palliative care. This review underscores the need for additional research on specific topics and methodologically rigorous research to inform health policy and practice.

Integration of geriatric mental health screening into a primary care practice: a patient satisfaction survey.

OBJECTIVE: Colocation of mental health screening, assessment, and treatment in primary care reduces stigma, improves access, and increases coordination of care between mental health and primary care providers. However, little information exists regarding older adults' attitudes about screening for mental health problems in primary care. The objective of this study was to evaluate older primary care patients' acceptance of and satisfaction with screening for depression and anxiety. METHODS: The study was conducted at an urban, academically affiliated primary care practice serving older adults. Study patients (N = 107) were screened for depression/anxiety and underwent a post-screening survey/interview to assess their reactions to the screening experience. RESULTS: Most patients (88.6%) found the length of the screening to be "just right." A majority found the screening questions somewhat or very acceptable (73.4%) and not at all difficult (81.9%). Most participants did not find the questions stressful (84.9%) or intrusive (91.5%); and a majority were not at all embarrassed (93.4%), upset (93.4%), or uncomfortable (88.8%) during the screening process. When asked about frequency of screening, most patients (72.4%) desired screening for depression/anxiety yearly or more. Of the 79 patients who had spoken with their physicians about mental health during the visit, 89.8% reported that it was easy or very easy to talk with their physicians about depression/anxiety. Multivariate results showed that patients with higher anxiety had a lower positive reaction to the screen when controlling for gender, age, and patient-physician communication. CONCLUSIONS: These results demonstrate strong patient support for depression and anxiety screening in primary care.

Assessing the feasibility, acceptability, and preliminary efficacy of a novel symptom management care delivery intervention for caregivers receiving home hospice care: The I-HoME protocol.

BACKGROUND: Terminally ill patients experience high symptom burden at the end of life (EoL), even when receiving hospice care. In the U.S., family caregivers play a critical role in managing symptoms experienced by patients receiving home hospice services. Yet, most caregivers don't receive sufficient support or formal training in symptom management. Therefore, providing additional visits and education to caregivers could potentially improve outcomes for both patient and caregiver. In response, we developed the Improving Home hospice Management of End-of-life issues through technology (I-HoME) intervention, a program designed for family caregivers of home hospice patients. This paper describes the intervention, study design, and protocol used to evaluate the intervention. METHODS: The I-HoME study is a pilot randomized controlled trial aimed at reducing patient symptom burden through weekly tele-visits and education videos to benefit the patient's family caregiver. One hundred caregivers will be randomized to hospice care with (n = 50) or without (n = 50) the I-HoME intervention. Primary outcomes include intervention feasibility (e.g., accrual, attrition, use of the intervention) and acceptability (e.g., caregivers' comfort accessing the tele-visits and satisfaction). We will also examine preliminary efficacy using validated patient symptom burden and caregiver outcome measures (i.e., burden, depression, anxiety, satisfaction). CONCLUSION: The trial is evaluating a novel symptom management intervention that supports caregivers of patients receiving home hospice services. The intervention employs a multi-pronged approach that provides needed services at a time when close contact and support is crucial. This research could lead to advances in how care gets delivered in the home hospice setting.

Association of Baseline Frailty with Patient-Reported Outcomes in Systemic Lupus Erythematosus at 1 Year.

The relationship of baseline frailty with subsequent patient-reported outcomes in systemic lupus erythematosus (SLE) remains unclear. We assessed these associations in a pilot prospective cohort study. Frailty based on the FRAIL scale and the Fried phenotype and patient-reported outcomes, namely Patient Reported Outcomes Measurement Information System computerized adaptive tests and Valued Life Activities disability, were measured at baseline and 1 year among women aged 18-70 years with SLE enrolled at a single center. Differences in Patient Reported Outcomes Measurement Information System computerized adaptive tests between frail and non-frail participants were evaluated using Wilcoxon rank sum tests, and the association of baseline frailty with self-report disability at 1 year was estimated using linear regression. Of 51 participants, 24% (FRAIL scale) and 16% (Fried phenotype) met criteria for frailty at baseline despite median age of 55.0 and 56.0 years, respectively. Women with (versus without) baseline frailty using either measure had worse 1-year Patient Reported Outcomes Measurement Information System computerized adaptive test scores across multiple domains and greater self-report disability. Baseline frailty was significantly associated with self-report disability at 1 year (FRAIL scale: parameter estimate 0.55, 95% confidence interval (CI) 0.21-0.89, p<0.01; Fried phenotype: parameter estimate 0.61, 95% CI 0.22-1.00, p<0.01), including only slight attenuation after adjustment for SLE cumulative organ damage (FRAIL scale: parameter estimate 0.45, 95% CI 0.09-0.81, p=0.02; Fried phenotype: parameter estimate 0.49, 95% CI 0.09-0.90, p=0.02). These preliminary findings support frailty as an independent risk factor for clinically relevant patient-reported outcomes, including disability onset, among women with SLE.

