Abstract
Context
Documentation of the emotional or psychological needs of seriously ill patients receiving specialty palliative care is endorsed by the “Measuring What Matters” project as a quality performance metric and recommended for use by hospice and palliative care programs for program improvement.
Objectives
The aim of this study was to increase the proportion of inpatient palliative care team encounters in which emotional or psychological needs of patients and family members were documented and to qualitatively enrich the nature of this documentation.
Methods
This is a mixed-methods retrospective study of 200 patient charts reviewed before and after implementation of a structured note template (SmartPhrase) for palliative care encounters. Patterns of documentation of emotional needs pre- and post-implementation were assessed quantitatively and qualitatively using thematic analysis.
Results
A total of 158 of 200 pre-intervention charts and 185 of 200 post-intervention charts included at least one note from the palliative care team. Documentation of emotional assessment increased after SmartPhrase implementation (63.9% [101 of 158] vs. 74.6% [138 of 185]; P < 0.03). Qualitative analysis revealed a post-intervention reduction in the use of generic phrases (“emotional support provided”) and an increase in the breadth and depth of emotion-related documentation.
Conclusion
A structured note template with a prompt for emotional assessment increases the overall quantity and richness of documentation related to patient and family emotions. However, this documentation remains mostly descriptive. Additional prompting for documentation of recommendations to address identified emotional needs, and the use of screening tools for depression and anxiety, when appropriate, may be necessary for clinically meaningful quality improvements in patient care.
Key Words
Introduction
The interdisciplinary palliative care team is expected to assess and address the physical, psychological, emotional, and spiritual needs of patients and their families to provide evidence-based care and to maximize patient and family coping and quality of life.
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Patients with serious illnesses nearing the end of life often experience high rates of not only physical distress but also emotional and spiritual distress.2
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Based on the goals of care, interventions may include assessing emotional and psychological needs, treating psychiatric diagnoses, and promoting emotional adjustment to the physical illness.6
The American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association have partnered on “Measuring What Matters” (MWM), a consensus recommendation of performance measures for all hospice and palliative care programs to use for program improvement.
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Adoption of these measures broadly in all palliative care programs would lay the foundation for benchmarking and making meaningful comparisons possible.6
MWM Performance Measure 5 relates to chart documentation of a discussion regarding emotional or psychological needs in seriously ill patients receiving specialty palliative care in an acute hospital setting of more than one day or more than seven days under hospice care.6
To our knowledge, there is no literature on current practice patterns in documentation of emotional or psychological needs or examining whether standardization of a documentation practice would improve quality.The objectives of our study were to 1) characterize baseline chart documentation practices by our palliative care team of inpatients' emotional or psychological needs, 2) determine the effect of an electronic medical record (EMR)-based structured note template with a reminder prompt for emotional assessment on chart documentation of patients' emotional or psychological needs. Structured note templates (referred to as SmartPhrases in the Epic system) can be created in most EMRs by designating a combination of keystrokes as a shortcut for entry of a preset phrase, sentence, or outline into a free text note; such outlines can include reminder prompts that guide the documenter to fill in relevant details.
Methods
Institutional Setting
The institution is an urban tertiary care Level 1 trauma teaching hospital. The palliative care team comprises two advanced practice nurses, both with national board certification as advanced certified hospice and palliative nurses, and two masters-level counselors, one with certification in Thanatology and the other a licensed professional counselor. The team works closely with the volunteer department and community chaplains. The team is present in the hospital Monday to Friday, 7:30 am to 6 pm, and is available by pager at all times. Patients and families are seen in all areas of the hospital including the emergency department, intensive care units, inpatient floors, and outpatient oncology. In 2014, the team had 1454 referrals (average 121 per month), provided 3782 visits on those referrals, and participated in 718 family meetings. Although the institution has physicians certified in hospice and palliative medicine, the physicians currently practice palliative medicine within their own primary specialty (e.g., pediatrics, emergency medicine, and surgery).
Improvement Process
We followed guidelines provided by the PEACE project (prepare, embrace, attend, communicate, empower) to collect baseline data.
