Palliative care for Latino patients and their families: whenever we prayed, she wept

Disparities in Healthcare-Seeking Behavior and Decision Preference Among Hispanics: A Comparative Study Across Races/Ethnicities, SES, and Provider Types

Purpose

Hispanics, the largest minority in America, have increased risk of several medical issues and face noteworthy health disparities. This study compares care-seeking behaviors and choice experience among Hispanics, Asians, Blacks, and Whites, considering SES (income, education, and insurance status) and across five healthcare provider (HCP) types. Concurrent analysis provides a comprehensive view of how and where inequity manifests in healthcare.

Methods

A cross-sectional online survey assessed 1485 adults (Hispanic=314, Asian=313, Black=316, White=542, recruited through a panel agency) of the frequency of visiting primary care providers, dentists, optometrists, gynecologists, and specialists for chronic conditions. Participants also rated the importance of self-selecting a HCP and difficulty in finding one.

Results

Whites visited each HCP most regularly. Compared to Asians, more Hispanics saw specialists regularly (45.1% vs 56.5%, p=0.042), and Blacks saw dentists less (47.0% vs 38.3%, p=0.028) and gynecologists more often (21.2% vs 33.1%, p=0.024). No other frequency differences were observed among minorities. Low-income participants across four races saw dentists and gynecologists with comparable infrequency. Hispanics and Asians assigned similarly significantly lower self-choice importance and experienced more difficulty relative to Whites or Blacks. Participants with lower income or education visited HCPs less regularly yet perceived the same choice importance as higher-SES peers (p>0.05). Notably, discrepancies in visit frequency between Whites and minorities were more pronounced in higher-SES than lower-SES group. Differences in experiencing care-seeking difficulty were associated with income (p=0.029) and insurance type (p=0.009) but not education (p>0.05).

Conclusion

Higher income and education increase healthcare utilization; however, racial disparities persist, particularly among higher-SES groups. Despite similarities among minorities, the extent of disparities varied by SES and provider type. The findings help explain evident inequity in healthcare access and health outcomes. Tailored patient education, culturally-specific navigation support, and more inclusive services are needed to address barriers faced by minorities and disadvantaged populations.

Beyond translation: Transcreation of a clinicians' guide to structure discussions about health-related values with Latinx patients throughout cancer

OBJECTIVE

This study aimed to ensure accurate translation and cultural appropriateness of a guide designed to help oncology clinicians provide person-centered care to Spanish-speaking Latinx patients with cancer.

METHODS

Initial translation of a clinician-patient values discussion guide in open-ended question format ("Guide") was pretested in interviews with 27 Spanish-speaking individuals, followed by national expert panel review. At three sites, semi-structured, in-depth, audio-recorded interviews in the participant's preferred language (Spanish/English) were then conducted with Latinx patients receiving systemic treatment for a solid tumor malignancy and family joining them at clinic.

RESULTS

Interviews of 43 patient/family participants representing diverse Latinx communities addressed the Guide's understandability, acceptability, relevance and responsiveness. Rapid analysis of interviews contributed to cultural adaptation/transcreation of the Guide for a pilot interventional trial.

CONCLUSION

Moving beyond translation to transcreation can help promote inclusion, equity, and cultural sensitivity in oncologic care/communication.

PRACTICE IMPLICATIONS

Clinicians now have a linguistically- and culturally-adapted guide including questions and prompts to help structure discussions in Spanish or English of health-related values with Latinx patients receiving oncologic care.

Physician Perceptions and Beliefs Regarding End-of-Life Care in a Central California Health System

Objective: We sought to describe the preparedness, beliefs, and experience regarding end-of-life (EOL) care for in-training and attending physicians. We hoped to clarify how medical training impacts views about EOL, and topics where physicians desire more EOL training. Methods: An online anonymous survey was sent to 766 physicians who worked at Community Medical Centers in Fresno, California from October to December 2016. Descriptive statistics of the population were compiled. Chi-squared and Mann-Whitney U tests comparing differences in personal experience, and preparedness and confidence with palliative care topics by training level were performed. Results: 195 physicians responded to the survey (25%). Respondents were 42% in-training, 55% male, 57% Caucasian, and 38% Christian. Compared to attendings those in-training were younger, more often female, and more likely to have a DO degree. The 2 groups did not differ in ethnicity, specialty, or religion. Attendings were more likely than those in-training (46% vs 14%, P < .001) to have an advance directive, reported a higher level of formal training in discussing prognosis (P = .037), and had higher confidence with palliative care topics like delivering bad news (P = .002), discussing resuscitation status (P = .015), and discussing the new California EOL Option Act (P < .001). Thirty-two percent of respondents believed patients often starve at EOL. Otherwise, knowledge was 90% correct. Conclusions: Physicians in-training are less prepared to discuss EOL topics. Physicians in-training and attendings desire more education in pain management at EOL.

Adaptation of a Multimedia Chemotherapy Educational Intervention for Latinos: Letting Patient Narratives Speak for Themselves

This study aims to adapt a video-based, multimedia chemotherapy educational intervention to meet the needs of US Latinos with advanced gastrointestinal malignancies. A five-step hybrid adaptation process involved (1) creating a multidisciplinary team with diverse Latino subject experts, (2) appraising the parent intervention, (3) identifying key cultural considerations from a systematic literature review and semi-structured Latino patient/caregiver interviews, (4) revising the intervention, highlighting culturally relevant themes through video interviews with Latino cancer patients, and (5) target population review with responsive revisions. We developed a suite of videos, booklets, and websites available in English and Spanish, which convey the risks and benefits of common chemotherapy regimens. After revising the English materials, we translated them into Spanish using a multi-step process. The intervention centers upon conversations with 12 Latino patients about their treatment experiences; video clips highlight culturally relevant themes (personalismo, familismo, faith, communication gaps, prognostic information preferences) identified during the third adaptation step. The adapted intervention materials included a new section on coping, and one titled "how to feel the best you can feel," which reviews principles of side effect management, self-advocacy, proactive communication, and palliative care. Ten Latinos with advanced malignancies reviewed the intervention and found it to be easily understandable, relatable, and helpful. A five-step hybrid model was successful in adapting a chemotherapy educational intervention for Latinos. Incorporation of video interviews with Latino patients enabled the authentic representation of salient cultural themes. Use of authentic patient narratives can be useful for cross-cultural intervention adaptations.

A qualitative exploration of allied health providers' perspectives on cultural humility in palliative and end-of-life care

BACKGROUND

Cultural factors, including religious or cultural beliefs, shape patients' death and dying experiences, including palliative and end-of-life (EOL) care preferences. Allied health providers must understand their patients' cultural preferences to support them in palliative and EOL care effectively. Cultural humility is a practice which requires allied health providers to evaluate their own values, biases, and assumptions and be open to learning from others, which may enhance cross-cultural interactions by allowing providers to understand patients' perceptions of and preferences for their health, illness, and dying. However, there is limited knowledge of how allied health providers apply cultural humility in palliative and EOL care within a Canadian context. Thus, this study describes Canadian allied health providers' perspectives of cultural humility practice in palliative and EOL care settings, including how they understand the concept and practice of cultural humility, and navigate relationships with patients who are palliative or at EOL and from diverse cultural backgrounds.

METHODS

In this qualitative interpretive description study, remote interviews were conducted with allied health providers who currently or recently practiced in a Canadian palliative or EOL care setting. Interviews were audio-recorded, transcribed, and analyzed using interpretive descriptive analysis techniques.

RESULTS

Eleven allied health providers from the following disciplines participated: speech-language pathology, occupational therapy, physiotherapy, and dietetics. Three themes were identified: (1) Interpreting and understanding of cultural humility in palliative and EOL care (i.e., recognizing positionality, biases and preconceived notions and learning from patients); (2) Values, conflicts, and ethical uncertainties when practicing cultural humility at EOL between provider and patient and family, and within the team and constraints/biases within the system preventing culturally humble practices; (3) The 'how to' of cultural humility in palliative and EOL care (i.e., ethical decision-making in palliative and EOL care, complexities within the care team, and conflicts and challenges due to contextual/system-level factors).

CONCLUSIONS

Allied health providers used various strategies to manage relationships with patients and practice cultural humility, including intra- and inter-personal strategies, and contextual/health systems enablers. Conflicts and challenges they encountered related to cultural humility practices may be addressed through relational or health system strategies, including professional development and decision-making support.

