Facilitators and Barriers for Advance Care Planning Among Ethnic and Racial Minorities in the U.S.: A Systematic Review of the Current Literature

Enhancing End-of-Life Care Knowledge Among Older Spanish-Speaking Adults: Results From a Pilot Educational Intervention on Advance Care Planning and Care Options

BACKGROUND

Disparities in advance care planning (ACP) among older Latinos necessitate targeted interventions to enhance engagement and knowledge in end-of-life care. This study aimed to evaluate the effectiveness of a resource-efficient, culturally tailored educational intervention in improving ACP readiness and knowledge among older Latino adults in the community.

METHODS

A quasi-experimental pretest-posttest design was used to assess the impact of the intervention. The study involved community-dwelling older Latinos (aged 61-94) in the U.S. attending community wellness centers. Measures included participants' knowledge of ACP, care options, familiarity with hospice and palliative care, and attitudes toward hospice, assessed using pre- and post-intervention surveys.

RESULTS

Statistically significant improvements were observed in ACP knowledge, understanding of care options, and attitudes towards hospice and palliative care post-intervention. Demographic factors influenced knowledge scores, with no significant gender differences in the intervention's efficacy.

CONCLUSIONS

The educational intervention effectively enhanced end-of-life care planning readiness and knowledge among older Latinos. The study highlights the potential for sustainable, accessible, and culturally sensitive educational strategies to reduce disparities in ACP knowledge and possibly engagement.

Advanced Care Plan Among Older Chinese in Residential Aged Care: A Retrospective Review

INTRODUCTION

Worldwide in the population of older people, ethnic diversity is prevalent and therefore warrants culturally sensitive advanced care planning. This study aimed to explore advanced care planning documentation related to the cultural needs of residents of Chinese ethnicity in Australian aged care facilities.

METHODS

A retrospective review of advanced care plan documentation was undertaken among 31 older Chinese residents with life-limiting illnesses across two residential aged care facilities in New South Wales, Australia. Data were analyzed using descriptive statistics.

RESULTS

90% of residents had advanced care planning documentation. The presence of the resident and their representative and medical care directives were well documented. Specific details on the provision of palliative care that considers the person's cultural needs and preferences were limited.

DISCUSSION

Findings suggest the need for further research that explores an optimal way of embedding culture-specific information and the development of a culturally sensitive advanced care plan for people of Chinese ethnicity.

Medical Mistrust Among Black Patients with Serious Illness: A Mixed Methods Study

BACKGROUND

Medical mistrust among Black patients has been used to explain the existence of well-documented racial inequities at the end of life that negatively impact this group. However, there are few studies that describe patient perspectives around the impact of racism and discriminatory experiences on mistrust within the context of serious illness.

OBJECTIVE

To better characterize experiences of racism and discrimination among patients with serious illness and its association with medical mistrust.

PARTICIPANTS

Seventy-two Black participants with serious illness hospitalized at an academic county hospital.

APPROACH

This is a convergent mixed methods study using data from participant-completed surveys and existing semi-structured interviews eliciting participants' perspectives around their experiences with medical racism, communication, and decision-making.

MAIN MEASURES

The experience of medical racism and its association with Group-Based Medical Mistrust (GBMM) scale scores, a validated measure of medical mistrust.

KEY RESULTS

Of the 72 Black participants, 35% participated in interviews. Participants were mostly men who had significant socioeconomic disadvantage, including low levels of wealth, income, and educational attainment. There were reported high levels of race-based mistrust in the overall GBMM scale score (mean [SD], 36.6 [9.9]), as well as high scores within the suspicion (14.2 [5.0]), group disparities in healthcare (9.9 [2.8]), and lack of support (9.1 [2.7]) subscales. Three qualitative themes aligned with the GBMM subscales. Participants expressed skepticism of healthcare workers (HCWs) and modern medicine, recounted personal experiences of discrimination in the medical setting, and were frustrated with poor communication from HCWs.

CONCLUSIONS

This study found high levels of mistrust among Black patients with serious illness. Suspicion of HCWs, disparities in healthcare by race, and a lack of support from HCWs were overarching themes that influenced medical mistrust. Critical, race-conscious approaches are needed to create strategies and frameworks to improve the trustworthiness of healthcare institutions and workers.

Definition and recommendations of advance care planning: A Delphi study in five Asian sectors

BACKGROUND

In Confucian-influenced Asian societies, explicit end-of-life conversations are uncommon and family involvement in decision-making is crucial, which complicates the adoption of culturally sensitive advance care planning.

AIM

To develop a consensus definition of advance care planning and provide recommendations for patient-centered and family-based initiatives in Asia.

DESIGN

A five-round Delphi study was performed. The rating of a definition and 84 recommendations developed based on systematic reviews was performed by experts with clinical or research expertise using a 7-point Likert scale. A median = 1 and an inter-quartile range = 0-1 were considered very strong agreement and very strong consensus, respectively.

SETTING/PARTICIPANTS

The Delphi study was carried out by multidisciplinary experts on advance care planning in five Asian sectors (Hong Kong/Japan/Korea/Singapore/Taiwan).

RESULTS

Seventy-seven of 115 (67%) experts rated the statements. Advance care planning is defined as "a process that enables individuals to identify their values, to define goals and preferences for future medical treatment and care, to discuss these values, goals, and preferences with family and/or other closely related persons, and health-care providers, and to record and review these preferences if appropriate." Recommendations in the domains of considerations for a person-centered and family-based approach, as well as elements, roles and tasks, timing for initiative, policy and regulation, and evaluations received high levels of agreement and consensus.

