HOSPICE CARE FOR STROKE PATIENTS: ANALYSIS OF ISSUES AND CHALLENGES IN THE HOSPICE CARE MODEL FOR CHRONIC STROKE PATIENTS

Background: The lives of stroke patients are often marked by changes in function and cognition that alter their lives, along with exacerbating symptoms. Hospice care emphasizes quality care that focuses on improving patient comfort, reducing pain, and providing emotional support to patients and their families. Objective : This study aims to discuss the hospice care model for chronic stroke patients. Method: The research methodology is conducted qualitatively through a literature review method, referring to printed materials such as journals, newspapers, magazines, and relevant books to elucidate the hospice care model and elements related to the care of chronic stroke patients. This article analyzes data from documents and selected texts, followed by a thematic coding process. Result: The study finds that the hospice care model has become an increasingly popular alternative in providing comprehensive and holistic care for chronic stroke patients. However, the implemented hospice care model has its own limitations and challenges. Conclusion: Overall, this article will provide a deeper understanding of the hospice care model for chronic stroke patients. A precise understanding of this model's provision will enhance the quality of hospice care for chronic stroke patients and improve overall well-being. Nursing Implications: The importance of this study lies in gaining a deeper understanding of the effectiveness of the hospice care model for chronic stroke patients and enhancing the provision of quality care for them. By understanding existing models and assessing strengths and weaknesses, we can identify aspects that need improvement in providing better and more appropriate care.


INTRODUCTION
The increasing number of patients and deaths due to chronic stroke is deeply concerning.
The Ministry of Health Malaysia (MOH) estimates an annual increase in the number of chronic stroke patients to 50,000 cases and categorizes it as one of the top three causes of death in the country.Many studies conducted by scholars involve the provision of care for chronic stroke patients, but they only focus on aspects like nutritional care, physical health, therapy, and ecology.Meanwhile, the spiritual aspect for both patients and caregivers also needs to be considered throughout the provision of care for these patients.
Every patient has the right to receive care and treatment.Hospice is one form of care service offered to chronic patients, including those with chronic stroke.The World Health Organization (WHO) recommends hospice care to be initiated as soon as a patient is identified with a chronic illness (WHO, 1998a).In addition, the Ministry of Health Malaysia (MOH) also affirms hospice care as specialized medical care for patients within the group of chronic patients (https://htwu.moh.gov.my/v3/modules/informasi/ item.php?itemid=43).
The statistics of chronic stroke patients in the country are expected to increase every year to reach 50,000 new cases, a figure equivalent to 15 million cases worldwide annually.In Malaysia, chronic stroke ranks as the third highest contributor to mortality after heart attacks and cancer (Institute for Health Metrics and Evaluation 2019).In 2018, the World Health Organization (WHO) placed Malaysia at 107th globally in terms of the highest contributors to mortality due to chronic stroke, with the death toll reaching 13,799.

Figure 1
Hospice Care-Related Search Trends Despite the serious concern, as evidenced by the hospice care-related search trend over the past three years as shown in Figure 1, the success of implementing hospice care for chronic stroke patients in Malaysia is still doubted by many due to its lack of empirical validation within a specific timeframe.Research on hospice care by scholars, touching on the paradigm aspect of tawhid in Malaysia, has not yet been found.Therefore, the issue of hospice care for chronic stroke patients is raised: to what extent can the efficiency of existing hospice care be improved and ensure patient well-being?Furthermore, how aware are chronic stroke patients of enhancing the quality of hospice care for their condition?This question arises due to research findings indicating that the implementation of various treatment activities has failed to meet the holistic needs of chronic stroke patients (Mohammad Khan et al. 2020;Musa and Che Zarrina 2019;Bernat and McQuillen 2017).The failure of such treatments has sparked concerns regarding the achievement of hospice care goals (Mohammad Khan et al. 2020).