End-of-life communication strategies for healthcare professionals: A scoping review

BACKGROUND

Timely and effective communication about end-of-life issues, including conversations about prognosis and goals of care, are extremely beneficial to terminally ill patients and their families. However, given the context, healthcare professionals may find it challenging to initiate and facilitate such conversations. Hence, it is critical to improving the available communication strategies to enhance end-of-life communication practices.

AIM

To summarise the end-of-life communication strategies recommended for healthcare professionals, identify research gaps and inform future research.

DESIGN

A scoping review performed in accordance with the Arksey and O'Malley framework.

DATA SOURCES

A literature search was conducted between January 1990 and January 2022 using PubMed, CINAHL, Embase, PsycINFO, Web of Science, Scopus, Cochrane Library and China National Knowledge Infrastructure databases and Google, Google Scholar and ProQuest Dissertations & Theses Global. Studies that described recommended end-of-life communication strategies for healthcare professionals were included.

RESULTS

Fifty-nine documents were included. Seven themes of communication strategies were found: (a) preparation; (b) exploration and assessment; (c) family involvement; (d) provision and tailoring of information; (e) empathic emotional responses; (f) reframing and revisiting the goals of care; and (g) conversation closure.

CONCLUSIONS

The themes of communication strategies found in this review provide a framework to integrally promote end-of-life communication. Our results will help inform healthcare professionals, thereby promoting the development of specialised training and education on end-of-life communication.

Palliative and End-of-Life Care Access for Immigrants Living in High-income Countries: A Scoping Review

This scoping review aimed to explore what is known about palliative and End-of-Life (EOL) care access by immigrants with culturally and linguistically diverse (CALD) background living in high-income Organization for Economic Co-operation and Development (OECD) countries. CaLD immigrants have low utilization of palliative care services with patients' family members taking up the role of caring, leading to immigrants not fully benefiting from the specialized services that are offered to alleviate suffering and promote quality of life. While there is some research in this area mainly in Europe, it cannot be said about all high-income OECD countries. Achieving person-centered care in high-income countries, requires identifying and addressing barriers to care access, especially by immigrants with CaLD background. Five-stage methodological framework by Arksey and O'Malley was used to undertake the review. Immigrants in OECD countries experience challenges in accessing palliative and EOL care services. The review also identified limited literature on the subject and establishes need for more research on the subject.

Racial and ethnic differences in retrospective end-of-Life outcomes: A systematic review

The purpose of this systematic review was to provide a comprehensive account of racial and ethnic differences in retrospective end-of-life outcomes. Studies were searched from the following databases: Abstracts in Social Gerontology, Academic Search Premier, CINAHL Plus with Full Text, ERIC, MEDLINE, PsycINFO, PubMED, and SocIndex. Studies were included if they were published in English, included people from groups who have been minoritized, included adults aged 18 and older, used retrospective data, and examined end-of-life outcomes. Results from most of the 29 included studies showed that people from groups who have been minoritized had more aggressive/intensive care, had less hospice care, were more likely to die in a hospital, less likely to engage in advance care planning, less likely to have good quality of care, and experienced more financial burden at the end of life. Implications for practice (timely referrals), policy (health insurance access), and research (intervention studies) are provided.

The Good Death Among Black, Indigenous, and/or People of Color: Which Aspects of a Good Death Are Most Important?

A good death is one where a patient's preferences and wishes are fully respected. The purpose of this study was to determine which aspects of a good death are most important to Black/Indigenous, and/or people of color (BIPOC). Participants were recruited from Amazon Mechanical Turk, and then directed to complete a quantitative survey indicating the importance of each item on the Good Death Inventory. A logistic regression model was used to identify any differences in the importance of each item based on the racial background of the respondent. After accounting for other independent variables, the results showed that BIPOC were more likely to indicate that factors such as life completion, receiving all treatment possible, and religious/spiritual support were important aspects of a good death. Results indicate the need for culturally tailored tools that account for cultural differences in what constitutes a good death.

End-of-life healthcare utilization and palliative care use among older adults with limited English proficiency

BACKGROUND

Little is known about end-of-life healthcare utilization and palliative care use among older adults with serious illness and limited English proficiency (LEP).

METHODS

We conducted a retrospective analysis of seriously-ill older adults (65+) with and without LEP, from a large health system, who died between 2010 and 2018. Primary outcomes were measures of healthcare utilization in the last 30 and 180 days of life: hospitalization, emergency department (ED) visits, intensive care unit (ICU) admission, and 30-day readmission. Secondary outcomes were palliative care consultation and advance care planning documents. We used multivariate analyses adjusted for sociodemographic factors including race and ethnicity.

RESULTS

Among 18,490 decedents, 1363 had LEP. Patients with LEP were older at time of death (median age 80 vs 77 years), more likely to be female (48% vs 44%), of Asian descent (64% vs 4%), of Hispanic ethnicity (10% vs 2%), with <12th grade education (38% vs 9%), and Medicaid (36% vs 6%). In the last 30 days of life, patients with LEP had higher odds of ED visits (33% vs 20%; aOR 1.41, 95% CI 1.26-1.72; p < 0.001), readmission (12% vs 8%; aOR 1.64, 95% CI 1.30-2.07; p < 0.001), and in-hospital death (45% vs 37%; aOR 1.24, 95% CI 1.07-1.44; p = 0.005) compared to patients without LEP. Findings were similar in the last 180-days of life. Only 14% of patients with LEP and 10% of those without LEP received palliative care consultation in the last month of life. Patients with LEP were less likely to have advance care planning documents than patients without LEP (36% vs 40%; aOR 0.68, 95% CI 0.50-0.80; p < 0.001).

CONCLUSIONS

Older adults with serious illness and LEP have higher rates of end-of-life healthcare utilization. Additional research is needed to identify drivers of these differences and inform linguistically- and culturally-appropriate interventions to improve end-of-life care in this population.

Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement

Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration.

Grief and Bereavement in the Latino/a Community: A Literature Synthesis and Directions for Future Research

Introduction

Bereavement and grief are social phenomena influenced by a multitude of cultural factors. Prior studies of bereavement adjustment have primarily focused on bereaved survivors who identify racially as white; knowledge of the experience of grief and bereavement among racial/ethnic and other minority groups, particularly among Latino/a groups, in the United States is limited.

Objective

The purpose of this review is to synthesize the literature documenting the bereavement experiences of the Latino/a community, evaluate the strength of the current evidence, and provide recommendations to guide future research.

Method

A narrative review of research on grief and bereavement in the Latino/a community published between 1990 and 2021. Two authors used a thematic, deductive approach to categorize emergent prevalent themes from the literature and used The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) and The Oxford Center for Evidence-Based Medicine-Evidence Quality Rating Scale (OCEBM) approaches to evaluate the strength of the qualitative and quantitative reports reviewed.

Results

Searches revealed 26 reports that were categorized into six themes: cultural values, mourning rituals, immigration, spirituality, disparities related to the COVID-19 pandemic, and the effects of COVID-19 on Latino/a communities. Our evaluation concludes that the evidence in this area is weak, with limited methodologically rigorous research examining the influence of culture on bereavement among Latino/a groups.

Conclusion

Research is needed to identify Latino/a groups' mental health, cultural, social, and family needs and how fulfillment of mourning rituals and other cultural factors may promote or impede bereavement adjustment. Investigation into factors that may protect bereaved survivors against adverse mental health outcomes is also needed. A better understanding of Latino/a grief and bereavement is a step toward the development of culturally competent interventions designed to promote the mental health and psychosocial adjustment of Latino/a mourners.

Important End-of-Life Topics among Latino Patients and Caregivers Coping with Advanced Cancer

There is a known end-of-life related disparity among Latino individuals, and there is a need to develop culturally sensitive interventions to help patients and caregivers cope with advanced cancer. Latino patients and caregivers coping with advanced cancer were asked to list important end-of-life topics to culturally inform a psychosocial intervention adaptation process. A qualitative study was conducted, and semi-structured interviews were performed, audio-recorded, and transcribed. Recordings and transcriptions were reviewed and analyzed using thematic content coding. The semi-structured interview described and demonstrated intervention components and elicited feedback about each. Free listing method was used to assess important topics among Latino advanced cancer patients (n = 14; stage III and IV) and caregivers. Patients and caregivers were given a list of 15 topics and asked which topics they deemed important to integrate into the intervention. Overall, more than half of the participants considered it important to include 13 of the 15 topics related to daily activities (eight subcategories), psychosocial support (three subcategories), discussing diagnosis and support (three subcategories), and financial difficulties (one subcategory). Patient-caregivers reported importance in most end-of-life topics. Future research and intervention development should include topics related to psychosocial support, daily activities, discussing diagnosis and support, and financial difficulties.

