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these patients, the indications for fentanyl use,the transmucosal route used for fentanyl admin-istration, the dose of fentanyl given, the fre-quency of use, and the effectiveness of themedication in managing symptoms.Methods/session descriptions. Informationabout the logistical issues encountered in imple-menting this practice will be highlighted. Theseincluded establishing a guideline for the avail-ability of the medication, the use of an atomizerin nasal medication delivery, and supportingstaff in this approach to managing symptomsin neonates at end of life.Conclusion. This session/poster will present thefindings of a retrospective chart review on theuse and effectiveness of intranasal fentanyl inpalliative symptom management of newbornsand infants. Practitioners in perinatal and pedi-atric palliative care will gain an understandingof how this novel approach can be implementedin their practice.

DomainPhysical Aspects of Care

Barriers to Hospice Admission: Resultsof a National Survey (417-A)Melissa Carlson, PhD MBA, Mount Sinai Schoolof Medicine, New York, NY. Elizabeth Bradley,PhD, Yale University, New Haven, CT.(All speakers for this session have disclosed norelevant financial relationships.)

Objectives1. Discuss potential barriers to hospice admission.2. Recognize hospice characteristics associated

with hospice admission practices.Background. There is mounting evidence thatfactors related to patients, physicians, and localmarkets are associated with hospice use. How-ever, there is no national data on the extent towhich hospice admission policies vary and maypresent barriers to hospice use.Research objectives. Determine the proportionof hospices that restrict admission to patientsbased on clinical, social, and financial criteriaand estimate the hospice characteristics (includ-ing size, years providing hospice care, chainmembership, ownership, and region) associatedwith hospice admission policies.Methods. We conducted a national survey of hos-pices (N ¼ 591; response rate 84%) regarding

their admissionpolicies.Weusedmultivariable lo-gistic regression to estimate the associations be-tween hospice characteristics and admissionpolicies.Results. Eighty-two percent of hospices reportedrestricting admission based on at least one crite-rion. Hospices reported not admitting patientswho wished to continue to receive palliative radi-ation (30%), who could not pay for hospice careeither through insurance or private pay (25%),and who lacked a caregiver (12%). Receipt ofcertain types of potentially high-cost medicalcare precluded admission including chemother-apy (61%), total parental nutrition (55%), trans-fusions (40%), intrathecal catheter (32%), andtube feedings (8%). Twenty-nine percent of hos-pices considered themselves to be ‘‘open access’’programs. In adjusted analyses, hospices thatwere larger were less likely to restrict admissionin each category measured and hospices thatwere larger, non-profit, and located in New En-gland were more likely to report being an‘‘open access’’ program.Conclusion. Patients who desire hospice but whoare receiving potentially high-cost medical care,lack a caregiver at home, or cannot pay for hos-pice may face significant barriers to hospiceenrollment due to the admission policies ofhospices.Implications for research, policy, or practice.Policies and payment mechanisms aimed at facil-itating the integration of hospice care with ongo-ing medical treatments may enable hospices tobroaden admission policies.

DomainStructure and Processes of Care

Determinants of Treatment Intensity in theLast 6 Months of Life: The Importanceof Patient Characteristics (417-B)Amy Kelley, MD MSHS, Mount Sinai School ofMedicine, New York, NY. Susan Ettner, PhD, Uni-versity of California Los Angeles, Los Angeles,CA. Sean Morrison, MD FAAHPM, Mount SinaiSchool of Medicine, New York, NY. QinglingDu, MS, Mount Sinai School of Medicine, NewYork, NY. Neil Wenger, MD, Universityof California Los Angeles, Los Angeles, CA.Catherine Sarkisian, MD MSHS, UCLA Schoolof Medicine, Los Angeles, CA.(All speakers for this session have disclosed norelevant financial relationships.)

