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Abstract

In Taiwan, hospice nurses often take family members of terminally ill patients on hospice ward tours and provide information on transfers. We conducted a study to investigate the tour’s effectiveness in encouraging family members to transfer their loved ones to hospice. We conceptualized our study framework based on the Andersen healthcare utilization model. The hospice nurses invited family members who participated in the tour to complete the survey to investigate the tour and hospice facilities’ influence on their willingness to transfer. A total of 87 participants responded to the study, with an average age of 48.84 ± 12.08 years. Most participants were women (78.16%) and the children of patients (55.17%). The results showed that the tour significantly increased willingness scores (before 4.46 ± 0.73, after 4.74 ± 0.58, p = .0036). Practical and activity-related facilities had the highest influence scores. However, binary logistic regression revealed that patients aged ≥65 years (odds ratio [OR]: 0.281, 95% confidence interval [CI] [0.099, 0.797]) and higher influence scores for psychospiritual care features (OR: 0.182, 95% CI [0.040, 0.821]) negatively affected the change in willingness score, possibly due to family members’ anticipatory grief. Hospice tour guides should be able to identify, assess, and deal with this issue. Overall, hospice tours can effectively encourage transfer to the hospice ward, but addressing psychological barriers such as anticipatory grief is crucial for success.

Plain Language Summary

A study in Taiwan investigated the effect of hospice tours on families’ decisions to move their terminally ill loved ones to the hospice ward. The results showed that the tours positively impacted families’ willingness to transfer their loved ones, especially when they saw practical and daily activity-related hospice facilities. However, for patients aged 65 and above or family members more concerned about psychospiritual care features, there was a negative impact on their willingness to transfer their loved ones. It could be due to anticipatory grief. Hospice tour guides should be able to identify and address this issue. The research provides valuable insight into developing effective strategies to encourage family acceptance. Still, the authors recommend conducting broader studies to explore this topic further, as their sample size was relatively small.

Keywords

aged environment design family grief hospice hospice facilities terminal care

Background

Many terminally ill patients and their family members can become aware of the fatal prognosis within the near future only after being informed by a physician (Csikai & Martin, 2010; Epstein et al., 2016; Hawley, 2017; Obermeyer et al., 2015). It is usually psychologically challenging for them to make end-of-life decisions, especially when specialist hospice palliative referral is recommended simultaneously (Cherlin et al., 2005; Oechsle et al., 2019; D. Waldrop et al., 2015).

The decision to switch from curative or life-prolonging therapy to hospice palliative care is difficult but important, as the focus becomes maintaining the quality of life and facilitating a good death for terminally ill patients (Gerber et al., 2020; Yip et al., 2023). Hospice is often taken to mean the cessation of all treatment, being given up by medical staff, losing traditional medical support, and dying alone. It is common for patients and their family members to resist a switch to specialist hospice palliative care. A large amount of information is required to clear up misconceptions (Buzgova et al., 2016; D. Waldrop et al., 2015).

Since 2000, Taiwan’s National Health Insurance (NHI) has covered hospice fees. The hospice ward is designated as a special care unit within the hospital. Medical expenses payable by patients for hospice are the same as those for medical care in the general ward of a hospital. Hospice enrollment criteria include receiving a terminal cancer diagnosis, motor neuron disease, or vital organ failure with physical or psychospiritual distress (National Health Insurance Administration, 2019). The Ministry of Health and Welfare regulates hospice ward standards to encourage enrollment by terminally ill patients and their families by ensuring a high-quality environment. The standards include relevant requirements for adequate activity space and providing certain exclusive facilities such as a bathing machine/shower room and psychospiritual care environments. Many hospitals set hospice wards because it can affect the hospital accreditation results.