RESEARCH BACKGROUND
News reports indicate that the interest of family members in caring for chronic stroke patients remains at a low level, often completely entrusting this responsibility to hospitals and specific care homes.Yet, the patients involved eagerly anticipate care and end-of-life support from their family members with compassion (Mohammad Khan et al. 2020;Enck 2013).They are compelled to accept their circumstances when managed and cared for by sources other than their own family members (Najmi 2020).Moreover, numerous complaints are received from patients when they are not visited regularly by their family members during hospitalization or care home stays (Nurul Husna Mahmud 2022).Based on these identified issues, it calls for the provision of effective measures for specialized care of chronic stroke patients among family members (Breitbart, 2006).Mendieta and Buckingham (2017) assert that caring for a patient encompasses understanding aspects of culture, religion, physicality, emotions, and spirituality.Khalid (2019), Knecht-Sabres et al. (2019), Lindley et al. (2020), Hudson et al. (2021) state that studies discussing hospice care from a spiritual perspective are limited.Based on the conducted review, the Islamic psychotherapy approach (paradigm element of tawhid) can aid patients in reducing stress experienced by breast cancer patients.This finding serves as inspiration for this study to explore the extent to which the tawhid paradigm approach can be applied in the formulation of a care treatment model for chronic stroke patients (Najmi 2020).
The hospice model emphasizes hospice care that enhances patient comfort, reduces pain, and provides emotional support to patients and their families (see figure 1).It involves a multidisciplinary team comprising medical experts, nurses, social workers, counselors, and other healthcare professionals who collaborate to deliver comprehensive care.

Attention to Hospice Care
This study examines the hospice care model targeted towards chronic stroke patients, also known as ischemic heart disease.This condition is a chronic disease that requires quality care and support to enhance patients' quality of life (Agren Bolmsjo 2008).The hospice care model has become an increasingly popular alternative in providing holistic and comprehensive care for patients with this chronic illness.Therefore, this study aims to identify the hospice care model for chronic stroke patients and discuss the extent of advantages and disadvantages of the utilized model.
The significance of this study lies in understanding the effectiveness of the hospice care model for chronic stroke patients.Additionally, it aims to assess the measures of effectiveness to enhance the quality of the care model.Awareness of this importance can identify areas for improvement in the provision of a better care model for patients.
Overall, this article will provide a deeper understanding of the hospice care model for chronic stroke patients and serve as a foundation for further discussions on the strengths and weaknesses of the utilized model.With a focused understanding, we can enhance the provision of hospice care for chronic stroke patients and improve their quality of life.
This study aims to examine the hospice care model applied to chronic stroke patients.
Chronic stroke patients, also known as ischemic heart disease patients, are individuals with a chronic condition that necessitates quality care and support.The hospice care model has become an increasingly popular alternative in providing comprehensive and holistic care to patients with this chronic illness.The focus of this study is to analyze the strengths and weaknesses of the currently employed model.This assessment is crucial to understanding how the hospice care model can address the holistic needs of chronic stroke patients, including symptom management, emotional support, and meaningful end-of-life experiences.

RESEARCH METHODOLOGY
This study takes the form of a qualitative research utilizing document analysis.The research design focuses on the hospice care model for chronic stroke patients, addressing the strengths and weaknesses of the existing hospice care model.Through documents, this study will gather and analyze qualitative data pertaining to the hospice care model for chronicstroke patients.
The approach of document and text analysis using coding and thematic methods, along with comparative analysis, will be employed to support this discussion.The references used include printed materials such as journals, newspapers, magazines, and relevant books to elucidate the hospice care model and elements related to caring for chronic stroke patients.
In this study, thematic analysis and comparative analysis are also employed to identify the main themes emerging from the documents, compare hospice care models, and identify the strengths and weaknesses of hospice care models for stroke patients.This coding and thematic 7 analysis will help organize the data more systematically.Furthermore, a comparison between existing hospice care models will be conducted to observe differences and similarities in their utilization.