Palliative Care Utilisation Among Non-Western Migrants in Denmark: A Qualitative Study Of the Experiences of Patients, Family Caregivers and Healthcare Professionals

This study explores care experiences while utilising palliative care services of non-western migrant families from the perspectives of patients, family caregivers, and healthcare professionals in Denmark. Twenty-three semi-structured individual and group interviews were conducted among eight patients with a life-threatening disease, 11 family caregivers, and ten healthcare professionals. Thematic analysis revealed three themes: 1) Communication between families and healthcare professionals; 2) Building and lack of trusting relations, and feeling safe, and 3) Access to information and navigating in the healthcare system. Moreover, ''language and culture'' emerged as transaction themes that are not mutually exclusive, however, interconnect across the mentioned three themes. Non-western migrant families can be supported by healthcare professionals' cultural competency training, negotiating on providing services concerning information, patient preferences, family involvement, and palliative care setting. This study findings urge inter-sectoral collaboration to ensure needs-oriented and linguistically and culturally appropriate palliative care services for non-western migrant families in Denmark.

Rural Hispanic/Latino cancer patients’ perspectives on facilitators, barriers, and suggestions for advance care planning: A qualitative study

Objective

Hispanic/Latinos living in rural areas have limited healthcare resources, including palliative and hospice care. Moreover, little is known about advance care planning (ACP) among Hispanic/Latino cancer patients in rural areas. This study explores facilitators and barriers for ACP. It elicits suggestions to promote ACP among rural Hispanic/Latino cancer patients in a US/Mexico border region.

Methods

Hispanic/Latino cancer patients (n = 30) were recruited from a nonprofit cancer organization. Data were collected via in-person interviews. Interviews were transcribed and translated from Spanish to English. Data were uploaded into NVivo 12 and analyzed using thematic analysis.

Results

A common theme for facilitators and barriers for ACP was safeguarding family. Additional facilitators included (1) Desire for honoring end-of-life (EoL) care wishes and (2) experience with EoL care decision making. Additional barriers include (1) Family's reluctance to participate in EoL communication and (2) Patient–clinicians’ lack of EoL communication. Practice suggestions include (1) Death education and support for family, (2) ACP education, and (3) Dialogue vs. documentation.

Significance of results

ACP functions not only as a decisional tool; its utility reflects complex dynamics in personal, social, and cultural domains. ACP approaches with this underserved population must consider family relationships as well as cultural implications, including language barriers.

Perspectives on Kidney Disease Education and Recommendations for Improvement Among Latinx Patients Receiving Emergency-Only Hemodialysis

IMPORTANCE

In most states, undocumented Latinx immigrants with kidney failure receive dialysis in acute care settings on an emergency-only basis. How much kidney disease education Latinx immigrants receive and how to improve kidney disease education and outreach among Latinx populations are unknown.

OBJECTIVE

To understand the kidney disease educational gaps of Latinx individuals who need but lack access to scheduled outpatient dialysis.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study used semistructured interviews in a Texas hospital system from March 2020 to January 2021 with 15 individuals who received emergency-only dialysis when they were first diagnosed with kidney failure. Demographic information was collected, and a thematic analysis was performed using the constant comparative method on interviews after they were audio-recorded, translated, and transcribed verbatim. Data analysis was performed from April 2020 to February 2021.

MAIN OUTCOMES AND MEASURES

Subthemes and themes from semistructured interviews.

RESULTS

All 15 persons interviewed (9 male individuals [60%]; mean [SD] age, 51 [17] years) identified as Hispanic, 11 (73%) were born in Mexico, and none reported knowing about their kidney disease more than 6 months before starting dialysis. The themes identified were (1) lack of kidney disease awareness, (2) education provided was incomplete and poor quality, (3) lack of culturally concordant communication and care, (4) elements that Latinx patients receiving emergency-only dialysis want in their education, (5) facilitators of patient activation and coping, and (6) Latinx patient recommendations to improve community outreach.

CONCLUSIONS AND RELEVANCE

Latinx adults receiving emergency-only dialysis are usually unaware of their kidney disease until shortly before or after they start dialysis, and the education they receive is poor quality and often not culturally tailored. Participants made feasible recommendations on how to improve education and outreach among Latinx communities.

Overcoming Disparities in Cancer: A Need for Meaningful Reform for Hispanic and Latino Cancer Survivors

Hispanic and Latino (HL) cancer survivors are at a critical disadvantage compared with non-Hispanic White (NHW) patients regarding sociodemographic adversities and access to equitable treatment options. By 2030, there will be about four million HL cancer survivors in the U.S., representing nearly 20% of survivors in this country. Hispanics and Latinos are subjected to significant challenges in accessing and receiving equitable care relative to NHWs. Hispanics and Latinos also experience lower rates of health insurance and financial resources, limiting health care options. These disparities often originate from disparate social determinants of health, including lower funding for education and school programs, greater neighborhood stressors and violence, lower access to healthy and affordable food, and greater barriers to community health and exercise opportunities. Even among HL cancer survivors with proper access to health care, they experience disparate treatment options, including low inclusion in clinical trials and/or access to experimental therapies. A solution to these barriers necessitates complex and systemic changes that involve, for example, investing in public health programs, increasing the diversity and cultural awareness of the medical workforce, and promoting research opportunities such as clinical trials that are inclusive of HLs. Only through meaningful reform will equitable cancer care be available for all in the U.S. regardless of racial and/or ethnic background. This article reviews some of the critical social determinants of health and biases relevant to HL cancer survivors and provides recommendations for achieving cancer health equity. IMPLICATIONS FOR PRACTICE: Hispanics and Latinos experience a significant and often disproportionate cancer-related burden compared with non-Hispanic and Latino White individuals and other racial and ethnic groups. Meaningful reform to achieve health equity in oncology should focus on approaches to gaining trust among diverse patients, cultural and community sensitivity and engagement in oncology care and research, diversifying the workforce, and improving inclusion in clinical trial participation. Taken together, these recommendations can lead to exemplary and equitable care for all patients.

"Are They Saying It How I'm Saying It?" A Qualitative Study of Language Barriers and Disparities in Hospice Enrollment

CONTEXT

Language barriers contribute significantly to disparities in end-of-life (EOL) care. However, the mechanisms by which these barriers impact hospice care remains underexamined.

OBJECTIVES

To gain a nuanced understanding of how language barriers and interpretation contribute to disparities in hospice enrollment and hospice care for patients with limited English proficiency.

METHODS

Qualitative, individual interviews were conducted with a variety of stakeholders regarding barriers to quality EOL care in diverse patient populations. Interviews were audiorecorded and transcribed verbatim. Data were coded using NVivo 11 (QSR International Pty Ltd., Melbourne, Australia). Three researchers analyzed all data related to language barriers, first individually, then in group meetings, using a grounded theory approach, until they reached consensus regarding themes. Institutional review board approval was obtained.

RESULTS

Twenty-two participants included six nurses/certified nursing assistants, five physicians, three administrators, three social workers, three patient caregivers, and two chaplains, self-identifying from a variety of racial/ethnic backgrounds. Three themes emerged regarding language barriers: 1) structural barriers inhibit access to interpreters; 2) variability in accuracy of translation of EOL concepts exacerbates language barriers; and 3) interpreters' style and manner influence communication efficacy during complex conversations about prognosis, goals of care, and hospice. Our theoretical model derived from the data suggests that Theme 1 is foundational and common to other medical settings. However, Theme 2 and particularly Theme 3 appear especially critical for hospice enrollment and care.

CONCLUSION

Language barriers present unique challenges in hospice care because of the nuance and compassion required for delicate goals of care and EOL conversations. Reducing disparities requires addressing each level of this multilayered barrier.