CONCLUSIONS

Our definition and recommendations can guide practice, education, research, and policy-making in advance care planning for Asian populations. Our findings will aid future research in crafting culturally sensitive advance care planning interventions, ensuring Asians receive value-aligned care.

Racial, Ethnic, and Socioeconomic Differences in Critical Care Near the End of Life: A Narrative Review

Patients from groups that are racially/ethnically minoritized or of low socioeconomic status receive more intensive care near the end of life, endorse preferences for more life-sustaining treatments, experience lower quality communication from clinicians, and report worse quality of dying than other patients. There are many contributory factors, including system (eg, lack of intensive outpatient symptom management resources), clinician (eg, low-quality serious illness communication), and patient (eg, cultural norms) factors. System and clinician factors contribute to disparities and ought to be remedied, while patient factors simply reflect differences in care and may not be appropriate targets for intervention.

Exploring Pediatric Code Status, Advance Care Planning, and Mode of Death Disparities at End of Life

CONTEXT

Children from marginalized groups are at risk for worse medical outcomes, yet little is known about their end of life experiences.

OBJECTIVE

We examine the characteristics of deceased children with a focus on race, ethnicity, and preferred language.

METHODS

We conducted a cross-sectional study of patients who died at Texas Children's Hospital from 2018 to 2019. Demographics, date of death, and final code status were extracted. Medical complexity prior to admission and mode of death were obtained from chart review.

RESULTS

We included 433 patients. Over one-third were Hispanic (39.3%) with 42.3% preferring Spanish. The majority were White (61.4%) or Black (21.0%). Most patients had significant medical complexity (52.0%) or were infants in their birth admission (29.4%). Half (52.4%) received palliative care; patients with increased medical complexity were more likely to have palliative care involved (P<0.001). There were no differences in palliative care, code status, or mode of death by race. Hispanic patients were less likely to have a full code status (OR 0.42, 95% CI: 0.25-0.73). Spanish-speaking patients were more likely to have palliative care involvement (OR 2.05, 95% CI: 1.21-3.46) and less likely full code orders (OR 0.24, 95% CI: 0.1-0.63).

CONCLUSION

Palliative care services are engaged with most children at end of life and is accessible to marginalized patient groups. Spanish-speaking patients have different code status orders and modes of death at end of life. Further studies are needed to elucidate explanatory factors for differences revealed and multicenter studies are needed to characterize more widespread experiences.

Informing Culturally Safe Advance Care Planning: An Interpretive Descriptive Study of Internationally Educated Nurses in Ontario

BACKGROUND

Maintaining cultural safety during advance care planning (ACP) discussions is an essential component of holistic care provision. Most nurses feel unprepared to engage in ACP and the current literature offers limited recommendations on how nurses can lead culturally safe ACP discussions. Internationally educated nurses (IENs) have unique personal and professional experiences to address this gap.

PURPOSE

The purpose of this study was to understand IENs' contributions to culturally safe ACP and its implications to nursing practice and ACP policy.

METHODS

An interpretive descriptive approach was undertaken. Ten IENs working in Ontario, Canada were individually interviewed using a semi-structured guide to understand their perspectives and experiences of engagement in culturally safe ACP practices.

RESULTS

IENs utilized various approaches that were reflected in three actions: practicing cultural humility, utilizing a cautious approach, and empowering clients and families. IENs engaged in intrapersonal and interpersonal cultural humility practices to recognize the unique influence of one's culture on the ACP process. Establishing trust in the nurse-client relationship and cautiously approaching ACP conversations was recognized as important in maintaining cultural safety. IENs also empowered clients by addressing knowledge deficits, misconceptions about ACP, and informing them of their decision-making rights.

CONCLUSION

Nurses require education and resources to carry out culturally safe ACP. Education should begin at the undergraduate level and include self-engagement in ACP and cultural humility training. Practicing nurses need ACP training and clear standards/guidelines. There is an opportunity for healthcare organizations and professional/governing nursing bodies to collaborate on developing culturally safe ACP guidelines.

Feasibility of Nurse-Facilitated Advance Care Planning Among Older Veterans in a Dialysis Unit and an Oncology Infusion Center

INTRODUCTION

Many veterans with serious illnesses, such as end-stage kidney disease requiring dialysis and advanced cancer requiring treatment infusions, must make complex decisions about their current and future medical care. Advance care planning (ACP) is a process where individuals identify, express, and communicate their personal values, life goals, and preferences for care. ACP may be feasible in chemotherapy infusion centers or chronic dialysis centers during patient treatment.

MATERIALS AND METHODS

We assessed the feasibility of a licensed vocational nurse (LVN) facilitator to help veterans review the PREPARE for Your Care program (www.prepareforyourcare.org) and complete an advance directive (AD) in an outpatient hemodialysis unit or a chemotherapy infusion center. PREPARE For Your Care is an evidence-based online program with written pamphlets and ADs that prepares patients to participate with clinicians in making medical decisions. We measured the time to complete a session and the level of assistance required from LVNs via LVN self-report. Self-reported ease-of-use, comfort, and helpfulness were assessed on a 10-point Likert scale from 1 (not at all) to 10 (very).

