Graduation Semester and Year




Document Type


Degree Name

Doctor of Philosophy in Social Work


Social Work

First Advisor

Debra Woody


Patients and families coping with a terminal illness are faced with a number of decisions over the course of their disease. The decision to continue further treatment versus utilization of a palliative approach, such as hospice, is often one of the most difficult and complex. There are many barriers to hospice care, causing the service to be underutilized. Family is a significant force in patients' choice for palliative care and patients place greater importance on communications related to end-of-life care with their family than with health care professionals. However, dying remains a taboo conversation, a key barrier to end-of-life care. Using an exploratory, cross-sectional approach, this study utilized multiple regression to examine the extent to which family communication about illness and death (FCID) and referral source (family referral versus medical referral alone) predicted both decision time (number of days between hospice referral and admission) and hospice length of stay within the context of other barriers to hospice.The sample of this study (N = 90) consisted of primarily Caucasian patients (n = 74, 82.2%) with high levels of both self-reported spirituality (mean = 8.08 on a scale from 0 to 10) and family communication (mean = 4.05 on a scale from 1 to 5). Though 14 different diagnoses were represented, 63% of the sample had cancer. Patient ages ranged from 37 to 96 with an average age of 71. Patients were admitted to hospice during stages of advanced illness as 86.7% scored a 50 or below on the PPS, meaning that they needed considerable assistance and mainly sat or stayed in bed. 40% were completely bedbound and in need of total care at the time of admission. 60% of the sample enrolled in hospice within a week, likely due to an advanced stage of illness, and just over half (51.5%) died within just over a month of admission (34 days).Overall, this dissertation brings a new perspective to hospice utilization through the use of decision time as an outcome variable. Decision time was correlated with a number of barriers to hospice from within literature and prior research. Referral source was also predictive of decision time for hospice, suggesting that when a patient is referred by a family member or a close friend in addition to or in lieu of a medical professional, decision times for hospice were longer. This was likely due to these patients starting a conversation about hospice as an option earlier during the illness process. However, referral source was overshadowed by the impact of functional status at the time of hospice admission and use of treatment. These were the largest predictors of decision time for hospice reinforcing the role of late referrals and current policy restrictions (limiting patients' abilities to seek treatment while accessing hospice care) on hospice utilization.This dissertation also provides a number of connections among barriers to hospice as a starting point for future research. Both the meaning of hospice and spirituality presented as impactful variables requiring more in-depth follow up about how patients and their families define and understand these constructs in relation to the decision to enroll in hospice. Involving family members early in discussions for care will help clinicians to identify and provide support to families who may be struggling to make timely decisions. Obtaining access to end-of-life care is important in improving quality of death, symptom management, and bereavement for family.


Social and Behavioral Sciences | Social Work


Degree granted by The University of Texas at Arlington

Included in

Social Work Commons