RESEARCH FINDINGS
There exists a model from previous studies related to hospice care proposed by earlier researchers.Furthermore, a continuous trend in hospice care studies is evident, as shown in Figure 1.Specialized stroke services are associated with a significant reduction in mortality and dependency, as well as hospital stay duration, although not every care model is linked to the same benefits.However, not all care models have the same benefits.A study conducted by Foley, N., Salter, K., and Teasell, R. (2006) aimed to identify and differentiate among three forms of stroke patient care in hospitals based on timing and duration of treatment, as well as to compare clinically important outcomes.This study compared hospice care with conventional care.The study found all three care models were associated with a significant reduction in the likelihood of death and dependency; however, acute stroke units were not associated with a significant reduction in mortality when analyzed separately.The study by Gardiner et al., (2013) demonstrated that palliative and end-of-life care had been accepted as essential components of expert stroke care in UK stroke units.The results align with the aforementioned study as well as with Weckmann et al., (2013) which supported hospice care as a potential measure to provide more effective and suitable care when it is judiciously controlled to manage patient treatment expenditure.Thus, according to the study by Holloway et al., (2010), acute stroke patients need advice from doctors in addition to medication intake and hospice treatment.

Figure 3
Hospice Care Study Trends Furthermore, the study by Zerwekh (1995) found that clinical methods are necessary for hospice nursing practice.This study identified at least 10 competencies of hospice nursing practice based on interviews with 32 hospice nurses.Therefore, this model can be utilized to articulate hospice nursing practice to students, colleagues, and those involved in future healthcare decision-making.
Due to the increasing mortality rate stemming from chronic stroke, the provision of consistent palliative and end-of-life care for these patients has not received adequate attention.
The study conducted by Wee, B., Adams, A., and Eva, G. (2010) found that chronic stroke affects both patients and those involved in their care.Challenges identified in meeting this palliative care involve communication issues and decision-making regarding patient nourishment.Most concerning is that patients who have recovered from the illness are left without follow-up care, leading to some experiencing worse health deterioration, such as physical disabilities and mental distress.Meanwhile, patients involved require consistent care to manage the experienced chronic pain.Savini et al., (2015) suggested improving patientcaregiver interactions and communication prior to stroke infection and making environmental changes to manage patient emotions.This is because chronic stroke significantly impacts the patient and caregiver environment.
Furthermore, Addington-Hall et al., (1995) found that the involvement of medical and nursing knowledge in the palliative treatment of chronic stroke patients can ensure that all these patients will receive quality care treatment.Hence, it becomes a necessity for patients facing themselves.This is due to hospital staff and medical experts not having sufficient time to give attention to patients.As a result, patients will not be aware of the progress and health outcomes due to the constraints.Therefore, the study suggests an improvement in symptom control and psychosocial support for chronic stroke patients.
Additionally, more effective communication between healthcare professionals and patients, as well as their families, is essential.The proficiency of medical staff and nurses caring for chronic stroke patients can help ensure that all these patients receive quality care.The findings of the above study align with the research conducted by Weng et al., (2017), which found that the capabilities of nurses in hospice and palliative care, including knowledge, accuracy, and methods of consultation and collaboration with hospice teams in Emergency Units in Taiwan, through dedicated training and education, can provide significant support to help acute chronic stroke patients.
Even Cowey (2012) strongly emphasizes the need for hospice care for end-of-life stroke patients, providing high-quality patient-centered services for those who have experienced strokes and their families.Spiritual care is a shared responsibility.He also expressed confidence in the potential of the approaches used to be achieved.Meanwhile, Wasserman (2008) also stated that hospice nurses for chronic stroke patients have adopted a method that begins by building therapeutic relationships with families and patients facing the event of death.The outcomes received, and the experiences of each of them are identified and framed within a care plan for chronic stroke patients.
However, not all chronic stroke patients are willing to enroll themselves for hospice treatment.A study conducted by Gelfman et al. (2018) indicated a low number of involved patients.This is because they perceive hospice care as incapable of effecting a cure, which further weakens their experienced health condition.This aspect also impacts the mortality rate of patients undergoing hospice treatment in intensive care units compared to traditional treatment (Harris et al., 2014;Eriksson et al., 2016).The study also suggests the creation of a tailored hospice model may be necessary to increase enrollment and provide benefits to chronic stroke patients.
Furthermore, the provision of hospice or palliative care in nursing care centers can enhance the clinical care received by residents, reduce hospitalization, and improve family members' perception of care (Cimino and McPherson 2014;Bishop et al. 2014)).Reduction in expenditure assistance is needed to aid patients.This is exemplified by the Pharmacy and Therapeutics (PandT) Committee as a management strategy for chronic stroke at Hospice of the Bluegrass in Lexington, Kentucky, which successfully saved significant costs and enhanced pharmacotherapy care for Hospice of the Bluegrass patients.A list of preferred medications has been recommended to patients to effectively manage pain and symptoms (Snapp, Kelley and Gutgsell 2002).However, a study conducted by Molidor et al., (2018) identified weaknesses in access to hospice care for patients and emphasized the need for a model study that integrates hospice care into chronic stroke management.