RESULTS

Twenty-eight patients were enrolled (mean age ± SD: 67 ± 11 years); all (100%) completed PREPARE and the AD within 1 session. The mean completion time was 100 (±40) minutes. Most of the patients required considerable assistance from the LVN. The mean scores were 8.0 of 10 for ease-of-use (±2.3), 7.7 of 10 (±2.8) for comfort, and 8.2 of 10 (±2.3) for helpfulness.

CONCLUSIONS

This pilot study demonstrates that using PREPARE as an ACP tool for veterans may be feasible for patients during hemodialysis and chemotherapy infusion. Patients required considerable assistance from the LVN to complete PREPARE. Hemodialysis and chemotherapy infusion are opportunities when patients have time and space to consider ACP.

Factors Associated with Do Not Resuscitate Status and Palliative Care in Hospitalized Patients: A National Inpatient Sample Analysis

Introduction

Patients from diverse sociocultural backgrounds and with differing medical conditions may have varying levels of acceptance of advanced care planning and palliative care.

Methods

We performed a retrospective analysis of the National Inpatient Sample for patients discharged from January 1, 2016, to December 31, 2019, with conditions associated with frequently terminal conditions. We recorded demographic variables, do not resuscitate (DNR) status, and palliative care (PC) status and analyzed the associations between outcomes, mortality, and length of stay (LOS).

Results

A total of 23,402,637 patient records were included in the study, of which 2% were DNR and PC, 5% were DNR only, and 1% was PC only. From 2016 to 2019, the percentage of patients with PC increased from 2.55% to 3.27% and DNR from 6.31% to 7.7%. Black patients were less likely to have DNR status (odds ratio [OR] 0.72 [0.71-0.72]) but had similar PC rates. Male patients were less likely to have a DNR order in place (OR 0.89 [0.89-0.89]) but more likely to be in PC (OR 1.05 [1.04-1.05]). The diagnoses with the highest association with DNR status were lung cancer (OR 4.1 [4.0-4.5]), pancreatic cancer (OR 4.6 [4.5-4.7]), and sepsis (OR 2.9 [2.9-2.9]) The diagnoses most associated with PC were lung cancer (OR 6.3 [6.2-6.4]), pancreatic cancer (OR 8.1 [7.1-8.3]), colon cancer (OR 4.9 [4.8-5.1]), and senile brain degeneration of the brain OR 6.5 [5.3-7.9]). Mortality and LOS decreased between 2016 and 2019, but hospital charges increased (p < 0.001). Black race and male gender were associated with higher inpatient mortality (OR 1.12 [1.12-1.14]), LOS, and hospital charges.

Conclusion

In the United States, the proportion of hospitalized patients with DNR, PC, and DNR with PC increased from 2016 to 2019. Overall, inpatient mortality and LOS fell, but hospital charges per patient increased. Significant gender and ethnic differences emerged. Black patients and males were less likely to have DNR status and had higher inpatient mortality, LOS, and hospital charges.

Service Provider Perspectives on Advance Care Planning Use in Rural Dementia Patients and Caregivers: A Qualitative Study

Advanced care planning (ACP) utilization remains very limited in rural communities compared to urban areas. ACP earlier in the disease trajectory is particularly important for people with dementia (PWD) due to its progressive nature affecting their decision-making ability. Considering the well-documented benefits of ACP in improving the quality of end-of-life (EOL) care, the rural vs. urban disparity may indicate poorer EOL quality for rural PWD. This study aimed to explore barriers and current resources for ACP of PWD from the perspectives of health or social service providers serving rural communities. Using a qualitative approach, semi-structured face-to-face interviews were conducted with 11 health or social service professionals serving older adults and their caregivers in rural Alabama. Thematic analysis revealed three major barriers: (1) lack of knowledge, (2) psychosocial barriers, and (3) limited access to healthcare. Participants also showed misconception that a lawyer or a notary is required for ACP. Two themes arose in the participants' recommendations to address the barriers: (1) providing ACP-relevant information and (2) addressing psychosocial stressors about ACP. This study highlighted an urgent need for social policy in ACP education for caregivers and service providers in rural settings.

Life-Stage and Contextual Factors of Advance Care Planning Among Older Adults With Limited Income

Patient perspectives are essential to understand healthcare disparities such as low rates of advance care planning (ACP) among adults with limited income. We completed twenty semi-structured interviews using purposive and snowball sampling. Initial and final themes emerged from inductive inclusion of recurring codes and deductive application of the cumulative disadvantage theory. Four themes emerged: (1) structural, (2) life-stage, (3) social stressors and resources, and (4) individual stress responses and ACP readiness. ACP resources among participants included positive structural and social support and previous familial death experiences that were mitigated by stress avoidance and competing priorities. Structural resources and healthcare stressors should be addressed with policy and research to improve continuous healthcare participation and support early, comprehensive ACP.