Patients and their families usually do not understand the differences in setting and care between hospice and general wards. Most referring physicians can neither explain these nor are comfortable with the discussion (Casarett et al., 2005). Although most people vaguely understand what a hospice ward offers, they do not know how the environmental facilities of a hospice ward benefit patients. Essential environment and comfort care information are commonly unmet needs among terminally ill patients and their family members (Buzgova et al., 2016; Csikai & Martin, 2010). Many hospitals offer hospice consultations and ward tours to provide comprehensive information regarding the hospice environment and reduce concerns about a hospice transfer in Taiwan.

The Andersen healthcare utilization model has been extensively utilized in healthcare research as a theoretical framework for understanding why people use health services, defining and measuring equitable access to health care, and planning policies to promote the use of health resources (R. Andersen, 1995; R. M. Andersen & Newman, 1973; Von Lengerke et al., 2014). This model proposes that healthcare utilization is influenced by individual characteristics, enabling/disabling factors, and perceived or actual need for healthcare services. In the present study, we used the Andersen model’s framework to explore the effectiveness of hospice tours and facilities’ influence in encouraging or discouraging families’ willingness to transfer their loved ones to hospice. As per the Andersen model, financing is essential to healthcare outcomes. However, the hospice fees are covered under Taiwan’s NHI. Patients do not have to pay any additional expenses for hospice. We have not included the financing factor in our model. Details are shown in Figure 1. By applying the Andersen model, we aimed to understand better the factors influencing family decision-making regarding hospice transfer, which could ultimately inform healthcare policies and practices in this area.

Figure 1.

Conceptual framework.

Methods

Recruitment and Data Collection

The present study was conducted at a top-tier medical center in southern Taiwan from September 1, 2018 to April 30, 2020. The study aimed to assess the effect of a hospice nurse-guided ward tour and hospice facilities on the decision-making process of family members of terminally ill patients. A professionally trained nurse would typically lead the hospice ward tour for the family members. The families were recommended to transfer their loved ones to the hospice ward for the first time by their attending physicians.

During the tour, the nurse explained the numerous benefits of a hospice environment and facilities for patients. The nurse also offered guidance on managing caregiving challenges and provided information on end-of-life issues. Families often had inquiries regarding the distinctions between hospice and general ward care, the duration of a patient’s stay, and who could accompany them during their stay. The tour typically lasted 30 min but could be extended to an hour to address additional concerns. The nurse offered emotional support to families throughout the tour, as needed. Detailed information about the hospice’s facilities and environmental features was provided in the supplementary materials.

While guided tours are available for all patients and families, it is common for families to request representatives for the tour. Previous studies have shown that family members are critical in determining whether a terminally ill patient is enrolled in hospice care (Oechsle et al., 2019; Schäfer et al., 2006; D. P. Waldrop & Meeker, 2014; D. Waldrop et al., 2015; Wallace, 2015). To assess the impact of the hospice nurse-guided tour on family members’ decision-making, we developed a questionnaire using a 5-point Likert scale (1 = strongly negative, 5 = strongly positive).

We employed the convenience sampling method for our study. The hospice nurses invited family members aged 20 years or older to participate because it is the legal age for full capacity in Taiwan at the time of the survey. Those who agreed to participate in the study signed a consent form and received a paper questionnaire. The hospice nurse explained the questionnaire’s relevant content to the participants. Before the tour, the participants were asked to record their transfer willingness scores. After the tour, the participants took away the questionnaire with them. They were asked to rate the impact of each facility on their decision-making and indicate their final transfer willingness score. Lastly, the completed questionnaire was submitted to the nurse. Each family completed only one questionnaire.

Survey

Our study aims to examine the impact of hospice tours and facilities on the decision of family members to move their loved ones from a regular ward to a hospice. We searched extensively for a questionnaire that met our requirements, but none were suitable. Therefore, we created our survey based on previous research on end-of-life care and our professional expertise.

