Ronald S. Schonwetter

Predictors of depression and life satisfaction among spousal caregivers in hospice: application of a stress process model.

Using a stress process model, risk factors (caregiving stressors, caregiver health, and negative social interactions) and protective factors (caregiving appraisals and social resources) were examined as predictors of family caregiver well-being (depression and life satisfaction). Eighty spousal caregivers of hospice patients with dementia or lung cancer completed structured interviews and self-report measures assessing components of the stress process model. Results suggest that objective measures of patient impairment or amount of care provided are not strong predictors of caregiver depression or life satisfaction. Female gender, caregiver health problems, and negative social interactions were risk factors for poorer caregiver well-being. Caregivers who subjectively appraised caregiving tasks as less stressful, who found meaning and subjective benefits from caregiving, and with more social resources had lower depression and higher life satisfaction, even after controlling for patient impairment and caregiver appraisal variables. Regression models accounted for 42% of variance in caregiver depression and 52% of variance in caregiver life satisfaction. Counseling for hospice family caregivers could utilize the stress process framework, and pay particular attention to finding meaning or subjective benefits from caregiving, and remaining active in social roles. Further research providing evidence on caregiver risk and protective factors could improve the conceptual and empirical basis for psychosocial interventions for hospice family caregivers.

Family caregiving in hospice: effects on psychological and health functioning among spousal caregivers of hospice patients with lung cancer or dementia.

ABSTRACT Introduction: Caregiving stress has been found to lead to depression and poor health among caregivers compared with age-matched non-caregiving controls. However, most of these studies have focused on dementia caregivers, and have not included hospice caregivers. The aim of this project was to assess the impact of caregiving stress on psychological and health functioning among spousal caregivers of hospice patients, in contrast to demographically matched non-caregiving controls. A secondary aim was to compare the caregiving stressors and psychological and health functioning between spousal caregivers of hospice patients with dementia versus lung cancer. Methods: Forty spousal caregivers of hospice patients with dementia, and 40 spousal caregivers of hospice patients with lung cancer, were compared on admission to hospice, using measures of caregiving stressors, depression, life satisfaction, and physical health, with a sample of 40 demographically equated control subjects. Results: Both groups of caregivers showed higher depression, lower life satisfaction and poorer physical health (p < .05) compared with non-caregivers. Over half of all caregivers evidenced clinically significant levels of depression, with rates of depression about three times the prevalence found in community samples of older adults. Conclusions: While family caregivers of hospice patients with dementia and lung cancer face very different objective stressors, the negative psychological and health impacts on the caregiver are marked and comparable across diagnosis. Hospice family caregivers are at high risk for both psychological and physical health disorders, and caregiver depression and health problems should be systematically assessed and treated by the hospice team. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: Website:

Resuscitation decision making in the elderly: the value of outcome data

Objective: To assess the relationship between cardiopulmonary resuscitation (CPR) information and desire for CPR in an elderly population and to determine the influence of outcome data on desire for CPR in older persons.Design: An interventional study utilizing an educational program.Setting: Elderly independent retirement community.Participants: One hundred two persons, all more than 62 years old, who were neither demented nor depressed.Intervention: Participants received an educational intervention consisting of descriptive CPR information and quantitative information about CPR outcomes. CPR information, survival estimates, and preferences were recorded prior to and after the intervention.Measurements and main results: Subjects exhibited a high level of basic knowledge about CPR, which did not change with the intervention. While subjects consistently overestimated their chances of survival post CPR, these estimates decreased toward more realistic levels after the intervention (p<0.001). CPR preferences changed in three of five hypothetical clinical scenarios after the intervention (p<0.05). Those who were more realistic in their estimates of CPR survival desired less CPR in the hypothetical scenarios (p<0.01). A trend in our data suggests that quantitative outcome information may have a greater influence on CPR preferences than has descriptive information (p=0.07).Conclusions: CPR preferences changed after an educational intervention. An improved understanding of quantitative outcome data appears to influence the desire for CPR and therefore should be included in CPR discussions with older patients.

Predictors of six-month survival among patients with dementia: an evaluation of hospice Medicare guidelines.

The goal of the present study was to assess the validity of the Medicare hospice eligibility guidelines for dementia patients, as well as identify predictors that could more accurately identify prognosis in dementia patients referred to hospice. A retrospective chart review was conducted, including initial assessment and longitudinal follow-up of patients until the time of death. In addition, a second validation cohort was also followed. Participants consisted of 245 patients admitted to a large community-based hospice with a diagnosis of dementia, including a validation sample of 80 patients. The Kaplan-Meier estimation of survival and a Cox regression analysis (p > 0.05) revealed no significant relationship between the Medicare guidelines or any component of the guidelines and survival at six months for the initial and validation samples. Significant multivariate predictors of shorter survival in both the initial and validation sample include greater age (p = 0.02) and anorexia (p < 0.001), as well as a combination of anorexia and greater functional impairment (p = 0.005). Overall, the results indicated that the Medicare guidelines were not valid predictors of survival in hospice patients with dementia and should be altered to include empirically valid predictors. Advanced age, as well as impaired nutritional and functional status, was associated with shortened survival in these patients. The predictor variables identified are an initial step toward providing improved prognoses for advanced dementia patients, their families, and practitioners. Broader issues in improving access to hospice care for dementia patients are discussed.