Racial Differences in Treatment Intensity at the End of Life Among Older Adults with Heart Failure: Evidence from the Health and Retirement Study

Background: Black Americans experience the highest prevalence of heart failure (HF) and the worst clinical outcomes of any racial or ethnic group, but little is known about end-of-life care for this population. Objective: Compare treatment intensity between Black and White older adults with HF near the end of life. Design: Negative binomial and logistic regression analyses of pooled, cross-sectional data from the Health and Retirement Study (HRS). Setting/Subjects: A total of 1607 U.S. adults aged 65 years and older with HF who identify as Black or White, and whose proxy informant participated in an HRS exit interview between 2002 and 2016. Measurements: We compared four common measures of treatment intensity at the end of life (number of hospital admissions, receipt of care in an intensive care unit (ICU), utilization of life support, and whether the decedent died in a hospital) between Black and White HF patients, controlling for demographic, social, and health characteristics. Results: Racial identity was not significantly associated with the number of hospital admissions or admission to an ICU in the last 24 months of life. However, Black HF patients were more likely to spend time on life support (odds ratio [OR] = 2.16, confidence interval [CI] = 1.35-3.44, p = 0.00) and more likely to die in a hospital (OR = 1.53, CI = 1.03-2.28, p = 0.04) than White HF patients. Conclusion: Black HF patients were more likely to die in a hospital and to spend time on life support than White HF patients. Thoughtful and consistent engagement with HF patients regarding treatment preferences is an important step in addressing inequities.

Advance care planning for patients undergoing gastrostomy tube procedures; prevalence, outcomes, and disparities

BACKGROUND

Advanced care planning (ACP) is the process of establishing goals for end-of-life care. We aimed to examine ACP's prevalence, associated factors, and impact in a cohort of patients undergoing gastrostomy tube procedures.

METHODS

Adult patients who underwent gastrostomy tube placement from 2016 to 2021 ​at a tertiary center were identified. Variables evaluated included age, sex, race, comorbidities, and median income of patient home zip code. Primary outcomes included the presence of ACP, length of stay (LOS), and 90-day mortality. Analysis was performed using independent T tests, Mann Whitney U-tests, and Chi Square analysis. ACP, LOS, and 90-day mortality were analyzed with multivariate analysis.

RESULTS

877 patients underwent gastrostomy tube placement and 10.6 ​% had ACP. Black race was an isolated factor negatively associated with ACP (OR 0.423, p ​= ​0.013). There was no difference in the proportion of patients with or without ACP who died within 90 days of the procedure (17 ​% vs. 15 ​%, p ​= ​0.836). Average LOS was 6 days shorter for patients with ACP (p ​< ​0.001).

CONCLUSION

This study highlights the significant underutilization and racial disparity in ACP, and found that ACP does not negatively impact outcomes or perioperative mortality for patients undergoing gastrostomy tube placement.

Using the Age-Friendly Environment Framework to Assess Advance Care Planning Factors Among Older Adults With Limited Income: A Cross-Sectional, Descriptive Survey Study

BACKGROUND AND OBJECTIVES

The World Health Organization created the Age-Friendly Environment (AFE) framework to design communities that support healthy aging and equitable decision making. This framework's resource domains may account for disparately lower advance care planning (ACP) among older adults with limited incomes compared to those with high incomes. We aimed to describe and examine associations of AFE factors with ACP.

RESEARCH DESIGN AND METHODS

We recruited and conducted cross-sectional surveys among older adults with limited incomes in 7 community-based settings in Nashville, TN. ACP and AFE item scales were dichotomized and analyzed with unadjusted phi correlation coefficients.

RESULTS

Survey participants (N = 100) included 59 women, 70 Black/African American, and 70 ≥60 years old. Most participants agreed that their community was age friendly (≥58%) and varied in ACP participation (22%-67%). Participants who perceived easy travel and service access and sufficient social isolation outreach were more likely to have had family or doctor quality-of-life discussions (phi = 0.22-0.29, p < .05). Having a healthcare decision maker was positively associated with age-friendly travel, housing, and meet-up places (phi = 0.20-0.26, p < .05).

DISCUSSION AND IMPLICATIONS

The AFE framework is useful for exploring the environmental factors of ACP, but further research is warranted to identify specific and immediate resources to support successful ACP among populations with socioeconomic disadvantage.

Past Disparities in Advance Care Planning Across Sociodemographic Characteristics and Cognition Levels in the United States

We aimed to examine past advance care planning (ACP) in U.S. older adults across different sociodemographic characteristics and cognition levels. We established the baseline trends from 10 years ago to assess if trends in 2024 have improved upon future data availability. We considered two legal documents in the Health and Retirement Study 2014 survey as measures for ACP: a living will and durable power of attorney for healthcare (DPOAH). Logistic regression models were fitted with outcome variables (living will, DPOAH, and both) stratified by cognition levels (dementia/impaired cognition versus normal cognition). Predictor variables included age, gender, ethnicity, race, education, marital status, rurality, everyday discrimination, social support, and loneliness. Age, ethnicity, race, education, and rurality were significant predictors of ACP (having a living will, DPOAH, and both the living will and DPOAH) across cognition levels. Participants who were younger, Hispanic, Black, had lower levels of education, or resided in rural areas were less likely to complete ACP. Examining ACP and its linkages to specific social determinants is essential to understanding disparities and educational strategies needed to facilitate ACP uptake among different population groups. Accordingly, this study aimed to examine past ACP disparities in relation to specific social determinants of health and different cognition levels. Future studies are required to evaluate whether existing disparities have improved over the last 10 years when 2024 data is released. Addressing ACP disparities among diverse populations, including racial and ethnic minorities with reduced cognition levels, is crucial for enhancing health equity and access to care.