The questionnaire was divided into two parts: the first part included questions relating to the demographic characteristics of the participants; the second part included 14 items pertaining to environmental features in the hospice ward and two items relating to the participant’s willingness to transfer their terminally ill relatives to the hospice before and after the tours. The environmental features were separated into three categories: psychospiritual care (1. aisle mural, 2. Mona Lisa collage, 3. patient artwork, and 4. viewing room), physical care (1. bathing equipment, 2. adjuvant therapy instruments, 3. family lounge, 4. room facilities, and 5. room size), and interior design (1. garden, 2. common room, 3. traffic flow within the ward, 4. ward tone, and 5. ward lighting). Experts of hospice palliative care, including two physicians and one nurse, rated the relevance of each item on a 4-point scale (1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, and 4 = highly relevant). The scale-level content validity index was 0.90. We then tested the questionnaire’s comprehensibility and acceptability on eight participants in a pilot phase.

Independent Variables

We calculated the scores of the three environmental features by averaging the score of each item in the categories. In a binary logistic regression, we divided the sample into two groups based on whether or not their scores for a given variable were higher than the mean value.

Outcome Variable

The outcome variable was the change in the willingness to hospice transfer score, which was the score after the tour minus before the tour. In a binary logistic regression, we divided the sample into two groups based on whether or not the post-tour willingness change score was higher than zero.

Statistical Analysis

All data were input into Office Excel 2013 and Stata version 14.0 for sorting and analysis. Cronbach’s alpha and Kaiser–Meyer–Olkin (KMO) values were used to validate the reliability and suitability of the environmental features for factor analysis. We conducted paired-sample t-tests to evaluate the difference in willingness before versus after the tour. Data were then summarized descriptively and analyzed through chi-square contingency analysis and binary logistic regression. We conducted multicollinearity diagnostics to check for any multicollinearity among the independent variables in the regression analysis, followed by the Hosmer-Lemeshow test to evaluate the goodness-of-fit. All p < .05 were considered significant.

Results

Study Population

In total, 297 family members were invited to complete the questionnaire, and 87 family members completed and returned the questionnaire. The mean age of the participants was 48.84 ± 12.08 years. The majority were women (78.16%) and the children of the patients (55.17%). The mean age of the patients was 69.05 ± 14.90 years, and the mean length of hospital stay was 10.76 ± 11.29 days. The majority of patients were male (55.17%), had a diagnosis of cancer (91.95%), do-not-resuscitate code (68.97%), and palliative performance scale of 10% to 20% (52.87%). The details are shown in Table 1.

Table 1.

Demographic Characteristics and Results of the χ² Test for Willingness Score Change (N = 87).

		Willingness score change
Variables	Categories	≤0N (%)	>0N (%)	p
Predisposing factors
Patient characteristics
Age	<65 years	18 (31.03)	16 (55.17)	.030*
	≥65 years	40 (68.97)	13 (44.83)
Gender	Female	25 (65.79)	13 (34.21)	.879
	Male	33 (67.35)	16 (32.65)
Cancer	No	6 (85.71)	1 (14.29)	.265
	Yes	52 (65.00)	28 (35.00)
Incharge specialty	Medical	37 (64.91)	20 (39.09)	.632
	Surgical	21 (70.00)	9 (30.00)
Enabling/disabling factors
DNR code	No	18 (66.67)	9 (33.33)	1.000
	Yes	40 (66.67)	20 (33.33)
Family member characteristics
Age	<50 years	28 (60.87)	18 (39.13)	.224
	≥50 years	30 (73.17)	11 (26.83)
Gender	Female	48 (70.59)	20 (29.41)	.142
	Male	10 (52.63)	9 (47.37)
Education level	None to high school	30 (66.67)	15 (33.33)	1.000
	Diploma or above	28 (66.67)	14 (33.33)
Relationship to patient	Spouse	14 (66.67)	7 (33.33)	.842
	Child	31 (64.58)	17 (35.42)
	Other	13 (72.22)	5 (27.78)
Religion	Yes	14 (60.87)	9 (39.13)	.492
	No	44 (68.75)	20 (31.25)
Need-for-care factors
PPS	10%–20%	34 (73.91)	12 (26.09)	.129
	≥30%	24 (58.54)	17 (41.46)
Hospital stay length	<11 days	37 (72.55)	14 (27.45)	.166
	≥11 days	21 (58.33)	15 (41.67)

Abbreviations. SD = standard deviation; DNR = do not resuscitate; PPS = palliative performance scale.