Vol. 41 No. 1 January 2011 239Schedule with Abstracts

Objectives1. Recognize the wide variation in Medicare

expenditures in the last 6 months of life.2. Identify patient and region characteristics

that are associated with the variation.Background. Medical expenditures at the end oflife vary substantially and vastly exceed costs dur-ing other periods. Such spending is unsustain-able as the population ages.Research objectives. (1) Identify and examinepatient-level determinants of Medicare expendi-tures in the last 6 months of life. (2) Determinethe contribution of these factors to the overallvariation in expenditures while accounting forregional characteristics.Methods. Using longitudinal data from the na-tionally representative Health and RetirementStudy, Medicare claims, and the Dartmouth At-las of Health Care, we constructed regressionmodels to investigate the relationship betweentotal Medicare expenditures in the last 6 monthsof life and (1) patient characteristics, (2) re-gional characteristics, and (3) both patient andregional characteristics.Results. Several patient characteristics, includingdecline in functional status (rate ratio 1.64, p <0.001), Hispanic ethnicity (1.47, p < 0.001), Afri-can American race (1.45, p < 0.001), and chronicdisease such as diabetes (1.16, p< 0.001), are asso-ciated with higher Medicare expenditures. Avail-ability of a nearby relative (0.90, p ¼ 0.01) anddementia diagnosis (0.78, p < 0.001) were associ-ated with lower expenditures. Regional resources,includingmorehospitals bedsper capita (1.02, p<0.001), were associated with higher expenditures.Patient characteristics explained 12% of overallvariance and retained statistically significant rela-tionships with expenditures after controlling forregional characteristics.Conclusion. Patient characteristics, includingfunctional decline, race/ethnicity, chronic dis-ease, and nearby family, are important determi-nants of Medicare expenditures at the end oflife, independent of regional characteristics.Implications for research, policy, or practice.Further research is needed to determine whenand if high-cost, life-sustaining treatment is con-sistent with patient preferences or indicative ofinappropriate, poor quality medical care. Inter-ventions and policies designed to decrease inap-propriate expenditures and patient suffering atthe end of life must address both regional andpatient-centered sources of variation.

DomainAll domains

What Do They Want Now? ContactsBetween Hospice and Family in theLast Week of Life (417-C)Kathleen Van Veldhuisen, BSN RN CHPN,University of Wisconsin-Madison, Madison, WI.Karen Kehl, PhD RN ACHPN, University ofWisconsin-Madison, Madison, WI.(All speakers for this session have disclosed norelevant financial relationships.)

Objectives1. Identify three of the most frequently docu-

mented symptoms in the last week of life.2. Identify two outcomes of contacts between

hospice staff and patients’ families in thelast week of life.

Background. There is limited information pub-lishedabout the last weekof life in ahomehospice.Examining this period can yield much informa-tion that may improve care during the final days.Research objectives. The purpose of this studywas to describe the reasons and outcomes ofcontacts, and most frequent symptoms in thelast week of life.Methods. This descriptive study used six monthsof records provided by a Midwest hospice. Re-cords from patients who resided in their home,did not receive crisis care, and died between Jan-uary 2008 and June 2008 were examined. Datawas extracted and reviewed by trained RNs.SPSS 16 was used for descriptive date analysis.Results. A review of 175 patient charts revealed2,204 contacts. The mean contacts per patientwas 12.59 (range 2e29). Most contacts were ini-tiated by the hospice staff (70.0%) or family(29.3%). The most frequent reasons include:symptom management (48.5%), emotional sup-port (24%), personal cares (21.2%), and death(13.7%). The most frequent outcomes were: in-struct family (40.65%), RN notified (20.8%),and medication change (7.8%). Symptoms wereaddressed in 62.6% of the contacts with themost frequent including: increased sleeping or fa-tigue (28.62% of those with symptoms docu-mented), incontinence (24.0%), pain (23.77%),breathing changes (21.2%), and coma (20.9%).Conclusion. This study reveals new informationabout what occurs during the last week of lifein hospice.