DISUSSION
Based on discussions from previous studies, there are essential elements in the hospice care model for chronic stroke patients.Several key themes that have been identified include:

HOLISTIC CARE
Quality hospice care for chronic stroke patients should be holistic and involve a multidisciplinary approach (Wasserman 2008).A comprehensive conceptual framework must be utilized to consider the interaction between pre-existing conditions before chronic stroke, new conditions brought about by chronic stroke, and the effects of patient and caregiver environmental variables (Savini et al. 2015;Holloway et al. 2010).This will ensure that the physical, emotional, spiritual, and social aspects of patients and their families are appropriately addressed (Cowey 2012).
A holistic hospice care model helps patients and families feel heard, understood, and comprehensively cared for.A study by Foley et al. (2006) suggested the integration of care for chronic stroke patients and rehabilitation.The study's findings indicated that the combined hospice care model for inpatient chronic stroke patients showed a significant reduction in likelihood of death and neglect.Additionally, there is a need and emphasis on tailoring end-of- The literature of this study demonstrates the significance of quality hospice care for stroke patients nearing the end of life.The effective implementation of a hospice model, the identification of patients at risk of death within six months, and the adaptation of end-of-life care for stroke patients are crucial elements in ensuring quality and suitable hospice care for patients and their families.

SYMPTOM MANAGEMENT
An important component of an effective end-of-life hospice care model (Gardiner et al., 2013) is the management of symptoms in stroke patients, including pain reduction, improved breathing, and monitoring of heart conditions.The establishment of a Pharmacy and Therapeutics Committee as a management strategy for specific hospices has proven effective in reducing costs and improving patient outcomes (Gardiner et al. 2013).The establishment of the Pharmacy and Therapeutics Committee (PandT) assists in developing protocols, guidelines, educational programs, and pharmacy bulletins for nurses, as well as educational materials for patients.This model emphasizes the importance of involving pharmacy experts to ensure better pharmacotherapy care for hospice patients (Snapp et al. 2002).
Furthermore, the hospice care model through telephone interventions for primary caregivers of stroke patients has the potential to reduce healthcare utilization and enhance the quality of life for both stroke patients and their primary caregivers (Bishop et al. 2014).
Therefore, the establishment of a hospice care model within the emergency department for providing end-of-life care to patients in need can identify those who require hospice care and ensure appropriate care in close collaboration between the emergency department and the hospice team.This model holds the potential to serve as a valuable reference for intensive care units in the future to enhance hospice and palliative care at the initial point of patient admission (Snapp et al. 2002).The ability to identify subgroups of patients with low mortality risk helps ensure that hospice care is provided to those in need of comprehensive care, without being disadvantageous for patients with hopes of recovery.The utilization of this model helps ensure the efficient and effective use of hospice resources (Molidor et al. 2018).