*p < .05.

The response rate was 30.64%, which falls in the lower range compared to usual medical research (30%–75%) (Sataloff and Vontela, 2021). Families commonly decline to participate in the survey for various reasons, such as being hesitant to sign informed consent, lack of interest, time constraints, and feeling tired or stressed. In addition, end-of-life decision-making regarding transferring terminally ill loved ones to hospice is complex and sensitive, requiring families to make difficult decisions while dealing with timing, psychological, and cultural challenges. These challenges can make it difficult for families to respond promptly and definitively to their behavioral intentions. In our survey, families whose relatives passed away while awaiting a hospice bed did not return the questionnaire, indicating this decision-making process’s potentially emotional and challenging nature. Moreover, the outbreak of the COVID-19 pandemic during the late data collection phase may have further complicated this process, potentially impacting the number of questionnaires returned. Therefore, the response rate is acceptable for this sensitive population.

Questionnaire Reliability and Suitability for Factor Analysis

The Cronbach’s alpha for the 14 environmental features was .929, and the KMO value was .832 for the environment scale. For the interior design, physical care, and psychospiritual care categories, the Cronbach’s alphas and KMO values were .867 and .777, .838 and 799, and .828 and .779, respectively. The questionnaire was reliable, and the data were eligible for factor analysis.

Change in Willingness Before Versus After the Tour

The mean scores of willingness to transfer before and after the tour were 4.460 and 4.736, respectively. The p value for the paired-sample t-test of the scores was .0036, which indicates the results were significant. The mean willingness score change is .276 (maximum +3 and minimum −2).

Influence of Environmental Features

The mean scores of all 14 environmental items were greater than 4. As shown in Table 2, the three items with the highest scores were the garden, bath machine/shower room, and common room. The three items with the lowest scores were room size, patient artwork, and viewing room. The mean scores for each feature category were interior design (4.439 ± 0.518), physical care (4.388 ± 0.556), and psychospiritual care (3.388 ± 0.551).

Table 2.

Influence of Environmental Features on Ward Transfer Willingness.

				Willingness change score
Rank	Variables	Mean ± SD	Score	≤0N (%)	>0N (%)	p
Model 1
1	Garden^c	4.575 ± 0.563	L	17 (29.31)	17 (58.62)	.008**
			H	41 (70.69)	12 (41.39)
1	Bathing equipment^b	4.575 ± 0.602	L	16 (27.59)	16 (55.17)	.012*
			H	42 (72.41)	13 (44.83)
3	Common room^c	4.517 ± 0.568	L	20 (34.48)	19 (65.52)	.006**
			H	38 (65.52)	10 (34.48)
4	Aisle mural^a	4.437 ± 0.623	L	21 (36.21)	19 (65.52)	.010*
			H	37 (63.79)	10 (34.48)
5	Traffic flow^c	4.436 ± 0.677	L	23 (39.66)	20 (68.97)	.010*
			H	35 (60.34)	9 (31.03)
6	Adjuvant therapy instruments^b	4.402 ± 0.722	L	21 (36.21)	19 (65.52)	.010*
			H	37 (63.79)	10 (34.48)
7	Ward tone^c	4.356 ± 0.698	L	26 (44.83)	20 (68.97)	.033*
			H	32 (55.17)	9 (31.03)
8	Family lounge^b	4.344 ± 0.679	L	28 (48.28)	19 (65.52)	.128
			H	30 (51.72)	10 (34.48)
8	Mona Lisa Collage^a	4.344 ± 0.700	L	23 (39.66)	23 (79.31)	<.001***
			H	35 (60.34)	6 (20.69)
10	Room facilities^b	4.322 ± 0.785	L	28 (48.28)	18 (62.07)	.224
			H	30 (51.72)	11 (37.93)
11	Ward lighting^c	4.310 ± 0.736	L	29 (50.00)	20 (68.97)	.093
			H	29 (50.00)	9 (31.03)
12	Room size^b	4.299 ± 0.764	L	26 (44.83)	23 (79.31)	.002**
			H	32 (55.17)	6 (20.69)
13	Patient artwork^a	4.218 ± 0.722	L	28 (48.28)	25 (86.21)	.001**
			H	30 (51.72)	4 (13.79)
14	Viewing room^a	4.184 ± 0.800	L	26 (44.83)	24 (82.76)	.001**
			H	32 (55.17)	5 (17.24)
Model 2
1	Interior design features	4.439 ± 0.518	L	21 (52.50)	37 (78.72)	.010*
			H	19 (57.50)	10 (21.28)
2	Physical care features	4.388 ± 0.556	L	18 (51.43)	40 (76.92)	.013*
			H	17 (48.57)	12 (23.08)
3	Psychosocial care features	3.388 ± 0.551	L	18 (43.37)	40 (81.63)	.001**
			H	20 (52.63)	09 (18.37)