American Muslim Engagement With Advance Care Planning: Insights From a Community Survey

Background and Objectives: Advance Care Planning (ACP) is a critical tool in advancing patient self-determination in health care delivery. Despite increasing research into racial/ethnic minorities' engagement with ACP in the US, studies on Muslim Americans are relatively scarce. We aimed to examine levels of ACP engagement among Muslim adults and measure associations between socio-demographic and religiosity characteristics and ACP engagement. Methodology: This was a survey study among Muslims attending mosque seminars in Chicago and Washington DC. Religiosity characteristics were assessed using a modified version of the Duke University Religion Index (DUREL) and the Psychological Measure of Islamic Religiousness (PMIR). ACP engagement was measured by the 4-item ACP Engagement Survey (4-ACPES) and 2 additional items covering ACP religious dimensions. Statistical analyses were performed using SPSS 28.0. Results: Out of 152 respondents, 56.2% to 72.6% were in the pre-contemplation stage of ACP across the 6 ACP items. Bivariate analyses showed that ACP engagement was correlated with participant age, ethnicity, duration of stay in the US and country of birth. Multivariable analyses demonstrated no association between religiosity characteristics and ACP engagement; independent predictors of ACP engagement were race/ethnicity (being South Asian), country of birth (born outside the US) and duration of stay in the US (longer years). Discussion/Conclusion: Our study suggests that American Muslims are largely unprepared to engage with ACP. Moreover, religiosity does not predict ACP engagement. We call for greater community outreach and educational programs that instill awareness and knowledge on the importance of ACP, and provide resources for tailored religiously-oriented conversations that assist individuals with ACP.

End-of-Life Care Planning: Perspectives of Returning Citizens

Demographic shifts toward an older and sicker prison population present challenges for corrections leaders and incarcerated people. The priority of custody and control over care in prisons can deprive people of a modicum of autonomy even about expressing their end-of-life wishes. This study was undertaken to inform best practices and identify essential components of end-of-life care planning (EOLCP) for people who will likely die incarcerated. Individual interviews with formerly incarcerated people (n = 16) provided insights on EOLCP knowledge, perceptions, and future plans as each reflected on experiences while incarcerated. Zoom Video Communications were used for the interviews, and audio recordings were transcribed verbatim, verified, and deidentified prior to thematic analysis. Themes were defined and discussed until consensus was reached between the 2 researchers. End-of-life care planning themes included the following: understanding of and experience with advanced directives/care planning (AD/ACP), defining AD/ACP, timing of AD/ACP accessibility to health care resources, how to approach EOLCP in prison, advantages of EOLCP, and barriers to EOLCP. Formerly incarcerated peoples' knowledge, perceptions, and future plans revealed important considerations when developing a contextually relevant toolkit for EOLCP for people living in prison.

Advance care planning as perceived by marginalized populations: Willing to engage and facing obstacles

BACKGROUND

Health disparities exist in end-of-life (EOL) care. Individuals and communities that are marginalized due to their race, ethnicity, income, geographic location, language, or cultural background experience systemic barriers to access and receive lower quality EOL care. Advance care planning (ACP) prepares patients and their caregivers for EOL decision-making for the purpose of promoting high-quality EOL care. Low engagement in ACP among marginalized populations is thought to have contributed to disparity in EOL care. To advance health equity and deliver care that aligns with the goals and values of each individual, there is a need to improve ACP for marginalized populations.

AIM

To describe how patients from marginalized populations experience and perceive ACP.

METHODS

We used an interpretive phenomenological approach with semi-structured qualitative interviews. Participants were recruited from four primary care clinics and one nursing home in a US Pacific Northwest city. Thirty patients from marginalized populations with serious illness participated in individual interviews between January and December 2021. Participants were asked to describe their experiences and perceptions about ACP during the interviews.

RESULTS

The mean age of 30 participants was 69.5; 19 (63%) were women; 12 (40%) identified as Asian/Pacific Islanders, 10 (33%) as Black; and 9 (30%) were non-native English speakers. Our three key findings were: 1) patients from marginalized populations are willing to engage in ACP; 2) there were multiple obstacles to engaging in ACP; and 3) meaningful ACP conversations could happen when clinicians listen. Although participants from marginalized populations were willing to engage in ACP, a fragmented and restrictive healthcare system and clinicians' biased behaviors or lack of interest in knowing their patients were obstacles. Participants who felt their clinicians took time and listened were encouraged to engage in ACP.

CONCLUSION

Patients from marginalized populations are willing to engage in ACP conversations despite a common belief otherwise. However, obstacles to meaningful ACP conversations with healthcare providers exist. Clinicians need to be aware of these obstacles and listen to build trust and engage marginalized patients in mutually meaningful ACP conversations.

Advance Care Planning Among Sexual Minority Men: Sociodemographic, Health Care, and Health Status Predictors

Objectives: Advance care planning (ACP) specifies decision-making surrogates and preferences for serious illness or end-of-life medical care. ACP research has largely neglected sexual minority men (SMM), a population that experiences disparities in health care and health status. Methods: We examined formal and informal ACP among SMM ages 40+ in the Multicenter AIDS Cohort Study (N = 1,071). Results: For informal ACP (50%), younger SMM and men with past cardiovascular events had greater odds of planning; single men had lower odds of planning. For formal ACP (39%), SMM with greater socioeconomic status had greater odds of planning; SMM who were younger, of racial/ethnic minority identities, who were single or in a relationship without legal protections, and who lacked a primary care home had lower odds of planning. Discussion: Findings warrant further exploration of both informal and formal planning. More equitable, culturally-humble engagement of SMM may facilitate access, uptake, and person-centered planning.