Overcoming Disparities in Cancer: A Need for Meaningful Reform for Hispanic and Latino Cancer Survivors

Hispanic and Latino (HL) cancer survivors are at a critical disadvantage compared with non-Hispanic White (NHW) patients regarding sociodemographic adversities and access to equitable treatment options. By 2030, there will be about four million HL cancer survivors in the U.S., representing nearly 20% of survivors in this country. Hispanics and Latinos are subjected to significant challenges in accessing and receiving equitable care relative to NHWs. Hispanics and Latinos also experience lower rates of health insurance and financial resources, limiting health care options. These disparities often originate from disparate social determinants of health, including lower funding for education and school programs, greater neighborhood stressors and violence, lower access to healthy and affordable food, and greater barriers to community health and exercise opportunities. Even among HL cancer survivors with proper access to health care, they experience disparate treatment options, including low inclusion in clinical trials and/or access to experimental therapies. A solution to these barriers necessitates complex and systemic changes that involve, for example, investing in public health programs, increasing the diversity and cultural awareness of the medical workforce, and promoting research opportunities such as clinical trials that are inclusive of HLs. Only through meaningful reform will equitable cancer care be available for all in the U.S. regardless of racial and/or ethnic background. This article reviews some of the critical social determinants of health and biases relevant to HL cancer survivors and provides recommendations for achieving cancer health equity. IMPLICATIONS FOR PRACTICE: Hispanics and Latinos experience a significant and often disproportionate cancer-related burden compared with non-Hispanic and Latino White individuals and other racial and ethnic groups. Meaningful reform to achieve health equity in oncology should focus on approaches to gaining trust among diverse patients, cultural and community sensitivity and engagement in oncology care and research, diversifying the workforce, and improving inclusion in clinical trial participation. Taken together, these recommendations can lead to exemplary and equitable care for all patients.

Mistrust Reported by US Mexicans With Cancer at End of Life and Hospice Enrollment

Hospice research with Hispanics mostly focuses on cultural barriers. Mindful of social justice and structural violence, we used critical grounded theory in a postcolonial theory framework to develop a grounded theory of hospice decision making in US Mexicans with terminal cancer. Findings suggest that hospice avoidance is predicted by mistrust, rather than culture, whereas hospice enrollers felt a sense of belonging. Cultural accommodation may do little to mitigate hospice avoidance rooted in discrimination-fueled mistrust. Future research with nondominant populations should employ research designs mitigating Eurocentric biases. Policy makers should consider concurrent therapy for nondominant populations with low trust in the health care system.

Depressive symptoms in child caregivers of very old Mexican Americans

OBJECTIVE

To study the effects of disability, cognitive impairment, and neuropsychiatric disturbance among older Mexican Americans on depressive symptoms in their children caregivers.

METHODS

This study utilizes data from Wave 7 (2010-2011) of the Hispanic Established Populations for the Epidemiologic Study of the Elderly (HEPESE). The final sample included 200 adult children caregivers that provided direct personal care with activities of daily living (ADL) (e.g. bathing, toileting, dressing, etc.) to their older parents (average age = 87). We analyzed the influence of ADL disability, cognition (MMSE), and neuropsychiatric symptoms (NPI) of the care recipient on depressive symptoms of the adult child caregiver. A cross-sectional multivariable linear regression analysis was conducted to examine the effect of neuropsychiatric disturbance on caregiver depressive symptoms.

RESULTS

Presence of care recipient NPI symptoms was associated with higher depressive symptoms for caregivers. Additional characteristics associated with caregiver depressive symptoms were not being married, and higher perceived social stress. ADL disability of the care recipient, cognitive functioning of the care recipient, or caregiver health status alone did not have a significant effect on depressive symptoms of the caregiver.

CONCLUSIONS

In a Mexican American familistic culture, disability and cognitive impairment might be better tolerated by families but neuropsychiatric behavioral symptoms related to dementia may take an increased toll on family member caregivers. The need to provide respite services, mental health resources and community services for caregivers of care recipients with neuropsychiatric symptoms is of paramount importance to alleviate depressive symptoms and burden among caregivers.

Racial/Ethnic Disparities in Hospice Utilization Among Medicare Beneficiaries Dying from Pancreatic Cancer

BACKGROUND

We sought to define the incidence and characterize the timing of hospice utilization among racial/ethnic minority patients following pancreatectomy for pancreatic cancer.

METHODS

The Medicare Standard Analytic Files from 2013 to 2017 were used to identify patients with pancreatic cancer who underwent a pancreatectomy. Logistic regression was utilized to identify the association between race and patterns of hospice utilization among deceased individuals.

RESULTS

Among the 14,495 individuals (median age 73; 52.3% female; 6.8% racial/ethnic minority) who underwent a pancreatectomy for pancreatic cancer, 47% (n = 6859) died by the end of the follow-period. Among deceased individuals, three-fourths of patients (n = 4978, 72.6%) used hospice leading up to the time of death. Racial/ethnic minority patients were less likely, however, to have used hospice services compared with white patients (racial/ethnic minorities n = 301, 67% vs. whites: n = 4677, 73%; p = 0.024). On multivariable analysis, after controlling for clinical factors, racial/ethnic minority patients remained 22% less likely than whites to initiate hospice services prior to death (OR 0.78, 95% CI 0.63-0.96). Despite overall lower use of hospice, racial/ethnic minority patients had comparable odds of late hospice utilization (i.e., within 3 days of death) versus white patients (OR 1.5, 95% CI 0.73-1.50).

DISCUSSION

While most patients undergoing pancreatectomy for pancreatic cancer utilized hospice services prior to death, racial/ethnic minorities were less likely to use hospice services than whites.

Association between Receipt of Emotional Support and Caregivers' Overall Hospice Rating

Background: A major goal of hospice care is to provide individually tailored emotional and spiritual support to caregivers of hospice patients. Objectives: Examine the association between reported emotional support and caregivers' overall rating of hospice care, overall and by race/ethnicity/language. Subjects: We analyzed survey data corresponding to 657,805 decedents/caregivers who received care from 3160 hospice programs during January 2017-December 2018. Measurements: Linear regression models examined the association between caregiver-reported receipt of emotional and spiritual support ("too little" vs. "right amount" vs. "too much") and overall rating of the hospice (0 vs. 100 rating). Interaction terms assessed variation in this association by race/ethnicity/language. Results: "Too much" emotional support was less common than "too little," except for caregivers of Hispanic decedents responding in Spanish. "Too little" support was strongly associated with lower hospice ratings for all groups (compared to "right amount" of support, p < 0.001). In contrast, the negative association between "too much" support and hospice rating was much smaller (p < 0.001) among caregivers of white and black decedents. "Too much" support was associated with more positive ratings among caregivers of Hispanic decedents (p < 0.001). Conclusions: Receipt of "too much" support is a less common and much weaker driver of poor hospice ratings than receipt of "too little" support for all groups, and is not always viewed negatively. This suggests that for hospice evaluation, "too much" support should not be scored equivalently to "too little" support and that providing enough support should be a hospice priority.

"Maintaining hope:" challenges in counseling latino patients with advanced cancer

BACKGROUND

Latino cancer patients are at risk of poor psychological adjustment. Therapeutic effectiveness in treating Latino cancer patients with advanced cancer requires managing distress, therapeutic skill, and cultural competency. This mixed-methods study explored mental health providers' perceptions of the challenging aspects of counseling and caring for Latino patients with advanced cancer.

METHODS

Mental health providers providing services to Latino or Hispanic cancer patients received an emailed web-based survey with open- and closed-ended questions. Providers included psychiatrists, psychologists, social workers, counselors, and other mental health professionals. We invited 154 providers to participate from July 2015 to January 2017. One hundred and four accessed the survey, and 66 eligible providers responded, for a response rate of 43%. Analyses were used to explore whether clinical experience factors and training characteristics were associated with perceiving conversations about cancer (diagnosis, prognosis, and end-of-life) as challenging. Second, the challenging aspects of these conversations were explored qualitatively. Four independent coders coded responses; an inductive content analysis was utilized to analyze the data.

RESULTS

Mental health providers describe encountering many challenges in their therapeutic discussions with Latino cancer patients.

CONCLUSIONS

It is imperative to understand the factors associated with the perceived difficulty of these conversations, as well as the characteristics of these conversations, to develop culturally sensitive interventions and programs for patients and training interventions for providers.

Patient Risk Factor Profiles Associated With the Timing of Goals-of-Care Consultation Before Death: A Classification and Regression Tree Analysis

BACKGROUND

Early palliative care consultation ("PCC") to discuss goals-of-care benefits seriously ill patients. Risk factor profiles associated with the timing of conversations in hospitals, where late conversations most likely occur, are needed.

OBJECTIVE

To identify risk factor patient profiles associated with PCC timing before death.

METHODS

Secondary analysis of an observational study was conducted at an urban, academic medical center. Patients aged 18 years and older admitted to the medical center, who had PCC, and died July 1, 2014 to October 31, 2016, were included. Patients admitted for childbirth or rehabilitationand patients whose date of death was unknown were excluded. Classification and Regression Tree modeling was employed using demographic and clinical variables.