Hospice Composition Based on Diagnosis is Associated with Caregiver-Reported Quality Measures.

Context: Given that the composition of hospice patients' terminal diagnoses has become increasingly diverse, understanding whether hospices provide quality care to patients, regardless of disease, is important. However, data comparing diagnosis and caregiver-reported outcomes remain scarce. Objectives: To analyze the association between the composition of patients' terminal diagnoses and caregiver-reported quality measures. Methods: Using cross-sectional, publicly available data from the Centers for Medicare & Medicare Services (CMS), we analyzed data collected from 2015-2019. We conducted general linear model analyses to identify associations between hospice characteristics/practices and caregiver-reported outcomes. Results: Of the 2810 hospices, those that cared for a greater percentage of dementia patients had fewer caregivers, on average, who rated hospice a 9 or 10 (where 0 = low, 10 = high; ß = -.094; 95% CI = -.147, -.038), reported they always received help for pain and symptoms (ß = -.106, CI = -.156, -.056), and reported definitely having received the training they needed (ß = -.151, CI = -.207, -.095). Those caring for more stroke patients had fewer caregivers, on average, who rated hospice a 9 or 10 (ß = -.184, CI = .252, -.115), reported they always received help for pain and symptoms (ß = -.188, CI = -.251, -.126), reported definitely having received the training they needed (ß = -.254, CI = -.324, -.184), and reported that the hospice offered the right amount of emotional/spiritual support (ß = -.056, CI = -.093, -.019). Conclusion: Hospices that cared for a greater proportion of dementia and stroke patients had poorer scores on caregiver-reported quality measures. These findings support efforts to identify mechanisms underlying these differences and to design strategies to ensure optimal outcomes for hospice patients regardless of diagnosis.

A comparison of the arthritis foundation self-help program across three race/ethnicity groups.

OBJECTIVE: Despite high prevalence rates of pain among older adults, relatively few studies have examined the impact of the Arthritis Foundation Self-Help Program (ASHP) in this age group, particularly older minority groups. DESIGN: This study compared the effects of the ASHP on groups of Hispanic, African American and non-Hispanic White older adults. SETTING: Three senior centers in New York City. PARTICIPANTS: Data are presented for 112 (37 African American, 38 Hispanic and 37 non-Hispanic White) participants (mean age= 75 years) age 60 and over with diverse noncancer pain disorders. INTERVENTION: Participants enrolled in the 6-week Arthritis Self Help Course. MAIN OUTCOME MEASURES: Participants were surveyed before and after course completion (in person) and at 18 weeks (by telephone). Demographic and clinical data were collected at baseline; outcomes included pain, mood, self-efficacy, and number of days per week spent exercising. RESULTS: All three groups experienced significant decreases in pain intensity (P< or =.05). Significant improvements were also found in mood scores for non-Hispanic White (P=.01) and Hispanic participants (P=.03). Hispanic participants also evidenced significant improvement in their confidence to self-manage pain (P=.003) and reported fewer arthritis-related symptoms (P=.02). All three race/ethnicity groups reported substantial increases in the number of days spent doing stretching, endurance and relaxation exercises (P< or =.01). CONCLUSION: Positive results were noted for all three race/ethnicity groups, particularly in the areas of pain reduction and uptake of stretching, endurance and relaxation exercises. Our findings support efforts to disseminate broadly the ASHP in community settings that serve older African American, Hispanic and non-Hispanic white adults.