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PEACE quality measures address domains of quality of care included in the National Consensus Project for Quality Palliative Care and are endorsed by the National Quality Forum.1
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PEACE materials were developed by a research team under contract to the Centers for Medicare and Medicaid Services. We used a five-step process for our quality improvement project:6
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, Organization Readiness Screen. PEACE project. Available at: http://www.med.unc.edu/pcare/files/organizational-readiness-screen. Accessed June 3, 2016.
12
, PEACE Project. Recommended quality measures and data collection, by domain. Available at: http://www.med.unc.edu/pcare/files/recommended-quality-measures-and-data-collection. Accessed June 3, 2016.
13
PEACE Project. Specifications for recommended quality measures. Available at: http://www.med.unc.edu/pcare/files/specifications-for-recommended-quality-measures. Accessed June 3, 2016.
- 1.Organizational readiness screen for standardization of care of psychological symptoms (Table 1).11,
Organization Readiness Screen. PEACE project. Available at: http://www.med.unc.edu/pcare/files/organizational-readiness-screen. Accessed June 3, 2016.
12,PEACE Project. Recommended quality measures and data collection, by domain. Available at: http://www.med.unc.edu/pcare/files/recommended-quality-measures-and-data-collection. Accessed June 3, 2016.
13PEACE Project. Specifications for recommended quality measures. Available at: http://www.med.unc.edu/pcare/files/specifications-for-recommended-quality-measures. Accessed June 3, 2016.
Table 1Standardization of Care for Psychological Symptoms: Organizational Readiness Screen11Organization Readiness Screen. PEACE project. Available at: http://www.med.unc.edu/pcare/files/organizational-readiness-screen. Accessed June 3, 2016.
Specified time frame to complete the initial screening for psychological symptoms No Specified person responsible for completing the initial screening for psychological symptoms No Specified instrument(s)/process(s) used to screen for psychological symptoms (recommended at a minimum for anxiety and depression) No Policy/process for identifying the level/severity that indicates the need for follow-up No Specified follow-up process for assessment and treatment for those who screen positive for psychological symptoms No Policy/process for modifying assessment when there are communication concerns (deafness, non-English, confusion, nonverbal) Yes (hospital policy) Policy/process indicating specific time frames(s) for reassessment after treatment to determine if the symptom improved No Policy/process indicating how often the psychological screening should be repeated No - 2.Informal review of a sample of charts to understand baseline processes and practices.
- 3.Discussion of team priorities to improve documentation of the emotional and psychological needs of patients (Table 2).Table 2SmartPhrase (.PC) Outline for Initial Palliative Care Assessment
Referred to Assist With: Patient/Family Narrative: Emotional Assessment: Spiritual Assessment: Symptoms: Pain Score (1–10): Dyspnea Score (1–10): Anxiety Depression Palliative Performance Scale: Advance Directive/Health Care Proxy Status: Summary/Goals: Recommendations: - 4.SmartPhrase implementation.
- 5.Retrospective chart review of emotional needs documentation before and after SmartPhrase implementation.
We reviewed informal preliminary data with the palliative care team and explored opportunities for clinical quality improvement. The team identified a standardized way to document the initial assessment of the patient as a priority and as a manageable step for themselves. They also identified that use of a structured note template could help standardize documentation practices. Of note, the team was aware of the existing SmartPhrase (.PC) that consisted of prompts for Narrative/Goals, Spiritual Assessment, Palliative Performance Scale, Symptoms, Assessment/Recommendation, and Advance Directive. However, this template was rarely used (not “meaningful” in practice). The .PC SmartPhrase was edited by team consensus to include: 1) a prompt to remind the team to document emotional and psychological assessment, 2) prompts to specifically identify anxiety/depression (Table 2). The revised SmartPhrase was endorsed by all team members and became available for clinical use (implementation) on July 1, 2015.
Data Collection and Analysis
We retrospectively reviewed 200 patient EMRs before (April to May 2015) and after (July to August 2015) the SmartPhrase implementation. Patients were identified from the palliative care team database that serves as a record of the consultations performed. For patients with multiple admissions during the time period, each hospital admission was considered to be a unique encounter.