Disparities in Advance Directive Documentation for Rural-Dwelling Persons With Lung Cancer

Purpose: Advance directives (AD) are recommended for persons with lung cancer, yet few studies have investigated AD and healthcare power of attorney (HCPOA) documentation for this population in rural regions of the United States. The purpose of this study was to examine demographic and clinical factors associated with AD and HCPOA documentation for persons with lung cancer in rural eastern North Carolina (ENC). Methods: A cross-sectional retrospective chart review was conducted to collect demographic and clinical data from electronic health records from 2017 to 2021 at a tertiary cancer center and regional satellite sites in ENC. Descriptive statistics and Chi-Square Tests of Independence were used for data analysis. Findings: The sample's mean age was 69.5 years (n = 402, SD = 10.5, range = 28 - 92). Most participants were male (58%) and had a smoking history (93%). Consistent with regional population statistics, 32% of persons were black, and 52% lived in rural counties. Just 18.5% of the sample had a documented AD and 26% had a healthcare power of attorney. Black persons had significantly lower AD and HCPOA (P < .001) documentation than white persons. Rural-dwellers had significantly lower HCPOA documentation than urban-dwellers (P = .03). For all other variables, no significant differences were found. Conclusions: These findings suggest that AD and HCPOA documentation are low for persons with lung cancer in ENC, particularly for black persons and rural-dwellers. This disparity highlights the need for enhanced advance care planning (ACP) access to and outreach in the region.

How Do Social Relationships Affect Later Life Planning?

Relatively little is known about how social relationships affect later life planning. Our study focuses on an underexamined aspect of social relationships, frequency of contact - not only with family members but also with friends. Using data from a survey of Floridians aged 50 and older conducted between December 2020 and April 2021 (n = 3,832), we examine the association between frequency of contact and five planning types: finances, health care, living arrangements, driving retirement, and end-of-life. We found that more frequent contact was associated with greater likelihood of planning, and this result was largely consistent across types of relationships and types of planning. Our findings suggest that contact with family members and friends may encourage more planning, which could reduce the stress that can accompany later life transitions. Our study offers further evidence of social relationships' centrality to later life well-being and points to the many benefits of enhancing them.

Advance Care Planning Engagement Strategies for Primary Care Providers Seeing Diverse Patient Populations: A Scoping Review

Diverse patients are less likely than Whites to have advance care planning. The primary purpose of this scoping review was to summarize recent evidence about advance care planning engagement interventions for primary care providers working with diverse patients. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for Scoping Reviews (PRISMA-ScR) Checklist was followed. Peer-reviewed articles published in English since 2000 reporting the results of studies testing intervention programs in primary care to improve advance care planning with adult, racially diverse populations were included. Searches were conducted in 5 online databases and yielded 72 articles. Gray literature yielded 23 articles. Two authors independently reviewed the abstracts of 72 articles determining that 9 articles met the aim of this review. These studies were analyzed by communication tools and other resources, population, intervention, primary outcomes, instruments, and primary findings and organized into 3 categories: ( a ) provider-focused interventions, ( b ) patient-focused interventions, and ( c ) multilevel interventions. Improvement in advance care planning outcomes can be achieved for racially diverse populations by implementing targeted advance care planning engagement interventions for both providers and patients. These interventions can be used in primary care to increase advance care planning for diverse patients. More research is needed that evaluates best practices for integrating advance care planning into primary care workflows.

Assessment of Feelings Towards Advanced Care Planning in the Latino Community

BACKGROUND

Previous studies have noted that participation in advanced care planning (ACP) and end-of-life (EOL) discussions remain low among Latino communities. Various studies have found that interventions within Latino communities can positively improve engagement in ACP, however, minimal research exists regarding patient satisfaction of ACP discussions with healthcare providers outside of preorganized educational interventions. Our study aims to understand how conversations about ACP are perceived by Latino patients in a primary care setting.

METHODS

Subjects were identified from the institution's family medicine clinic from October 2021 to October 2022. Participants were those over the age of 50 who identified as Latino and were available at the clinic on the day of survey administration. An 8-question, 5-point, Likert scale survey assessed perceptions about ACP planning and gauged satisfaction of conversations with health care providers. The survey concluded with a multiple-choice question inquiring about individuals whom patients have spoken to regarding ACP/EOL wishes. Survey data was gathered through Qualtrics.

RESULTS

Of the 33 patients, the majority have at least somewhat thought about their EOL wishes (avg = 3.48/5). Most usually felt they were given enough time with their doctor (avg = 4.12/5) and comfortable speaking about ACP and EOL decisions (avg = 4.55/5). Generally, participants felt somewhat happy with how their doctor has spoken about ACP/EOL care (avg = 3.24/5). However, patients only felt a little to somewhat satisfied with the explanation of ACP/EOL from providers (avg = 2.82/5) and a little to somewhat confident in having the proper forms in place (avg = 2.76/5). Religious officials were a little to somewhat important to these conversations (avg = 2.55/5). Overall, patients have discussed ACP more frequently with family members and friends than health care providers, lawyers, or religious leaders.

CONCLUSIONS

The initial data demonstrates that many Latino patients are engaging in ACP conversations, both with healthcare providers and loved ones. Patients largely feel comfortable discussing EOL wishes with their doctor suggesting a trustful relationship. However, patients are only somewhat happy with these ACP conversations. Our study highlights a need for enhanced ACP education to improve satisfaction and confidence in formal documentation. Physicians should continue to engage and individualize ACP discussions to increase EOL preparedness among Latino patients.