RESULTS

Of 1141 patients, 54% had PCC "close to death" (0-14 days before death); 26% had PCC 15 to 60 days before death; 21% had PCC >60 days before death (median 13 days before death). Variables associated with receiving PCC close to death included being Hispanic or "Other" race/ethnicity intensive care patients with extreme illness severity (85%), with age <46 or >75 increasing this probability (98%). Intensive care patients with extreme illness severity were also likely to receive PCC close to death (64%) as were 50% of intensive care patients with less than extreme illness severity.

CONCLUSIONS

A majority of patients received PCC close to death. A complex set of variable interactions were associated with PCC timing. A systematic process for engaging patients with PCC earlier in the care continuum, and in intensive care regardless of illness severity, is needed.

Do Hispanics prefer to be full code at the end of life? The impact of palliative care consults on clarifying code status preferences and hospice referrals in Spanish-speaking patients

BACKGROUND

Hispanics often have disparities at the end of life. They are more likely to die full code and less likely to have discussions regarding prognosis and do not resuscitate (DNR)/do not intubate (DNI), despite studies showing Hispanic values comfort over the extension of life. Barriers to patient-centered care include language,socioeconomic status and health literacy.

CONTEXT

We evaluated the impact of palliative care (PC) consults on the change of code status and hospice referrals, comparing seriously ill Hispanic and non-Hispanic white patients.

METHOD

A retrospective cohort study of all white and Hispanic patients referred to the PC service of a county hospital from 2006 to 2012. We evaluated ethnicity, language, code status at admission and after PC consult, and hospice discharge. Chi-squared tests were used to analyze characteristics among three groups: non-Hispanic white, English-speaking Hispanic, and Spanish-speaking Hispanic patients.

RESULTS

Of 925 patients, 511 (55%) were non-Hispanic white, 208 (23%) were English-speaking Hispanic, and 206 (22%) were Spanish-speaking Hispanic patients. On admission, there was no statistically significant difference in code status among the three groups (57%, 64%, and 59% were full code, respectively, p = 0.5). After PC consults, Spanish-speaking Hispanic patients were more likely to change their code status to DNR/DNI when compared with non-Hispanic white and English-speaking Hispanic patients (44% vs. 32% vs. 28%, p = 0.05). Spanish-speaking Hispanic patients were more likely to be discharged to hospice when compared with English-speaking Hispanics and non-Hispanic whites (33%, 29%, and 23%, respectively, p = 0.04).

SIGNIFICANCE OF RESULTS

Spanish-speaking Hispanic patients were more likely to change from full code to DNR/DNI compared with non-Hispanic white and English-speaking Hispanic patients, despite similar code status preferences on admission. They were also more likely to be discharged to hospice. PC consults may play an important role in helping patients to align their care with their values and may prevent unwanted aggressive interventions at the end of life.

Challenges and facilitators of hospice decision-making: a retrospective review of family caregivers of home hospice patients in a rural US-Mexico border region-a qualitative study

OBJECTIVES

Hospice care (HC) is seen as a comprehensive approach, that enhances quality of end-of-life (EOL) care, for terminally ill patients. Despite its positive aspects, HC enrolment is disproportionate for rural patients, who are less likely to use HC in comparison to their urban counterparts. The purpose of this study was to explore decision-making experiences, related to utilisation of HC programmes from a retrospective perspective, with family caregivers (FCGs) in a rural US-Mexico border region.

DESIGN

This qualitative study was conducted from May 2017 to January 2018 using semistructured face to face interviews with FCGs. Data were analysed using thematic analysis.

SETTING

The HC programme was situated at a local home health agency, located in rural Southern California, USA.

PARTICIPANTS

Twenty-eight informal FCGs of patients who were actively enrolled in the HC programme agreed to participate in the study.

RESULTS

Conversation about HC as an option was initiated by home healthcare staff (39.3%), followed by physicians (32.1%). Emerging themes related to challenges in utilisation of HC and decision-making included: (1) communication barriers; (2) lack of knowledge/misperception about HC; (3) emotional difficulties, including fear of losing their patient, doubt and uncertainty about the decision, denial and (4) patients are not ready for HC. Facilitators included: (1) patient's known EOL wishes; (2) FCG-physician EOL communication; (3) the patient's deteriorating health and (4) home as the place for death.

CONCLUSIONS

HC patients' FCGs in this rural region reported a lack of knowledge or misunderstanding of HC. It is recommended that healthcare providers need to actively engage family members in patient's EOL care planning. Optimal transition to an HC programme can be facilitated when FCGs are informed and have a clear understanding about patients' medical status along with information about HC.

End-of-Life Decision-Making for ICU Patients With Limited English Proficiency: A Qualitative Study of Healthcare Team Insights

OBJECTIVES

Research indicates that the increasing population of over 25 million people in the United States who have limited English proficiency experience differences in decision-making and subsequent care at end of life in the ICU when compared with the general population. The objective of this study was to assess the perceptions of healthcare team members about the factors that influence discussions and decision-making about end of life for patients and family members with limited English proficiency in the ICU.

DESIGN

Qualitative study using semistructured interviews with ICU physicians, nurses, and interpreters.

SETTING

Three ICUs at Mayo Clinic Rochester.

SUBJECTS

Sixteen ICU physicians, 12 ICU nurses, and 12 interpreters.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

We conducted 40 semistructured interviews. We identified six key differences in end-of-life decision-making for patients with limited English proficiency compared with patients without limited English proficiency: 1) clinician communication is modified and less frequent; 2) clinician ability to assess patient and family understanding is impaired; 3) relationship building is impaired; 4) patient and family understanding of decision-making concepts (e.g., palliative care) is impaired; 5) treatment limitations are often perceived to be unacceptable due to faith-based and cultural beliefs; and 6) patient and family decision-making styles are different. Facilitators of high-quality decision-making in patients with limited English proficiency included: 1) premeeting between clinician and interpreter; 2) interpretation that communicates empathy and caring; 3) bidirectional communication of cultural perspectives; 4) interpretation that improves messaging including appropriate word choice; and 5) clinician cultural humility.

CONCLUSIONS

End-of-life decision-making is significantly different for ICU patients with limited English proficiency. Participants identified several barriers and facilitators to high-quality end-of-life decision-making for ICU patients and families with limited English proficiency. Awareness of these factors can facilitate interventions to improve high-quality, compassionate, and culturally sensitive decision-making for patients and families with limited English proficiency.

The Use of a Mobile Application to Increase Access to Interpreters for Cancer Patients With Limited English Proficiency: A Pilot Study

BACKGROUND

Language barriers can influence the quality of health care and health outcomes of limited English proficient patients with cancer. The use of medical interpretation services can be a valuable asset for improving communications in emergency care settings.

OBJECTIVE

To evaluate whether a mobile translation application increased call frequency to interpreter services among providers in an Urgent Care Center at a comprehensive cancer center and to assess provider satisfaction of the mobile application.

RESEARCH DESIGN

Prospective pre-post nonrandomized intervention of a mobile translation application with access to an over the phone interpreter (OPI) service at the push of a button and poststudy satisfaction survey.

SUBJECTS

Sixty-five clinicians working at the Urgent Care Center in a cancer center in New York City.

MEASURES

Mean call frequency to OPI services, tested by the nonparametric Wilcoxon Mann Whitney test, and self-reported provider satisfaction descriptives.

RESULTS

The mobile application contributed to increasing the frequency of phone calls to OPI services during the intervention period (mean=12.8; P=0.001) as compared with the preintervention period (mean=4.3), and showed continued use during the postintervention period (mean=5.7). Most clinicians were satisfied with the use of the mobile application and access to the OPI services.

CONCLUSIONS

The results suggest that mobile application tools contribute to increasing the use and ease of access to language services. This has the potential to improve the quality of communication between medical providers and limited English proficient patients in the delivery of cancer care in urgent care settings.

Missed Opportunities When Communicating With Limited English-Proficient Patients During End-of-Life Conversations: Insights From Spanish-Speaking and Chinese-Speaking Medical Interpreters

CONTEXT

Research has shown that using medical interpreters in language-discordant patient-provider encounters improves outcomes. There is limited research evaluating the views of medical interpreters on best interpreter practices when they are used to break bad news or participate in end-of-life (EOL) conversations.

OBJECTIVES

To develop insights from medical interpreters about their role when interpreting discussions regarding EOL issues, identify practices interpreters perceive as helping to improve or hinder patient-provider communication, and obtain suggestions on how to improve communication during EOL conversations with Spanish-speaking and Chinese-speaking patients.