We retrieved and recorded demographic data from the palliative care database and the EMR in Excel and imported it into SAS (SAS Institute, Inc., Cary, NC) for analysis. Descriptive statistics were obtained using frequency distributions for categorical variables and means (±SDs) for quantitative variables. P-values were obtained for count data using continuity-corrected Chi-squared analysis. An alpha level of 0.05 was used to determine statistical significance.
Results
Our baseline analysis revealed that a structured process existed for interpreter services but not for other aspects of the organizational readiness screen for standardization of care of psychological symptoms (Table 1).
Patient demographics before and after the SmartPhrase implementation (intervention) are presented in Table 3. Patients were seen by the palliative care team on average one week after admission to hospital, and most consultations were from the medicine service. The severity of illness in the patient cohort is reflected by the facts that ∼33% of patients had intensive care unit stays, and 15%–20% of patients died during the study period.
Table 3Patient Demographics and Characteristics Pre- and Post-SmartPhrase Implementation
| Category | Pre-intervention (Mean ± SD), n = 200 | Post-intervention (SmartPhrase) (Mean ± SD), n = 200 |
|---|---|---|
| Age (years) | 57.19 ± 19.02 | 55.51 ± 17.24 |
| Hospital admit to palliative team consult (days) | 6.07 ± 10.15 | 6.94 ± 10.68 |
| Hospital lengths of stay (days) | 10.99 ± 13.46 | 10.02 ± 11.08 |
| ICU lengths of stay (days) | 6.46 ± 5.76 | 8.30 ± 3.61 |
| Proportion (%) | Proportion (%) | |
| Gender | ||
| Men | 98/200 (49.0) | 116/200 (58.0) |
| Women | 102/200 (51.0) | 84/200 (42.0) |
| Race | ||
| Caucasian | 32/200 (16.0) | 36/199 (18.1) |
| Black/African American | 121/200 (60.5) | 114/199 (57.3) |
| Hispanic | 39/200 (19.5) | 45/199 (22.6) |
| Other | 8/200 (4.0) | 4/199 (2.0) |
| Referring service | ||
| Medicine, medicine subspecialty | 145/200 (72.5) | 149/200 (74.5) |
| Surgery, surgical subspecialty | 36/200 (18.0) | 35/200 (17.5) |
| Pediatrics | 5/200 (2.5) | 3/200 (1.5) |
| Other | 14/200 (7.0) | 13/200 (6.5) |
| Discharge disposition | ||
| Death | 42/174 (24.1) | 27/176 (15.3) |
| Home | 64/174 (36.8) | 86/176 (48.9) |
| Hospice (home and inpatient) | 22/174 (12.6) | 18/176 (10.2) |
| Long-term care, rehabilitation | 40/174 (23.0) | 37/176 (21.0) |
| Other | 6/174 (3.4) | 8/176 (4.5) |
| Social work consult | 111/194 (57.2) | 118/185 (63.8) |
| Bereavement services | 116/125 (92.8) | 100/111 (90.1) |
| Patients with ICU admission | 57/164 (34.8) | 55/174 (31.6) |
Numbers may vary because of missing data from palliative care database.
a Other referring services included emergency medicine, neurology, and obstetrics/gynecology.
Quantitative Data Analysis
Of the 200 pre-intervention EMRs reviewed, 158 had at least one note on the chart from the palliative care team. Charts with at least one palliative care team note were included for further analysis. On average, there were 1.93 ± 1.59 palliative care notes per admission. The preexisting SmartPhrase template was never used. Chaplain support and psychiatric evaluation was recommended rarely (15 of 158 and 5 of 158 patients, respectively). Emotional assessment was documented in at least one note for 101 of 158 (63.9%) patient encounters. For these 101 encounters, an average of 1.65 ± 1.05 notes per patient included documentation of emotion. If emotion was documented on a patient chart, this occurred mainly in the first note (93 of 101, 92%) by the palliative care team.