Abbreviations. SD = standard deviation; L = ≤ mean score; H = > mean score.

Psychosocial care features.

Physical care features.

Interior design features.

*p < .05. **p < .01.

Statistical Analysis for Environmental Features Influencing Willingness

Table 1 summarizes the results of our comparison between groups divided according to whether their willingness to change score was above or below zero according to the variables listed in the conceptual model in Figure 1. Table 2 summarizes our results according to the influence of environmental items and features on the transfer willingness. We conducted binary logistic regression analysis for variables with a p < .05 to model the probability that an item or feature influenced willingness. After a multicollinearity test, we excluded the aisle mural from the multivariate regression analysis due to high variance.

In Model 1, which included all significant environmental items, the results revealed that patients aged ≥65 years (odds ratio [OR]: 0.152, 95% confidence interval [CI] [0.040, 0.563]) and patient artwork (OR: 0.172, 95% CI [0.021, 0.989]) had a negative impact on willingness. The average variance inflation factor (VIF) was 3.71, suggesting no significant multicollinearity issues. The statistical power analysis based on the willingness change scores and relevant factors is .801, indicating that the sample size is statistically sound. For Model 2, including the three environment categories constructed by related questionnaire items, patients aged ≥65 years (OR: 0.281, 95% CI [0.099, 0.797]) and psychospiritual care features (OR: 0.18, 95% CI [0.040, 0.821]) were found to have a negative influence on willingness. The mean VIF was 1.89, indicating minimal multicollinearity concerns. The p-values of the Hosmer–Lemeshow test for Model 1 and Model 2 were .547 and .333, respectively. These results showed that both models exhibit a good fit. Additional details of the regression results can be found in Table 3.

Table 3.

Binary Logistic Regression for the Influence of Environmental Features on Willingness Change Score.

Variables	Odds Ratio	95% Confidence Interval	p
Model 1
Patient age ≥65	0.114	[0.027, 0.478]	.003**
Garden	0.829	[0.156, 4.400]	.826
Bathing equipment	0.887	[0.182, 4.318]	.882
Common room	1.868	[0.099, 35.171]	.677
Traffic flow of ward	2.132	[0.254, 17.873]	.485
Aisle mural	0.537	[0.204, 14.165]	.710
Adjuvant therapy instruments	1.030	[0.197, 5.399]	.972
Ward tone	4.836	[0.513, 45.560]	.168
Mona Lisa collage	0.888	[0.149, 5.300]	.896
Room size	0.089	[0.008, 0.929]	.043*
Patient artwork	0.089	[0.011, 0.747]	.026*
Viewing room	0.413	[0.087, 1.956]	.265
Model 2
Patient age ≥65	0.281	[0.099, 0.797]	.017*
Interior design features	1.140	[0.222, 5.846]	.875
Physical care features	0.738	[0.183, 2.968]	.668
Psychospiritual care features	0.182	[0.040, 0.821]	.027*

p < .05. **p < .01.

