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end-of-life, hospice, long-term care, nursing home, palliative



  1. Tarzian, Anita J. PhD, RN
  2. Hoffmann, Diane E. JD, MS


This article reports on findings from a cross-sectional survey the authors conducted to identify perceived barriers to hospice referrals of nursing home residents. Respondents from 25 of 28 licensed Maryland hospices participated in a telephone survey, and respondents from 108 of 248 licensed Maryland nursing homes took part in a mail-in survey in 2001-2002. Nursing home and hospice respondents differed in their perceptions of the primary obstacles to nursing home referral to hospice. Nursing home respondents were more concerned about financial disincentives and difficulty determining hospice eligibility, whereas hospice respondents were more concerned with lack of knowledge about hospice and attitudes toward hospice and end-of-life care. In order to increase referrals to hospice, the following barriers must be addressed: hospice knowledge deficits and negative attitudes toward hospice among nursing home staff and residents/families, disparity between hospice and nursing home organizational cultures, financial disincentives to refer some nursing home residents to hospice, and ambiguity regarding Office of the Inspector General requirements for nursing home-hospice relationships.