METHODS

Semistructured interviews were conducted with Spanish or Chinese medical interpreters. Participants were recruited until thematic saturation was reached. Twelve interviews were conducted, audiotape recorded, transcribed, and analyzed using standard qualitative methods.

RESULTS

Six major themes were identified: medical interpreters' perceived comfort level during EOL interpretation; perception of interpreter role; communication practices perceived as barriers to effective communication; communication practices felt to facilitate effective communication; concrete recommendations how to best use medical interpreters; and training received/perceived training needs.

CONCLUSION

Medical interpreters provide literal interpretation of the spoken word. Because of cultural nuances in Chinese-speaking and Spanish-speaking patients/family members during EOL conversations, medical interpreters can translate the meaning of the message within a specific cultural context. Conducting premeetings and debriefings after the encounter are potentially important strategies to maximize communication during EOL conversations.

Racial/Ethnic Differences in Dialysis Discontinuation and Survival after Hospitalization for Serious Conditions among Patients on Maintenance Dialysis

BACKGROUND

Racial and ethnic minorities on dialysis survive longer than whites, and are less likely to discontinue dialysis. Both differences have been attributed by some clinicians to better health among minorities on dialysis.

METHODS

To test if racial and ethnic differences in dialysis discontinuation reflected better health, we conducted a retrospective cohort study of survival and dialysis discontinuation among patients on maintenance dialysis in the US Renal Data System after hospitalization for either stroke (n=60,734), lung cancer (n=4100), dementia (n=40,084), or failure to thrive (n=42,950) between 2003 and 2014. We examined the frequency of discontinuation of dialysis and used simulations to estimate survival in minorities relative to whites if minorities had the same pattern of dialysis discontinuation as whites.

RESULTS

Blacks, Hispanics, and Asians had substantially lower frequencies of dialysis discontinuation than whites in each hospitalization cohort. Observed risks of mortality were also lower for blacks, Hispanics, and Asians. In simulations that assigned discontinuation patterns similar to those found among whites across racial and ethnic groups, differences in survival were markedly attenuated and hazard ratios approached 1.0. Survival and dialysis discontinuation frequencies among American Indians and Alaska Natives were close to those of whites.

CONCLUSIONS

Racial and ethnic differences in dialysis discontinuation were present among patients hospitalized with similar health events. Among these patients, survival differences between racial and ethnic minorities and whites were largely attributable to differences in the frequency of discontinuation of dialysis.

Meaning-Centered Psychotherapy for Latino Patients with Advanced Cancer: Cultural Adaptation Process

Background: Latino patients with advanced cancer need culturally responsive, effective psychotherapeutic interventions that can assist them in coping with their diagnosis and improve spiritual and existential well-being and psychological adjustment. Objective: This study describes the cultural and linguistic adaptation of individual meaning-centered psychotherapy for Latinos with advanced cancer. Design: A mixed-methods, concurrent integrative approach was used for this study, using the ecological validity and cultural adaptation process models as frameworks for cultural adaptation. Setting/Subjects and Measurements: Quantitative and qualitative data were collected through (1) a survey of mental health professionals (n = 70) who offer services to Latino cancer patients; (2) a questionnaire for Latino patients with advanced cancer (n = 54), measuring relevant intervention concepts; and (3) in-depth interviews with 24 Latino patients. Results: Quantitative findings showed that most of the goals and concepts were highly acceptable for patients and providers. The qualitative findings supported adaptations to include using more simple definitions; changing phrases that are challenging to translate and comprehend; using words that are common to all Latino cultures, providing more than one option if needed; simplifying the questions/reflections, as needed; changing the metaphors to be culturally congruent; and modifying content to make it responsive to Latino cultural values and norms. Conclusions: Findings demonstrate the need for adaptation to achieve the aims of the intervention, accounting for both linguistic and cultural considerations, emphasizing issues related to literacy, cultural and linguistic diversity, cultural values, and culturally congruent content. The mixed-methods approach is described to provide recommendations for clinicians, researchers, and program developers.

Family members' experiences of assisted dying: A systematic literature review with thematic synthesis

BACKGROUND

Families' experiences of assisted dying are under-investigated and families are rarely considered in clinical guidelines concerning assisted dying.

AIM

To systematically review family experiences of assisted dying.

DESIGN

A systematic literature review using thematic synthesis.

DATA SOURCES

MEDLINE, Embase, CINAHL, AMED (Allied and Complementary Medicine) and PsycINFO databases (January 1992 to February 2019). Studies investigating families' experiences on the practice of legalised assisted dying were included. We excluded studies prior to legalisation within the jurisdiction, secondary data analysis and opinion papers.

RESULTS

Nineteen articles met the inclusion criteria. Publications were derived from four countries: The Netherlands, United States (Oregon, Washington and Vermont), Canada and Switzerland. Dutch studies predominately investigated family involvement in euthanasia, while Swiss and American studies only reported on assisted suicide. Eleven studies had a qualitative design, using predominately in-depth interviews; seven were retrospective surveys. Five analytical themes represented families' experiences in assisted dying: (1) context of the decision, (2) grounding the decision, (3) cognitive and emotional work, (4) experiencing the final farewell and (5) grief and bereavement. The results showed that families can be very involved in supporting patients seeking assisted dying, where open communication is maintained. Family involvement appeared to be influenced by the type of legislation in their country and the families' perception of the social acceptability of assisted dying.

CONCLUSION

Our data confirm that families across all jurisdictions are involved in assisted suicide decision and enactment. Family needs are under-researched, and clinical guidelines should incorporate recommendations about how to consider family needs and how to provide them with evidence-based tailored interventions.

Outcomes of in-hospital cardiopulmonary resuscitation for patients with end-stage liver disease

BACKGROUND AND AIMS

There have been improving survival trends after in-hospital cardiac arrest for the general population, but there is limited information on the outcomes of hospitalized patients with end-stage liver disease (ESLD) who undergo cardiopulmonary resuscitation (CPR). We aimed to examine survival to hospital discharge after receipt of in-hospital CPR in patients with ESLD using a nationally representative sample.

METHODS

We used the Nationwide Inpatient Sample database from 2006 to 2014 to identify adult patients who underwent in-hospital CPR. Using multivariate modelling, we compared survival to hospital discharge for patients with ESLD to those without ESLD. We also compared outcomes of patients with ESLD to patients with metastatic cancer.

RESULTS

A total of 177 533 patients underwent in-hospital CPR, of which 1474 (0.8%) had ESLD. Patients with ESLD had lower rates of survival to hospital discharge compared to patients without ESLD (10.7% vs 28.6%, P < 0.01). In multivariate modelling, ESLD was significantly associated with lower odds of survival to hospital discharge after in-hospital CPR (OR 0.35, 95% CI 0.28-0.44, P < 0.01). Among survivors of in-hospital CPR, ESLD patients had a significantly lower chance of discharge to home compared to patients without ESLD (3.2% vs 8.0%, P < 0.05). Patients with ESLD also had lower rates of survival to hospital discharge compared to those with metastatic cancer (10.7% vs 15.5%, P < 0.01).

CONCLUSIONS

Outcomes are poor after in-hospital CPR in patients with ESLD and are worse than for patients with metastatic cancer. The current analysis can be used to inform goals of care discussions for patients with ESLD.

A scale to assess religious beliefs in end-of-life medical care

BACKGROUND

Studies postulate that certain religious beliefs related to medical care influence the end-of-life (EOL) medical decision making and care of patients with advanced cancer. Because to the best of the authors' knowledge no current measure explicitly assesses such beliefs, in the current study the authors introduced and evaluated the Religious Beliefs in EOL Medical Care (RBEC) scale, a new measure designed to assess religious beliefs within the context of EOL cancer care.

METHODS

The RBEC scale consists of 7 items designed to reflect religious beliefs in EOL medical care. Its psychometric properties were evaluated in a sample of 275 patients with advanced cancer from the Coping With Cancer II study, a National Cancer Institute-funded, multisite, longitudinal, observational study of communication processes and outcomes in EOL cancer care.

RESULTS

The RBEC scale proved to be internally consistent (Cronbach α, .81), unidimensional, positively associated with other indicators of patients' religiousness and spirituality (establishing its convergent validity), and inversely associated with patients' terminal illness understanding and acceptance (establishing its criterion validity), suggesting its potential clinical usefulness in promoting informed EOL decision making. The majority of patients (87%) reported some ("somewhat," "quite a bit," or "a great deal") endorsement of at least 1 RBEC item and a majority (62%) endorsed ≥3 RBEC items.