Discussion

Nurse-guided tours significantly increased ward transfer willingness. Patient age ≥65 years, patient artwork, room size, and psychospiritual care features negatively affected the transfer willingness. The results indicated that older patient age is a barrier to hospice access. Moreover, environmental elements relating to death could negatively affect family members’ decision to transfer their loved ones to the hospice.

Influence of Tour on the Willingness

The decision to transfer terminally ill loved ones to hospice can be difficult for family members, who may perceive it as giving up hope or waiting for the death of their loved ones (Loke et al., 2011). However, hospice is designed to provide patients with the highest possible quality of life. It is essential to dispel misconceptions and misunderstandings about this important form of care (Back et al., 2023; Noh et al., 2017). Family members require access to comprehensive information to make informed decisions about hospice enrollment (Tate et al., 2020). Professional hospice care training and collaboration among healthcare professionals are crucial for accomplishing such requirements, as Yip et al. (2021) emphasized.

In the present study, the professional training hospice nurse is critical in providing emotional support to patients and their families during the tour. The nurse helps families cope with the challenges of caregiving, includes information about end-of-life issues, and offers guidance on the benefits of hospice’s holistic facilities for managing symptoms, which may have led to a decrease in uncertainty and anxiety, ultimately increasing the willingness to transfer terminally ill relatives to the hospice ward.

Item Ranking

Caring for terminally ill relatives is physically and mentally exhausting (Girgis et al., 2013; Mcmillan, 2005; Ullrich et al., 2017). Terminally ill patients often lack the physical ability to perform daily activities and have physical and psychospiritual symptoms that are difficult to treat. As can be seen in Table 2, the environmental items that most strongly influenced willingness were the garden, bath machine/shower room, common room, traffic flow within the ward, aisle mural, and adjuvant therapy instruments. Most of these items are practical and daily activities related. On the contrary, many psychospiritual care-related items, including the viewing room, patient artwork, and the Mona Lisa collage, are somewhat abstract and may be considered by family members to be irrelevant to patient care or related to death.; thus, family members ranked these lower.

Andersen Healthcare Utilization Model Analysis

Our research did not reveal any significant factors that increase a family’s willingness to transfer their loved one to hospice, which is often challenging for families. However, the presence and guidance of professional hospice nurses during the tour process may have contributed to the increase in the family’s willingness to transfer. Per the NHI regulations, hospice nurses must undergo 80 hr of professional hospice palliative care training and attend at least 20 hr of continuing education annually, including communication skills and family dynamic assessment topics. We have identified some factors that negatively impact a family’s willingness to transfer their loved one to the hospice, which we will discuss below.

Predisposing Factor: Older Patient Age

Effective life-prolonging treatment may be unavailable when older adults suffer from potentially life-threatening diseases. Therefore, they should be the main target of hospice palliative care. However, they are often disadvantaged in accessing hospice care and making autonomous end-of-life decisions (Chen et al., 2022; Dobson, 2005; Lo et al., 2012; Tobin et al., 2022; United Nations Department of Economic and Social Affairs, 2018). In the present study, we found that patients aged ≥65 were negatively correlated with family members’ willingness change to transfer them to the hospice ward after the tour.

Hospice environments are intentionally designed to offer comprehensive support, including physical, emotional, and spiritual care, to patients requiring end-of-life care. However, in some cultures, discussing death with terminally ill older adults is deemed taboo due to social norms and the belief that such conversations may cause psychological distress or diminish hope for survival (Baker & Gallagher, 2017; Cox et al., 2006; Lindskog et al., 2015).