Of the 200 post-intervention records reviewed, 185 had at least one note from the palliative care team. Documentation regarding emotions was seen in 138 of 185 (74.6%) patient encounters. The SmartPhrase was used to document initial assessment in 116 of 185 (63%) encounters. The use of SmartPhrase, therefore, significantly increased the chart documentation of discussions of emotional needs (63.9% vs. 74.6%, P < 0.03).
In our institution's heart failure program, one member of the palliative care team is assigned to specifically address health proxy/advance directives with admitted patients. Excluding these dedicated, focused encounters by this team member (17 in the pre-intervention phase and 44 in the post-intervention phase), the rate of chart documentation of discussions of emotional needs for all other patients under care of the palliative care team was significantly higher after the SmartPhrase implementation (71.6% [101/141] vs. 97.8% [138/141], P < 0.0001).
Qualitative Data Analysis
Three authors (R.G., A.B., and S.L.) independently reviewed all notes by the palliative care team to identify categories and themes related to documentation of discussions regarding emotional and psychological needs. These were analyzed for pre- and post-intervention differences and were merged by author consensus into the following themes:
Generic Phrases Are Commonly Used to Document Discussions of Emotional and Psychological Needs
In the pre-intervention group, there were 87 mentions of the phrase “emotional support provided.” Often, this phrase was used alone with no other qualifiers. The use of this generic phrase decreased with SmartPhrase use (25 mentions), and meaningful narrative description of patient or family emotional needs increased. However, we noticed the appearance of the phrase “unable to assess” after SmartPhrase implementation, particularly in patients who were unable to communicate (e.g., who were on a ventilator).
Observations and Descriptions of Emotions Are More Commonly Documented Than Are Interventions to Address Emotional Needs
In contrast to descriptive statements, documentation of recommendations or specific interventions, such as “validation of his distress, fatigue, and suffering,” “administer anti-anxiety medication,” and “include therapy and psychiatric medication management as she is struggling with depression,” was infrequent.
There Exist Missed Opportunities for Documentation of Family Members' Emotional and Psychological Needs
Some encounters detailed grave and serious clinical scenarios without mention of the emotional reactions, needs, or suffering that one would expect to accompany the situation. For example, emotions were glaringly absent in the pre-implementation documentation of an interaction with the family of a patient who had suffered severe neurologic devastation from a stroke.
The Descriptive Terms Used to Document Emotions (Both Positive and Negative) Per Note Increased After SmartPhrase Use
The breadth and depth of descriptors used in documenting emotions and emotional assessments increased after implementation. Positive examples, such as “appeared pleasant and appreciative,” “grateful for a good life,” “expressed sincere appreciation,” “appeared calm, hopeful, moved beyond anger,” were especially common. Documentation of affect (e.g., “flat affect”) and “made good eye contact,” etc., were only noted in documentation using the SmartPhrase.
Discussion
We found that documentation of emotional and psychological needs, an essential care practice for interdisciplinary palliative care teams, is often missing, limited, and/or inconsistent. Use of a structured note template in the EMR to document an initial palliative care assessment is an effective systematic way to prompt clinicians to enter clinical data regarding emotional and psychological discussions and assessments. Importantly, we noted instances of glaring missed opportunities for documentation of the emotional needs of patients and families during the pre-intervention phase; this was remedied after implementation of the SmartPhrase.
Our level of stringency for assigning compliance with documentation of emotional needs (MWM Measure 5) was low.