Decisions for Hospice Care in Patients with Advanced Cancer

OBJECTIVES: To identify factors that may influence the decision of whether to enter a hospice program or to continue with a traditional hospital approach in patients with advanced cancer and to understand their decision‐making process.

Estimation of survival time in terminal cancer patients: an impedance to hospice admissions?

Accurate estimation of survival time in terminal cancer patients is difficult yet may provide useful information. A historical prospective study on 172 patients admitted to a home based hospice service was performed to determine which variables were best correlated with survival time. Mean and median survival were 48 and 22 days, respectively, representing a highly skewed distribution of life span in this sample. As age increased, survival time decreased. All Activities of Daily Living (ADLs) recorded (Bathing, Continence, Dressing and Transfer) as well as other measures of performance (mobility and pulse) and nutrition (appetite and nourishment) were each strongly associated with survival. Multivariate analysis limited significant variables to dressing ability, pulse rate, level of appetite and transferring ability. Outliers (survival greater than 180 days) were differentiated from the remainder of the sample by significant differences in all ADLs recorded as well as the level of appetite. These findings establish the importance of assessing ADLs, a measure of functional status, and reinforce the importance of performance and nutrition measures when estimating length of survival in terminal cancer patients.

Predictors of well-being in bereaved former hospice caregivers: The role of caregiving stressors, appraisals, and social resources

OBJECTIVE The current literature on caregiving and bereavement indicates that the relationship between these two common life events is complex and needs to be further studied in order to gain a more comprehensive understanding of their interaction. METHODS In the current project, 50 spouses of hospice patients with end-stage lung cancer or dementia were assessed while caregiving and at an average of 4 months after the death on a variety of measures, including caregiving stressors, appraisals, social resources, and well-being. A stress process model was utilized in order to examine which preloss factors were associated with postloss depression, life satisfaction, and grief. RESULTS Our results indicated that patient diagnosis (cancer or dementia) and caregiver appraisals (stressfulness of functional impairment and positive aspects of caregiving) were not predictors on any of our well-being outcomes. However, fewer months caregiving was a significant predictor of both higher depression and grief postloss. Additionally, lower levels of social activities, smaller social networks, and lower satisfaction with social support were significantly associated with higher postloss depression. SIGNIFICANCE OF RESULTS Results support both the resource depletion and anticipatory grief hypotheses and suggest that short-term bereavement outcomes are different than factors that predict well-being while caregiving. Future studies should address whether long-term bereavement outcomes differ by baseline caregiving characteristics to guide intervention research.

Life Values, Resuscitation Preferences, and the Applicability of Living Wills in an Older Population

OBJECTIVES: To determine whether life values are related to resuscitation preferences and living will completion in an older population and to assess beliefs about the applicability of living wills.

Prognostic factors for survival in terminal lung cancer patients

AbstractObjective: To determine the factors that are related to short-term survival and to develop a model that can be used to estimate prognosis in terminal lung cancer patients. Design: Longitudinal cohort study of hospice lung cancer patients followed from date of admission to hospice until death. Setting: Community-based nonprofit home hospice service. Patients: Three hundred ten consecutive lung cancer patients admitted to hospice, with a separate validation sample of 78 consecutive hospice lung cancer patients. Measurements: The relationships between survival and admission demographic characteristics, information from the history and physical examination, assessments of performance and nutrition, particular symptoms, and the presence of a living will were evaluated. Results: Mean survival was 51 days, with a median survival of 27 days. Shorter survival was independently associated with those who had no living will on admission to hospice (p=0.008), those who had tissue types other than squamous cell or adenocarcinoma (p=0.008), those who had liver metastases (p=0.04), those who were tachycardic (p<0.001), those who required assistance or were dependent in their toileting (p<0.001) and feeding (p=0.001), those who had dry mouths (p=0.01), and those who had severe or incapacitating pain (p<0.05). A model estimating survival time based on the number of these significant variables present is reported (r=0.53 in the original sample; r=0.38 in the validation sample). Conclusions: Multiple factors, including tissue type, the presence of metastases, assessments of functional status, specific symptoms, and the presence of a living will, were related to short-term survival in terminal lung cancer patients admitted to hospice. A model utilizing these specific factors allows useful estimates of short-term survival for these patients.

Educational objectives for medical training in the care of the terminally ill

BACKGROUND. Palliative medicine is developing as a distinct clinical discipline worldwide. The U.S. literature describes goals for education in palliative medicine, yet this literature lacks validated educational objectives. METHOD. To develop and validate appropriate educational objectives for medical training in the care of the terminally ill, 200 randomly selected members of the Academy of Hospice Physicians were asked in 1992 to evaluate 39 educational objectives by an item-objective congruence procedure. Each objective was rated as −1 (inappropriate), 0 (unsure), or 1 (appropriate). RESULTS. Of the 200 members surveyed, 127 (64%) responded. Of the 39 objectives, 34 were considered valid, with a mean score of > or = .8. The index of content validity was .87. The objectives not considered valid all dealt with nonmedical issues related to hospice or palliative care. CONCLUSION. This study validated 34 educational objectives for medical training in the care of the terminally ill. Training programs using these objectives, amended for specific audiences, should be included in the various levels of U.S. medical education.