When senior patients nearing the end of their life are moved from general wards to the hospice, they may notice a significant change in their surroundings, leading to questions or anxious thoughts. Consequently, family members of these patients must carefully consider how to disclose the purpose of transfer to their loved ones, ensuring that the information does not cause undue distress or depression. Furthermore, families may be apprehensive that others may perceive the transfer to hospice as a sign that they are giving up on prolonging the patient’s life. These can reduce their willingness to choose hospice enrollment for their elderly relatives even after the tour.

Medical professionals need to approach the topic of life-prolonging treatments for senior patients with sensitivity. Due to the natural limitations of human life and age-related organ function decline, such treatments may not benefit them significantly. Moreover, comorbid conditions can increase their vulnerability to medication side effects. Therefore, healthcare providers should prioritize symptom management and improving their quality of life instead of solely focusing on prolonging their lifespan (Yu et al., 2020).

After providing information and suggestions on the tour, it is essential to provide opportunities for further discussion. Clinicians should empathize with and respect the concerns of family members of terminally ill, older patients. Family members should be allowed to think about the transfer decision. Clinicians may remind family members that terminally ill, older adult patients who remain in the general ward usually cannot receive adequate physical and psychospiritual care (Binda et al., 2021; Sato et al., 2008). The hospice ward has specialist staff and a thoughtful environment that not only effectively improves the patient’s quality of life but also reduces the burden on caregivers. Professionals working in hospice can use their communication skills to gently inquire about a patient’s expectations in life and offer proper support and resources. Such an approach can aid families in dealing with emotional challenges and increase their willingness to enroll in hospice care, as per the findings of Riordan et al. (2020).

Disabling Environment Factors: Room Size

The hospice ward rooms are renovated general ward rooms. The layout and size of rooms are the same as those of general wards. However, the beds are electric and take up more space than the conventional manual beds in some general wards. In addition, each room has a TV and a refrigerator. Therefore, rooms in the hospice seem smaller than rooms in the general ward, which might negatively influence the willingness to transfer a relative to the hospice ward. We suggest that designers of new hospice wards consider caregivers’ spatial needs.

Disabling Environment Factors: Psychospiritual Care Features

The patient’s mental and spiritual well-being needs are met through psychospiritual care, which involves various forms of support and guidance, such as counseling, prayer, meditation, music and art therapy, pet therapy, and religious or spiritual assistance. The ultimate goal is to help patients face the end of their life with a sense of peace and dignity (Delgado-Guay, 2014; Puchalski et al., 2014; Rosa, 2019). Hospice wards are typically equipped with religious or artistic facilities that serve this purpose, and the products of patients’ creative efforts are often displayed or sold for charity. Hospice nurses highlight these features and showcase the artwork of patients who have achieved a peaceful and fulfilling end-of-life experience.

Entering a hospice ward for the first time can cause anticipatory grief to family members of terminally ill patients because the environment can remind them of their relatives’ imminent death (Cholbi, 2016; Tate et al., 2020). Anticipatory grief is grief experienced before the actual end of a loved one (Rando, 1988). Anticipatory grief may impair an individual’s decision-making ability and frequently leads to avoidance behavior (Coelho et al., 2018; Fowler et al., 2013; Glick et al., 2018; Yu et al., 2022). For some, enrolling a family member in hospice can be difficult as it may signify that the end of life is near. Consequently, there can be a reluctance to make this choice.

Clinical staff must be sensitive to anticipatory grief being experienced by family members. Through early identification, assessment, and management, family members can learn to cope with the loss of relatives (D’Antonio, 2014; Johansson & Grimby, 2012). Professionals who lead tours should understand that reluctance to enroll a relative in hospice may not be due to dissatisfaction with the environment but rather represent the close bond between the family member and the patient. Some individuals believe that enrollment in hospice may hasten the death of their relative. Clinical staff should reassure family members that patients will have adequate care in the hospice. If family members experience any delays, uncertainty, or reluctance while deciding to transfer their terminally ill loved ones to hospice, holding family meetings to facilitate discussions can be beneficial.