CONCLUSIONS

The RBEC scale is a reliable and valid tool with which to assess religious beliefs within the context of EOL medical care, beliefs that frequently are endorsed and inversely associated with terminal illness understanding.

Impact of Immigrant Status on Aggressive Medical Care Counter to Patients' Values Near Death among Advanced Cancer Patients

BACKGROUND

Little is known about disparities in end-of-life (EoL) care between U.S. immigrants and nonimmigrants.

OBJECTIVE

To determine immigrant/nonimmigrant advanced cancer patient differences in receipt of values-inconsistent aggressive medical care near the EoL.

DESIGN

Analysis of data from Coping with Cancer, a federally funded, prospective, multi-institutional cohort study of advanced cancer patients with limited life expectancies recruited from 2002 to 2008.

SETTING/SUBJECTS

U.S. academic medical center and community-based clinics. Self-reported immigrant (n = 41) and nonimmigrant (n = 261) advanced cancer patients with poor prognoses who died within the study observation period.

MEASUREMENTS

The primary independent/predictor variable was patient immigrant status. Primary outcome variables: (1) aggressive medical care near death, operationalized as the use of mechanical ventilation, resuscitation, feeding tube, and/or antibiotics in the last week of life and (2) receipt of values inconsistent aggressive care, operationalized as receiving aggressive care inconsistent with stated preferences for comfort-focused EoL care.

RESULTS

In a propensity-weighted sample (N = 302), in which immigrant and nonimmigrant groups were weighted to be demographically similar, immigrants were significantly more likely than nonimmigrants to receive aggressive medical care [OR 1.9; 95% CI (1.0-3.6); p = 0.042] and values-inconsistent aggressive medical care [OR 2.1; 95% CI (1.1-4.2); p = 0.032] near death.

CONCLUSIONS

Immigrant, as compared with nonimmigrant, advanced cancer patients are not only more likely to receive aggressive EoL care, but also more likely to receive care counter to their wishes. These findings indicate potential disparities in, rather than differences in preference for, aggressive care and a need for further investigation into potential causes of these disparities.

Psychometric evaluation and cultural adaptation of the Spanish version of the "Scale for End-of Life Caregiving Appraisal"

OBJECTIVE

To translate, culturally adapt, and psychometrically evaluate the Spanish version of the "Scale for End-of Life Caregiving Appraisal" (SEOLCAS).

METHOD

Observational cross-sectional study. Convenience sample of 201 informal end-of-life caregivers recruited in a southern Spanish hospital. The reliability of the questionnaire was assessed through its internal consistency (Cronbach's α) and temporal stability (Pearson's correlation coefficient [r] between test-retest). The content validity index of the items and the scale was calculated. Criterion validity was explored through performing a linear regression analysis to evaluate the SEOLCAS' predictive validity. Exploratory factor analysis was used to examine its construct validity.

RESULTS

The SEOLCAS' reliability was very high (Cronbach's α = 0.92). Its content validity was excellent (all items' content validity index = 0.8-1; scale's validity index = 0.88). Evidence of the SEOLCAS' criterion validity showed that the participants' scores on the SEOLCAS explained approximately 79.3% of the between-subject variation of their results on the Zarit Burden Interview. Exploratory factor analysis provided evidence of the SEOLCAS' construct validity. This analysis revealed that two factors ("internal contingencies" and "external contingencies") explained 53.77% of the total variance found and reflected the stoic Hispanic attitude toward adversity.Significance of resultsThe Spanish version of the SEOLCAS has shown to be an easily applicable, valid, reliable, and culturally appropriate tool to measure the impact of end-of-life care provision on Hispanic informal caregivers. This tool offers healthcare professionals the opportunity to easily explore Hispanic informal end-of-life caregivers' experiences and discover the type of support they may need (instrumental or emotional) even when there are communicational and organizational constraints.

The Voice Is As Mighty As the Pen: Integrating Conversations into Advance Care Planning

Advance care planning allows patients to articulate preferences for their medical treatment, lifestyle, and surrogate decision-makers in order to anticipate and mitigate their potential loss of decision-making capacity. Written advance directives are often emphasized in this regard. While these directives contain important information, there are several barriers to consider: veracity and accuracy of surrogate decision-makers in making choices consistent with the substituted judgement standard, state-to-state variability in regulations, literacy issues, lack of access to legal resources, lack of understanding of medical options, and cultural disparities. Given these issues, it is vital to increase the use of patient and healthcare provider conversations as an advance care planning tool and to increase integration of such discourse into advance care planning policy as adjuncts and complements to written advance directives. This paper reviews current legislation about written advance directives and dissects how documentation of spoken interactions might be integrated and considered. We discuss specific institutional policy changes required to facilitate implementation. Finally, we explore the ethical issues surrounding the increased usage and recognition of clinician-patient conversations in advance care planning.

End-of-Life Care for Unauthorized Immigrants in the U.S

The Universal Declaration of Human Rights recognizes the inherent dignity, the equal and unalienable rights to be universally protected for all humans irrespective of race, color, gender, language, religion, political or other opinion, national or social origin, property, birth or other status. Though this includes the right to dignity-conserving care for terminally ill unauthorized immigrants, access to quality end-of-life care eludes them. Most of the estimated 11.3 million unauthorized immigrants either entered the country without the knowledge of the U.S. Immigration and Customs Enforcement, or were admitted on a temporary visa and stayed past its expiration date. Unsafe living conditions, occupational hazards, lack of access to routine healthcare, scarceness of a social and financial support system, fear of deportation, discrimination and incarceration limit healthcare access of unauthorized immigrants. Lack of access to preventative primary care encounters often results in this population's dependence on acute emergency services for treatment. Lack of opportunity for advance care planning discussions and lack of eligibility to hospice services commonly contributes to poor end of life care. As unauthorized immigrants approach the last days of life, they may often die alone, away from their loved ones, with little-to-no psychosocial support in their final moments. This article provides an overview on end-of-life care for unauthorized immigrants and makes recommendations for potential strategies to providing humane care and support to this vulnerable population.

Culture and Palliative Care: Preferences, Communication, Meaning, and Mutual Decision Making

Palliative care is gaining acceptance across the world. However, even when palliative care resources exist, both the delivery and distribution of services too often are neither equitably nor acceptably provided to diverse population groups. The goal of this study was to illustrate tensions in the delivery of palliative care for diverse patient populations to help clinicians to improve care for all. We begin by defining and differentiating culture, race, and ethnicity, so that these terms-often used interchangeably-are not conflated and are more effectively used in caring for diverse populations. We then present examples from an integrative literature review of recent research on culture and palliative care to illustrate both how and why varied responses to pain and suffering occur in different patterns, focusing on four areas of palliative care: the formation of care preferences, communication patterns, different meanings of suffering, and decision-making processes about care. For each area, we provide international and multiethnic examples of variations that emphasize the need for personalization of care and the avoidance of stereotyping beliefs and practices without considering individual circumstances and life histories. We conclude with recommendations for improving palliative care research and practice with cultural perspectives, emphasizing the need to work in partnerships with patients, their family members, and communities to identify and negotiate culturally meaningful care, promote quality of life, and ensure the highest quality palliative care for all, both domestically and internationally.

Enhancing Pediatric Palliative Care for Latino Children and Their Families: A Review of the Literature and Recommendations for Research and Practice in the United States

As the demand for pediatric palliative care (PC) increases, data suggest that Latino children are less likely to receive services than non-Latino children. Evidence on how to best provide PC to Latino children is sparse. We conducted a narrative review of literature related to PC for Latino children and their families in the United States. In the United States, Latinos face multiple barriers that affect their receipt of PC, including poverty, lack of access to health insurance, language barriers, discrimination, and cultural differences. Pediatric PC research and clinical initiatives that target the needs of Latino families are sparse, underfunded, but essential. Education of providers on Latino cultural values is necessary. Additionally, advocacy efforts with a focus on equitable care and policy reform are essential to improving the health of this vulnerable population.

Understanding patient needs without understanding the patient: the need for complementary use of professional interpreters in end-of-life care

High-quality doctor-patient communication in end-of-life care results in better quality of life for patients. In linguistically and culturally diverse societies, language discordant consultations become daily practice, leading to difficulties in eliciting patient preferences toward end-of-life care. Although family members invariably act as informal interpreters, this may cause some ethical dilemmas. We present a case of a palliative patient whose son acted as an interpreter. This case generated a triple- layered ethical dilemma: (i) how to safeguard patient autonomy against paternalistic interventions by family members, (ii) how to respect the relational context in which patient autonomy can be realized, and (iii) how to respect the ethno-cultural values of the patient and his family. These issues are being discussed and reflected upon within the framework shared decision making involving informal- and professional interpreters. The complementary use of professional interpreters next to family members acting as informal interpreters is recommended.