EMOTIONAL AND SOCIAL SUPPORT (COMMUNICATION)
A well-designed hospice care model provides emotional and social support to patients and their families.This includes counseling and a network of social support to assist patients and their families in coping with emotional challenges that arise.This is because acute stroke patients experience pain, mental confusion, feelings of sadness, and urinary incontinence in the last year of life (Zerwekh 1995;Foley et al. 2006).Therefore, the provision of hospice care in elderly care institutions can enhance the clinical care received by residents, reduce hospitalization, and improve family members' perceptions of care.Reducing hospitalization is a crucial element in hospice care for stroke patients to alleviate pain and ensure high-quality care (Wee et al. 2010).Additionally, effective communication between healthcare professionals and patients, as well as their families, is essential.Effective communication helps patients and families understand the care process and provides them with sufficient treatment options.
Hence, the inclusion for hospice care participation must be tailored to the individual needs of acute stroke patients (Addington-Hall et al. 1995).By ensuring this element is present in hospice care for acute stroke patients, there can be an enhancement in the quality and effectiveness of care for patients and appropriate support for their families.Quality hospice care can also help alleviate pain and improve the quality of life for patients facing end-of-life strokes.This is crucial to ensure informed treatment decisions are made, with patients and families actively engaged in the end-of-life care process (Cowey 2012).

PATIENT EDUCATION AND TRAINING MODEL
An effective hospice care model provides education and training to patients and their families about disease management, self-care, and home care (Addington-Hall et al. 1995).
Therefore, there is a need for medical and nursing personnel working with acute stroke patients to receive education in hospice care principles, ensuring that all deceased stroke patients receive high-quality care (Harris et al. 2014;Eriksson et al. 2016).This education can help enhance symptom control and psychosocial support for patients who die due to strokes, as well as improve communication between healthcare professionals and patients and their families (Cimino and McPherson 2014).A patient-centered hospice care model ensures that they can experience a meaningful end-of-life and fulfill their religious or spiritual needs.13 The hospice nursing model takes into consideration the essential abilities within hospice nursing practice.This model helps to comprehend and articulate hospice nursing practices to students, colleagues, and those who will make decisions regarding future healthcare.The reduction of mortality and dependency is a primary focus within this care.The study by Gelfman et al. (2018) introduced a crucial aspect in hospice nursing practice by introducing the family nursing model.All these elements can contribute to enhancing the quality of hospice care for stroke patients and their families.
Furthermore, the benefits of hospice care contribute to cost reduction and shorter hospital stays.The study by Weckmann et al. (2013) indicates that enrollment in hospice during terminal admission can lead to decreased costs and duration of patient stays.This shows that hospice care provides more cost-effective and suitable care for patients nearing the end of life (Weng et al. 2017).Hospice care emphasizes improving the quality of life for patients and their families by providing appropriate and timely support during their final moments.

INTERDISCIPLINARY COLLABORATION
Among the characteristics of quality hospice care is the necessity for interdisciplinary collaboration involving healthcare providers, stroke specialists, and other support professionals such as social workers and counselors.This consideration is crucial as a significant step to ensure efficient and effective utilization of hospice resources (Wasserman 2008).To achieve this objective, there is a need for the provision of specialized care involving the integration of acute care and rehabilitation (Cowey 2012).This approach can help reduce the likelihood of mortality and neglect in appropriate care.The study by Molidor et al. (2018) emphasizes the need for a model that integrates palliative care into stroke management.The integration of hospice care throughout a patient's treatment becomes essential to enhance access to hospice care for stroke patients and their families.By ensuring the presence of these elements in hospice care for stroke patients, we can enhance the quality of care, reduce healthcare costs, improve the quality of life for patients and their families, and provide suitable support for stroke patients and their families throughout the disease journey (Holloway et al. 2010).The integration of palliative care into stroke management is key to delivering high-quality hospice services and ensuring the needs of stroke patients are managed and nurtured appropriately.
In summary, quality hospice care for stroke patients involves a holistic conceptual framework, effective communication, anticipatory care planning and delivery, and workers (Qtait 2023).The complexity of fostering these collaborative relationships may pose challenges in realizing an optimal hospice care model.