Review of Muslim Patient Needs and Its Implications on Healthcare Delivery

BACKGROUND

In the rapidly changing environment of healthcare, striving toward health equity and providing patient-centered care is imperative to the patient's experience. To achieve these goals, a comprehensive understanding of the diverse patient populations seeking these services, their needs, and the multitude of religious, cultural, and structural elements that impact their well-being is required. Muslim patients represent a considerable demographic, both in number and complexity of religious and cultural beliefs and practices. This scoping review examines the intersection of religion and cultural values with healthcare delivery in the context of the Muslim patient experience.

OBJECTIVES

The objective of this review is to identify key concepts and challenges that impact the Muslim patient experience.

SEARCH METHODS

The research databases Cochrane Library, OVID Medline, and PubMED were used to conduct a comprehensive systemic review of original, empirical peer-reviewed publications with the following search terms: "Muslim healthcare," "Muslim patient," and "Muslim experience."

SELECTION CRITERIA

Inclusion and exclusion criteria were used to narrow down articles to those that addressed Muslim patient needs and their healthcare experience.

RESULTS

A total of 21 articles met the criteria of this scoping review. Five central topics were identified during thematic analysis: Ramadan and Fasting, Barriers in the Patient-Physician Relationship, Trauma and Perceived Discrimination, Mental Health Awareness and Stigma, and Awareness of Advanced Care Planning.

CONCLUSION

This scoping review demonstrates that in order to provide patient-centered care addressing the unique needs of Muslim patients, religious and cultural values need to be explored under the frameworks of cultural humility and structural competency.

Racial and Ethnic Differences in Hospice Use Among Medicaid-Only and Dual-Eligible Decedents

Importance

Hospice care enhances quality of life for people with terminal illness and is most beneficial with longer length of stay (LOS). Most hospice research focuses on the Medicare-insured population. Little is known about hospice use for the racially and ethnically diverse, low-income Medicaid population.

Objective

To compare hospice use and hospice LOS by race and ethnicity among Medicaid-only individuals and those with dual eligibility for Medicare and Medicaid (duals) in the Connecticut Medicaid program who died over a 4-year period.

Design, Setting, and Participants

This retrospective population-based cohort study used Medicaid and traditional Medicare enrollment and claims data for 2015 to 2020. The study included Connecticut Medicaid recipients with at least 1 of 5 most common hospice diagnoses who died from 2017 to 2020.

Exposure

Race and ethnicity.

Main Outcomes and Measures

Hospice use (yes/no) and hospice LOS (1-7 days vs ≥8 days.) Covariates included sex, age, and nursing facility stay within 60 days of death.

Results

Overall, 2407 and 23 857 duals were included. Medicaid-only decedents were younger (13.8% ≥85 vs 52.5%), more likely to be male (50.6% vs 36.4%), more racially and ethnically diverse (48.7% non-Hispanic White vs 79.9%), and less likely to have a nursing facility stay (34.9% vs 56.1%). Race and ethnicity were significantly associated with hospice use and LOS in both populations: non-Hispanic Black and Hispanic decedents had lower odds of using hospice than non-Hispanic White decedents, and Hispanic decedents had higher odds of a short LOS. In both populations, older age and female sex were also associated with more hospice use. For duals only, higher age was associated with lower odds of short LOS. For decedents with nursing facility stays, compared with those without, Medicaid-only decedents had higher odds of using hospice (odds ratio [OR], 1.49; 95% CI, 1.24-1.78); duals had lower odds (OR, 0.60; 95% CI, 0.57-0.63). Compared with decedents without nursing facility stays, duals with a nursing facility stay had higher odds of short LOS (OR, 2.63; 95% CI, 2.43-2.85).

Conclusions and Relevance

Findings raise concerns about equity and timing of access to hospice for Hispanic and non-Hispanic Black individuals in these understudied Medicaid populations. Knowledge about, access to, and acceptance of hospice may be lacking for these low-income individuals. Further research is needed to understand barriers to and facilitators of hospice use for people with nursing facility stays.

Advance care planning among older adults in Belgium with Turkish backgrounds and palliative care needs: A qualitative interview study

BACKGROUND

Data on advance care planning (ACP) among migrants in Europe is lacking. Research has shown that few older migrants in the United States perform ACP due to healthcare system distrust, collectivistic values and spirituality/religion.

OBJECTIVES

To explore the ACP knowledge and perspectives of older Turkish-origin adults in Belgium requiring palliative care.

METHOD

General practitioners (GPs) in Brussels and Antwerp recruited Turkish-origin participants aged ≥ 65 years with palliative care eligibility for this qualitative study. A GP conducted semi-structured interviews in Turkish in respondents' homes between May 2019 and February 2022 using a topic guide. Two researchers performed combined inductive/deductive thematic data analysis.

RESULTS

All 15 interviewees (average age, 79 years) lacked ACP awareness and information. Some had discussed specific end-of-life preferences (e.g. care location, burial place) with family. Still, many did not feel the need to discuss future healthcare preferences, due mainly to trust in God and family for caretaking and decision-making. Some respondents viewed ACP discussions as applicable, relieving the burden on family and enabling proactive addressing of 'what if' questions. Self-identified ACP barriers were fear of making wrong decisions, 'living in the moment' and difficulty discussing death. Facilitators were obtaining sufficient ACP information and recent family illness or death.

CONCLUSION

Our sample of Turkish-origin older adults in Belgium requiring palliative care lacked ACP knowledge. Our findings suggest that their lack of engagement in discussing end-of-life medical care planning was linked to their family dynamics and religion. The findings have implications for healthcare providers to ethnic-minority groups.