Preparing to implement a self-management program for back pain in new york city senior centers: what do prospective consumers think?

OBJECTIVE: Prior to testing the feasibility/potential efficacy of a newly developed self-management pain program for seniors with back pain, this study sought to: 1) determine prospective consumers' prior exposure to self-management pain programs, 2) determine their willingness to participate in the new program, and 3) ascertain perceived barriers/facilitators to program participation. DESIGN: Cross-sectional survey. SETTING: Six senior centers located in New York City. PARTICIPANTS: We enrolled a race/ethnicity stratified (African American, Hispanic, or non-Hispanic White) sample of 90 subjects who were ages 60 years or older and had chronic back pain. RESULTS: While 60% of non-Hispanic Whites reported prior participation in a self-management pain program, fewer Hispanic (23%) and African Americans (20%) participants reported prior participation. Most participants (80%) were strongly willing to participate in the new program. Multivariate analyses revealed that only pain intensity had a trend toward significance (P = 0.07), with higher pain scores associated with greater willingness to participate. Few barriers to participation were identified, however, respondents felt that tailoring the course to best meet the needs of those with physical disabilities, providing flexibility in class timing, and informing individuals about program benefits prior to enrollment could help maximize program reach. No race/ethnicity differences were identified with respect to willingness to participate or program participation barriers. CONCLUSIONS: These data support efforts to disseminate self-management pain programs in older populations, particularly minority communities. The recommendations made by participants can help to guide implementation efforts of the newly developed pain program and may help to enhance both their reach and success.

Caregiver-Reported Quality Measures and Their Correlates in Home Hospice Care.

Background: A majority of hospice care is delivered at home, with significant caregiver involvement. Identifying factors associated with caregiver-reported quality measures could help improve hospice care in the United States. Objectives: To identify correlates of caregiver-reported quality measures: burden, satisfaction, and quality of end-of-life (EoL) care in home hospice care. Design: A cross-sectional study was conducted from April 2017 through February 2018. Setting/Subjects: A nonprofit, urban hospice organization. We recruited caregivers whose patients were discharged from home hospice care. Eligible caregiver participants had to be 18 years or older, English-speaking, and listed as a primary caregiver at the time the patient was admitted to hospice. Measures: The (1) short version of the Burden Scale for Family Caregivers; (2) Family Satisfaction with Care; and (3) Caregiver Evaluation of the Quality of End-Of-Life Care. Results: Caregivers (n = 391) had a mean age of 59 years and most were female (n = 297, 76.0%), children of the patient (n = 233, 59.7%), and non-Hispanic White (n = 180, 46.0%). The mean age of home hospice patients was 83 years; a majority had a non-cancer diagnosis (n = 235, 60.1%), were female (n = 250, 63.9%), and were non-Hispanic White (n = 210, 53.7%). Higher symptom scores were significantly associated with greater caregiver burden and lower satisfaction with care; but not lower quality of EoL care. Caregivers who were less comfortable managing patient symptoms during the last week on hospice had higher caregiver burden, lower caregiver satisfaction, and lower ratings of quality of EoL care. Conclusion: Potentially modifiable symptom-related variables were correlated with caregiver-reported quality measures. Our study reinforces the important relationship between the perceived suffering/symptoms of patients and caregivers' hospice experiences.

The association of sexual trauma with persistent pain in a sample of women veterans receiving primary care.