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This is especially relevant for the pre-intervention emotional assessments in which the common generic phrase, “emotional support provided” would be compliant with the MWM Measure 5 performance metric despite the fact that this statement does not reflect an actual documentation/assessment of emotional “need.” The clinical value of documenting an emotional discussion stating “emotional support provided”—the most commonly documented phrase pre-intervention—is questionable. On the other hand, documenting that “the family's anger and frustration were validated, coping strategies were reviewed, and follow-up planned” provides some evidence of a high-quality intervention that is likely to provide clinical benefit. Statements like these were much more frequent post-intervention. Being that both these examples were scored as equally compliant with the performance metric despite the disparity in clinically meaningful contributions to the patient's care, our results may underestimate the true quality-mediating effect of SmartPhrase use.Our qualitative analysis demonstrated a post-intervention reduction in the use of generic phrases and an increase in the breadth and depth of documentation of emotional and psychological states and—by extension, needs—demonstrated by patients and family members. We believe that this greater depth correlates to some extent with improved substance and quality of care. Statements such as “recommendation made to team to administer anti-anxiety medication” are most likely to result in improved quality of care but were infrequently documented. More substantial improvements in quality would likely be achieved by documentation support tools that promote the leap from assessment to intervention. In other words, we argue that prompting the provider to move from a descriptive or observational stance in the encounter to an interventional stance in which evidence-based recommendations for next steps in treatment are made would foster more clinically meaningful improvements in patient and family care.
We also learned through this project that SmartPhrase generated outlines might better serve documentation needs if they were to clearly include both the family and the patient in the prompt. We found multiple instances in which the emotional assessment of intubated patients was documented as “unable to assess.” It is important to acknowledge that even when patients are unresponsive, patients and family must be treated as a unit, and the family may have emotional needs that should be addressed. We, therefore, suggest the use of “family and/or patient emotional assessment” prompt in the SmartPhrase to address this issue.
In addition, it is worth mentioning that we mainly targeted documentation of emotional and psychological needs in the “initial” palliative care assessment note, particularly in the intervention phase. However, as other programs look to improve documentation and overall care practice in this domain (MWM Measure 5), it may be useful to consider additional metrics.
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, Organization Readiness Screen. PEACE project. Available at: http://www.med.unc.edu/pcare/files/organizational-readiness-screen. Accessed June 3, 2016.
12
, PEACE Project. Recommended quality measures and data collection, by domain. Available at: http://www.med.unc.edu/pcare/files/recommended-quality-measures-and-data-collection. Accessed June 3, 2016.
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These include: 1) documentation of “regular,” “ongoing” assessment of psychological reactions related to the illness, including stress, coping strategies, and anticipatory grieving and also psychiatric conditions, 2) use of validated and context-specific assessment tools, such as a depression screen, 3) patient and family education about the disease, symptoms, and side effects, and also caregiving needs and coping strategies that may impact emotional and psychological distress, 4) documentation of treatment of psychiatric diagnoses, such as depression, anxiety, and delirium, whether a consequence of the illness or in patients with comorbid psychiatric illness.PEACE Project. Specifications for recommended quality measures. Available at: http://www.med.unc.edu/pcare/files/specifications-for-recommended-quality-measures. Accessed June 3, 2016.
11
, Organization Readiness Screen. PEACE project. Available at: http://www.med.unc.edu/pcare/files/organizational-readiness-screen. Accessed June 3, 2016.
12
, PEACE Project. Recommended quality measures and data collection, by domain. Available at: http://www.med.unc.edu/pcare/files/recommended-quality-measures-and-data-collection. Accessed June 3, 2016.
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Related calculated outcome variables to consider in patients who screen positive for psychological symptoms are listed in Table 4.PEACE Project. Specifications for recommended quality measures. Available at: http://www.med.unc.edu/pcare/files/specifications-for-recommended-quality-measures. Accessed June 3, 2016.
11
, Organization Readiness Screen. PEACE project. Available at: http://www.med.unc.edu/pcare/files/organizational-readiness-screen. Accessed June 3, 2016.
12
, PEACE Project. Recommended quality measures and data collection, by domain. Available at: http://www.med.unc.edu/pcare/files/recommended-quality-measures-and-data-collection. Accessed June 3, 2016.
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PEACE Project. Specifications for recommended quality measures. Available at: http://www.med.unc.edu/pcare/files/specifications-for-recommended-quality-measures. Accessed June 3, 2016.
Table 4Additional Quality Outcome Variables to Consider in Patients With Psychological Symptoms
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, PEACE Project. Recommended quality measures and data collection, by domain. Available at: http://www.med.unc.edu/pcare/files/recommended-quality-measures-and-data-collection. Accessed June 3, 2016.