Strengths and Weaknesses of the Study

As far as the authors are aware, the present study is the first to explore the influence of hospice nurse-guided tours and environmental facilities on the family member’s willingness to transfer their terminally ill relatives to the hospice ward. Our findings revealed that family members who joined the tour were more willing to accept hospice transfers. These findings hold the potential to foster hospice acceptance by family members and offer valuable knowledge into the decision-making factors that impact family members while considering hospice enrollment. It indicates that by conducting informative tours and addressing concerns, we can enhance their comprehension of hospice care, thereby mitigating their fears and hesitations. This information can further be utilized to develop effective strategies for promoting family acceptance.

Our study had a limitation in that we could not measure the actual transfer results as a dependent variable. This was because some patients were discharged or passed away before a hospice bed became available. However, previous research has demonstrated that the viewpoints and preferences of family members play a significant role in determining whether or not to enroll their loved ones in hospice care. This is an important matter that needs to be addressed. We also recognize that our study is limited by a small sample size and a focus only on environmental and facility factors during the tour. We realize the necessity for future research that includes more extensive and diverse samples and investigates the specific communication techniques or strategies that impacted families the most during the tour process.

Conclusion

Hospice enrollment can enhance the quality of life for terminally ill patients, reduce the burden on caregivers, and facilitate meaningful end-of-life care decisions. However, due to a lack of understanding of the hospice ward environment, family members often have difficulty making decisions and require professionals to provide information. The present study found that professional-trained hospice nurse-guided tours increased an individual’s willingness to transfer a relative to the hospice ward. Environmental features that ranked highly among participants were those that affected patient care, such as the garden, bath machine/shower room, and common room. Tour leaders should explain these in more detail. Family members may worry that living in a hospice is psychologically damaging. Family members are rarely exposed to psychospiritual matters and their relation to a good death in the general ward. Hence, these issues may trigger anticipatory grief and reduce family members’ willingness to transfer their terminally ill relatives. Medical staff should be able to identify and assess these concerns, assist families in dealing with their emotions, and respect final decisions.

Supplemental Material

sj-docx-1-sgo-10.1177_21582440241256257 – Supplemental material for The Role of Hospice Tours in Promoting Hospice Enrollment: A Study of Taiwanese Family Members

Supplemental material, sj-docx-1-sgo-10.1177_21582440241256257 for The Role of Hospice Tours in Promoting Hospice Enrollment: A Study of Taiwanese Family Members by Tzu-Ya Huang, Ru-Yih Chen, Ying-Chun Li, Chun-Hao Yin, Chin-Hao Hsu and Chia Chen in SAGE Open

Supplemental Material

sj-docx-2-sgo-10.1177_21582440241256257 – Supplemental material for The Role of Hospice Tours in Promoting Hospice Enrollment: A Study of Taiwanese Family Members

Supplemental material, sj-docx-2-sgo-10.1177_21582440241256257 for The Role of Hospice Tours in Promoting Hospice Enrollment: A Study of Taiwanese Family Members by Tzu-Ya Huang, Ru-Yih Chen, Ying-Chun Li, Chun-Hao Yin, Chin-Hao Hsu and Chia Chen in SAGE Open

Footnotes

Acknowledgements

The authors would like to thank the nurses, Many-Zng Lin, Shin-Hui Tzeng, and Jui-Mei Chung, for their support in inviting participants and collecting questionnaires.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Kaohsiung Veterans General Hospital grant number VGHKS107-D08-4.

Ethical Approval

The Institutional Review Board of Kaohsiung Veterans General Hospital approved this study. Approval number VGHKS19-CT11-09.

ORCID iD

Ru-Yih Chen

Data Availability Statement

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Supplemental Material

Supplemental material for this article is available online.

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