BACKGROUND: Women veterans report high rates of persistent pain and high rates of sexual trauma. We sought to determine whether the presence and intensity of persistent pain, as well as level of pain-related interference, in the VA Connecticut Women's Clinic population was positively associated with reports of sexual trauma. METHODS: Women presenting for routine appointments at the VA Connecticut Women's Health Center were recruited for study. Participants (N = 213) provided detailed information about their demographic, psychosocial, clinical, pain, and sexual trauma status. Bivariate and multivariate analyses were conducted to determine whether a report of sexual trauma was independently associated with the presence of pain, and levels of pain intensity and pain-related interference. RESULTS: A substantial majority (78%) reported an ongoing pain problem, whereas the prevalence of any reported sexual trauma was 36%. In bivariate analysis, persistent pain was associated with a greater number of chronic conditions (P < 0.01), depression symptom severity (P < 0.05), a history of military sexual harassment (P < 0.05), and military forced sex (P < 0.05). In a multivariate logistic regression analysis, persistent pain was independently associated with having at least two (OR 3.32, 95% CI 1.11, 9.90), or three or more chronic conditions (OR 7.56, 95% CI 2.34, 24.4) and depressive symptom severity score (OR 1.10, 95% CI 1.02, 1.19), but was not associated with sexual trauma (OR 1.70, 95% CI 0.66, 4.42). In multivariate linear regression analyses that included only those who reported pain at the time of the assessment, white race (P < 0.05) and sexual trauma histories (P < 0.05) were significantly associated with level of pain intensity, whereas being married (P < 0.01) was negatively associated with pain intensity. Depressive symptom score (P < 0.001) and sexual trauma (P < 0.05) were also significantly associated with level of pain interference. CONCLUSIONS: Reported sexual trauma is prevalent and while not independently associated with the presence of pain among women veterans in our study, for those who have pain, it is associated with greater pain intensity and pain-related interference.

Palliative Care Gaps in Providing Psychological Treatment: A Review of the Current State of Research in Multidisciplinary Palliative Care.

BACKGROUND: Patients with advanced illness often have high rates of psychological symptoms. Many multicomponent palliative care intervention studies have investigated the efficacy of overall symptom reduction; however, little research has focused explicitly on how interventions address psychological symptoms associated with serious illness. METHODS: The current study reviewed 59 multicomponent palliative care intervention articles and analyzed the mental health components of palliative care interventions and their outcomes in order to better understand the current state of psychological care in palliative care. RESULTS: The majority of articles (69.5%) did not provide any details regarding the psychological component delivered as part of the palliative care intervention. Most (54.2%) studies did not specify which provider on the team was responsible for providing the psychological intervention. Studies varied regarding the type of outcome measure utilized; multi-symptom assessment scales were used in 54.2% of studies, mental health scales were employed in 25.4%, quality of life and distress scales were used in 16.9%, and no psychological scales were reported in 28.8%. Fewer than half the studies (42.4%) documented a change in a psychological outcome. DISCUSSION AND CONCLUSION: The majority of analyzed studies failed to describe how psychological symptoms were identified and treated, which discipline on the team provided the treatment, and whether psychological symptoms improved as a result of the intervention. Future research evaluating the effects of palliative care interventions on psychological symptoms will benefit from using reliable and valid psychological outcome measures and providing specificity regarding the psychological components of the intervention and who provides it.

Examining the Role of Primary Care Physicians and Challenges Faced When Their Patients Transition to Home Hospice Care.

BACKGROUND: The transition into home hospice care is often a critical time in a patient's medical care. Studies have shown patients and caregivers desire continuity with their physicians at the end of life (EoL). However, it is unclear what roles primary care physicians (PCPs) play and what challenges they face caring for patients transitioning into home hospice care. OBJECTIVES: To understand PCPs' experiences, challenges, and preferences when their patients transition to home hospice care. DESIGN: Nineteen semi-structured phone interviews with PCPs were conducted. Study data were analyzed using standard qualitative methods. PARTICIPANTS: Participants included PCPs from 3 academic group practices in New York City. Measured: Physician recordings were transcribed and analyzed using content analysis. RESULTS: Most PCPs noted that there was a discrepancy between their actual role and ideal role when their patients transitioned to home hospice care. Primary care physicians expressed a desire to maintain continuity, provide psychosocial support, and collaborate actively with the hospice team. Better establishment of roles, more frequent communication with the hospice team, and use of technology to communicate with patients were mentioned as possible ways to help PCPs achieve their ideal role caring for their patients receiving home hospice care. CONCLUSIONS: Primary care physicians expressed varying degrees of involvement during a patient's transition to home hospice care, but many desired to be more involved in their patient's care. As with patients, physicians desire to maintain continuity with their patients at the EoL and solutions to improve communication between PCPs, hospice providers, and patients need to be explored.