13
PEACE Project. Specifications for recommended quality measures. Available at: http://www.med.unc.edu/pcare/files/specifications-for-recommended-quality-measures. Accessed June 3, 2016.
| Quality Measure by Domain: Care of Psychological Symptoms | Recommended Data Collection: Patient Chart Review | Calculated Variables to Consider |
|---|---|---|
| For patients who “screen positive for depression” | Use of standard questions to assess patient depression Percent who receive further assessment, counseling, or medication treatment | Depression time = depression screening date - date of admission |
| For patients “diagnosed with depression” | Percent who receive interpersonal or medication treatment within two weeks of diagnosis | |
| For patients who “screen positive for anxiety” | Percent who receive treatment within two weeks of diagnosis | Anxiety time = anxiety screening date - date of admission |
Improved documentation alone may not translate into improvement in the quality of care provided. Efforts to improve documentation of emotional needs ideally should be accompanied by educational interventions and system-based tools to support an actual increase in the quality of care rendered.
Limitations
This is a single-center study limited to the initial palliative care assessment. Results may not be generalizable to other contexts or applicable to the practices of other palliative care teams in other care settings. Of note, our palliative care team does not bill independently for services and as such may not have the same documentation pressures as a consultation service that bills for physician services. The brief follow-up time for monitoring SmartPhrase use did not permit us to determine whether this practice will increase with habitual use or will decay without reinforcement over time. As argued earlier, improved documentation may not necessarily translate to improved quality of patient and family care.
Conclusion
A structured note template that includes emotional assessment reminder prompts increases documentation of patient and family emotions by the palliative care team, increases emotional assessments overall, and decreases the use of generic phrases in the electronic medical record. Although descriptive terms that are most commonly used to document emotions may meet minimal performance measure requirements, additional interventions such as prompting for recommendations to address identified emotional needs and the use of screening tools for depression and anxiety, when appropriate, may be necessary to produce clinically meaningful quality improvements related to MWM Measure 5.
Disclosures and Acknowledgments
Support for Dr. Berlin and Dr. Goett was provided by the New Jersey Medical School Hispanic Center of Excellence, Health Resources and Services Administration through Grant D34HP26020. The authors declare no conflicts of interest.
Member of the American Academy of Hospice and Palliative Medicine Research Committee Writing group: Rebecca A. Aslakson, MD, PhD (The Johns Hopkins Schools of Medicine and Public Health); Katherine Ast, MSW, LCSW (American Academy of Hospice and Palliative Medicine); Ronit Elk, PhD (University of South Carolina); Kimberly K. Garner, MD (University of Arkansas for Medical Sciences); Robert Gramling, MD, DSc (University of Rochester Schools of Medicine & Nursing); Corita Grudzen, MD, MSHS (NYU School of Medicine); Arif H. Kamal, MD, MHS (Duke Cancer Institute); Sangeeta Lamba, MD, MSHPEd (Rutgers New Jersey Medical School); Thomas W. LeBlanc, MD, MA (Duke Cancer Institute); Ramona L. Rhodes, MD, MPH (University of Texas Southwestern Medical Center); Eric Roeland, MD (University of California, San Diego); Dena Schulman-Green, PhD (Yale School of Nursing); and Kathleen T. Unroe, MD, MHA (Indiana University School of Medicine).
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Organization Readiness Screen. PEACE project. Available at: http://www.med.unc.edu/pcare/files/organizational-readiness-screen. Accessed June 3, 2016.
PEACE Project. Recommended quality measures and data collection, by domain. Available at: http://www.med.unc.edu/pcare/files/recommended-quality-measures-and-data-collection. Accessed June 3, 2016.
PEACE Project. Specifications for recommended quality measures. Available at: http://www.med.unc.edu/pcare/files/specifications-for-recommended-quality-measures. Accessed June 3, 2016.
Article info
Publication history
Published online: May 27, 2016
Accepted:
May 4,
2016
Series Editor: Robert Gramling, MD, DScIdentification
Copyright
© 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc.