CONCLUSION
Through the analysis of coding and thematic exploration of past studies related to hospice care models for stroke patients, it can be observed that there are essential elements that must be considered in the development and implementation of an effective hospice care model.
Effective symptom management, holistic care, emotional and social support, patient education, and interdisciplinary collaboration are crucial factors to be taken into account in providing quality care for stroke patients.A comprehensive understanding of the hospice care model is expected to provide a strong foundation for the enhancement of a better and more patient-centric hospice care model for stroke patients.
The findings of this study indicate that the hospice care model provides numerous benefits to stroke patients.The hospice care model can enhance the quality of life for patients by offering holistic care that encompasses physical, emotional, social, and spiritual aspects.
Patients and their families are actively involved in the decision-making process regarding care and treatment.This model also emphasizes hospice care that focuses on pain reduction, improving comfort, and providing emotional support to patients and families.However, there are shortcomings that need attention, such as accessibility to hospice services.
When considering the hospice care model for stroke patients, it is important to recognize the strengths and weaknesses associated with the model.While the emphasis on holistic care, symptom management, emotional and social support, and meaningful quality of life are strengths of the hospice care model, shortcomings such as limited accessibility, significant resource requirements, and the complexity of service coordination need to be addressed.By understanding these factors, we can develop and enhance a hospice care model that provides holistic and quality treatment for stroke patients on their journey towards a meaningful end-oflife experience.
Despite the improvement in end-of-life care for stroke patients, further research and studies related to the care of these patients are needed.Ongoing research contributes to enhancing comprehensive and quality care for patients nearing the end of life due to stroke.

Hospice
Care for Stroke Patients: Analysis of Issues and Challenges in the Hospice Care Model for Chronic Stroke Patients ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.5 | p.1-18 | e05057 | 2024.9 the fate of death to receive comprehensive care and treatment.This study is a result of interviews with patients in twenty health districts in England.The respondents of Addington-Hall et al.'s (1995) study were 237 patients, with over half of the patients reported to have experienced pain (65%), mental confusion (51%), feelings of sadness (57%), and urinary incontinence (56%) in the last year before death.Feedback received from respondents indicated overall dissatisfaction with the treatment received, either from medical experts or caregivers

Hospice
Care for Stroke Patients: Analysis of Issues and Challenges in the Hospice Care Model for Chronic Stroke Patients ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.5 | p.1-18 | e05057 | 2024.11 life care for chronic stroke patients who require specialized care to address symptoms such as death rattle, confusion, shortness of breath, anxiety, and pain.Education and the implementation of effective and integrated hospice care principles become crucial in ensuring quality end-of-life care for all patients.

Hospice
Care for Stroke Patients: Analysis of Issues and Challenges in the Hospice Care Model for Chronic Stroke Patients ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.5 | p.1-18 | e05057 | 2024.14 identification of patients with low mortality risk.With the recognition and understanding of these elements, hospice care for stroke patients can be enhanced and provided in a more effective and efficient manner.While acute stroke hospice care holds advantages, there are shortcomings in the hospice care model that require attention.Among these are: (a) Limited access to hospice services.There are constraints in the distribution of hospice services in certain areas, which may result in some groups of stroke patients being unable to access necessary hospice care.(b) The hospice care model is comprehensive and requires adequate resources, including trained personnel, equipment, and appropriate facilities.Shortages in these resources may limit the available hospice treatment capacity and impact the accessibility and quality of services.(c) An effective hospice care model involves close collaboration and coordination among various healthcare stakeholders, including stroke specialists, family physicians, nurses, counselors, and social