Palliative and End-of-Life Care for Patients with Malignancy

Patients with cancer continue to have unmet palliative care needs. Concurrent palliative care is tailored to the needs of patients as well as their families to relieve suffering. Specialty palliative care referral is associated with improved symptom management, improved end-of-life quality, and higher family-rated satisfaction. Optimal timing for palliative care referral has not been determined. Barriers to palliative care referral include workforce limitations, provider attitudes and perceptions, and potential ethnic and racial disparities in access to palliative care. Future work should focus on novel, patient-centered approaches to identify and address unmet palliative care needs for patients living with cancer.

Patient-family EoL communication and its predictors: Reports from caregivers of Latino patients in the rural U.S.-Mexico border region

OBJECTIVE

Family caregivers play an important role in end-of-life (EoL) decision making when the patient is unable to make his/her own decisions. While communication about EoL care between patients and family is perhaps a first step toward advance care planning (ACP)/EoL decisions, not every culture puts great value on open communication about this topic. The aims of the present study were to explore EoL communication and the aspects of communication among caregivers of Latino patients in the rural United States (U.S.)-Mexico border region.

METHOD

This study analyzed data from a hospice needs assessment collected from 189 family caregivers of Latino patients at a home health agency in a rural U.S.-Mexico border region. Bivariate tests and logistic regression were used to address our aims.

RESULTS

About half of the family caregivers (n = 96, 50.8%) reported to have ever engaged in EoL discussion with patients. Significant predictors of EoL discussion included life-sustaining treatment preference (odds ratio [OR] = 0.44, p < 0.05); knowledge of an advance directive (AD) (OR = 5.50, p < 0.01); and distrust of physicians (OR = 0.29, p < 0.01). Caregivers who preferred extending the life of their loved one even if he/she had to rely on life supports were less likely to engage in EoL communication. Also, caregivers who worried that physicians might want to stop treatments (i.e., "pull the plug") too soon were less likely to do so. Conversely, caregivers who had knowledge about ADs were more likely to engage in EoL communication.

SIGNIFICANCE OF RESULTS

EoL communication is a complex process influenced by individual, social, and cultural values and the beliefs of both the patient and his/her family. Inclusion of family caregivers in the ACP process and facilitating culturally tailored EoL communication between patients and family caregivers is important.

Association Between Immigrant Status and End-of-Life Care in Ontario, Canada

IMPORTANCE

People who immigrate face unique health literacy, communication, and system navigation challenges, and they may have diverse preferences that influence end-of-life care.

OBJECTIVE

To examine end-of-life care provided to immigrants to Canada in the last 6 months of their life.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study (April 1, 2004, to March 31, 2015) included 967 013 decedents in Ontario, Canada, using validated linkages between health and immigration databases to identify immigrant (since 1985) and long-standing resident cohorts.

EXPOSURES

All decedents who immigrated to Canada between 1985 and 2015 were classified as recent immigrants, with subgroup analyses assessing the association of time since immigration, and region of birth, with end-of-life care.

MAIN OUTCOMES AND MEASURES

Location of death and intensity of care received in the last 6 months of life. Analysis included modified Poisson regression with generalized estimating equations, adjusting for age, sex, socioeconomic position, causes of death, urban and rural residence, and preexisting comorbidities.

RESULTS

Among 967 013 decedents of whom 47 514 (5%) immigrated since 1985, sex, socioeconomic status, urban (vs rural) residence, and causes of death were similar, while long-standing residents were older than immigrant decedents (median [interquartile range] age, 75 [58-84] vs 80 [68-87] years). Recent immigrant decedents were overall more likely to die in intensive care (15.6% vs 10.0%; difference, 5.6%; 95% CI, 5.2%-5.9%) after adjusting for differences in age, sex, income, geography, and cause of death (relative risk, 1.30; 95% CI, 1.27-1.32). In their last 6 months of life, recent immigrant decedents experienced more intensive care admissions (24.9% vs 19.2%; difference, 5.7%; 95% CI, 5.3%-6.1%), hospital admissions (72.1% vs 68.2%; difference, 3.9%; 95% CI, 3.5%-4.3%), mechanical ventilation (21.5% vs 13.6%; difference, 7.9%; 95% CI, 7.5%-8.3%), dialysis (5.5% vs 3.4%; difference, 2.1%; 95% CI, 1.9%-2.3%), percutaneous feeding tube placement (5.5% vs 3.0%; difference, 2.5%; 95% CI, 2.3%-2.8%), and tracheostomy (2.3% vs 1.1%; difference, 1.2%; 95% CI, 1.1%-1.4%). Relative risk of dying in intensive care for recent immigrants compared with long-standing residents varied according to recent immigrant region of birth from 0.84 (95% CI, 0.74-0.95) among those born in Northern and Western Europe to 1.96 (95% CI, 1.89-2.05) among those born in South Asia.

CONCLUSIONS AND RELEVANCE

Among decedents in Ontario, Canada, recent immigrants were significantly more likely to receive aggressive care and to die in an intensive care unit compared with other residents. Further research is needed to understand the mechanisms behind this association.

Living With "Man's Fate" Away From Home

Edward Nilges is a former software consultant who came from Chicago to Hong Kong in 2005, and has since worked as a teacher. Having been residing in Hong Kong for all these years, Edward fell ill with cancer and its complications. He choose to receive medical treatment in Hong Kong, where both the dominant culture and medical system were foreign to him. Here, he gives an account of his physical, psychological, social and existential experience, in quest of meaning away from home, while his physician discusses the clinician’s perspective.

Who Decides: Me or We? Family Involvement in Medical Decision Making in Eastern and Western Countries

Background. Research suggests that desired family involvement (FI) in medical decision making may depend on cultural values. Unfortunately, the field lacks cross-cultural studies that test this assumption. As a result, providers may be guided by incomplete information or cultural biases rather than patient preferences. Methods. Researchers developed 6 culturally relevant disease scenarios varying from low to high medical seriousness. Quota samples of approximately 290 middle-aged urban residents in Australia, China, Malaysia, India, South Korea, Thailand, and the USA completed an online survey that examined desired levels of FI and identified individual difference predictors in each country. All reliability coefficients were acceptable. Regression models met standard assumptions. Results. The strongest finding across all 7 countries was that those who desired higher self-involvement (SI) in medical decision making also wanted lower FI. On the other hand, respondents who valued relational-interdependence tended to want their families involved – a key finding in 5 of 7 countries. In addition, in 4 of 7 countries, respondents who valued social hierarchy desired higher FI. Other antecedents were less consistent. Conclusion. These results suggest that it is important for health providers to avoid East–West cultural stereotypes. There are meaningful numbers of patients in all 7 countries who want to be individually involved and those individuals tend to prefer lower FI. On the other hand, more interdependent patients are likely to want families involved in many of the countries studied. Thus, individual differences within culture appear to be important in predicting whether a patient desires FI. For this reason, avoiding culture-based assumptions about desired FI during medical decision making is central to providing more effective patient centered care.

A qualitative study of the emotional and spiritual needs of Hispanic families in hospice

Background:

As the older U.S. population becomes more ethnically diverse, there will be an increased need for culturally sensitive hospice care services. Hispanics often experience multiple barriers to quality end-of-life care services.

Objective:

To address the underlying disparities in the cultural, emotional, and spiritual aspects of hospice care, the objective of the present qualitative study was to examine the emotional and spiritual needs of Hispanic patients' families while in hospice.

Method:

Semistructured in-person interviews were conducted with 29 Hispanic patients' families regarding their perceived experience of the hospice-based emotional and spiritual support received. Demographic information was collected on both the family member and the patient. Interviews were digitally recorded, transcribed, and analyzed using thematic content analysis.

Results:

Participant narratives fell into five main themes: (1) the influence of Hispanic culture in the relationship with hospice care providers; (2) types of social support received from hospice; (3) barriers to receiving support; (4) lack of health literacy regarding hospice care; and (5) cultural preferences for religious/spiritual support in hospice.

Significance of Results:

Our results provide insight into the specific emotional and spiritual needs of Hispanic families receiving hospice services. Our findings highlight that cultural values play an important role in the hospice care experiences of Hispanic families.