Death Preparedness: Development and Initial Validation of the Advance Planning Preparedness Scale

Delayed advance planning and costs of life sustaining treatments at end of life significantly contribute to the economic burden of healthcare. Clinician barriers include perceptions of inappropriate timing, lack of skills in end-of-life communication and viewing readiness as a behavior rather than a death attitude. This study developed and validated a measurement of psychological preparedness for advance directive completion. Confirmatory factor analysis (N = 543) of a 35 item pool (Cronbach α = .96) supported five sub-scales; psychological comfort (α = .87), desire to know (α = .88), thinking (α = .84), willingness (α = .82) and existential reflection (α = .79) with a possible common factor (α = .84). Results suggested significant predictors of completing directives in 30 days included discussion (OR .08, p < .001), preparedness (OR 4.08, p = .03) and uncertainty (OR 4.37, p = .02). APP = 35 is a reliable and valid measure with utility to assess readiness for completion of EOL documents.

Early Integrated Palliative Care Within a Surgical Oncology Clinic

Importance

Advance directive (AD) designation is an important component of advance care planning (ACP) that helps align care with patient goals. However, it is underutilized in high-risk surgical patients with cancer, and multiple barriers contribute to the low AD designation rates in this population.

Objective

To assess the association of early palliative care integration with changes in AD designation among patients with cancer who underwent surgery.

Design, Setting, and Participants

This cohort study was a retrospective analysis of a prospectively maintained registry of adult patients who underwent elective surgery for advanced abdominal and soft tissue malignant tumors at a surgical oncology clinic in a comprehensive cancer center with expertise in regional therapeutics between June 2016 and May 2022, with a median (IQR) postoperative follow-up duration of 27 (15-43) months. Data analysis was conducted from December 2022 to April 2023.

Exposure

Integration of ACP recommendations and early palliative care consultations into the surgical workflow in 2020 using electronic health records (EHR), preoperative checklists, and resident education.

Main Outcomes and Measures

The primary outcomes were AD designation and documentation. Multivariable logistic regression was performed to assess factors associated with AD designation and documentation.

Results

Among the 326 patients (median [IQR] age 59 [51-67] years; 189 female patients [58.0%]; 243 non-Hispanic White patients [77.9%]) who underwent surgery, 254 patients (77.9%) designated ADs. The designation rate increased from 72.0% (131 of 182 patients) before workflow integration to 85.4% (123 of 144 patients) after workflow integration in 2020 (P = .004). The AD documentation rate did not increase significantly after workflow integration in 2020 (48.9% [89 of 182] ADs documented vs 56.3% [81 of 144] ADs documented; P = .19). AD designation was associated with palliative care consultation (odds ratio [OR], 41.48; 95% CI, 9.59-179.43; P < .001), palliative-intent treatment (OR, 5.12; 95% CI, 1.32-19.89; P = .02), highest age quartile (OR, 3.79; 95% CI, 1.32-10.89; P = .01), and workflow integration (OR, 2.05; 95% CI, 1.01-4.18; P = .048). Patients who self-identified as a race or ethnicity other than non-Hispanic White were less likely to have designated ADs (OR, 0.36; 95% CI, 0.17-0.76; P = .008). AD documentation was associated with palliative care consulation (OR, 4.17; 95% CI, 2.57- 6.77; P < .001) and the highest age quartile (OR, 2.41; 95% CI, 1.21-4.79; P = .01).

Conclusions and Relevance

An integrated ACP initiative was associated with increased AD designation rates among patients with advanced cancer who underwent surgery. These findings demonstrate the feasibility and importance of modifying clinical pathways, integrating EHR-based interventions, and cohabiting palliative care physicians in the surgical workflow for patients with advanced care.

Advance Care Planning Among Older Adults with Cognitive Impairment

In this study, we used data from the Health and Retirement Study (HRS) to investigate factors associated with older adults' engagement with advance care planning (ACP) across varying levels of cognitive functioning status. Our analysis used a sample of 17,698 participants in the HRS 2014 survey. Survey descriptive procedures (Proc SurveyMeans, Proc SurveyFreq) and logistic regression procedures (Proc SurveyLogistic) were used. Race, ethnicity, level of cognition, education, age, and number of chronic diseases consistently predicted ACP. Participants with lower levels of cognition were less likely to have a living will and durable power of attorney for healthcare (DPOAH). African American and Hispanic participants, younger participants, and those with lower cognition and education levels were less likely to engage in ACP. Marital status and loneliness predicted ACP engagement. Some results varied across the cognition cohorts. Our results indicated that sociodemographic status, together with health and cognitive status, has a significant role in predicting ACP. The results can provide valuable insights on ACP for older adults with or at risk of Alzheimer's disease and related dementia and other cognitive impairments, caregivers, families, and healthcare providers.

End-of-Life Systemic Oncologic Treatment in the Immunotherapy Era: The Role of Race, Insurance, and Practice Setting

PURPOSE

Receipt of antineoplastic systemic treatment near end of life (EOL) has been shown to harm patient and caregiver experience, increase hospitalizations, intensive care unit and emergency department use, and drive-up costs; yet, these rates have not declined. To understand factors contributing to use of antineoplastic EOL systemic treatment, we explored its association with practice- and patient-level factors.

METHODS

We included patients from a real-world electronic health record-derived deidentified database who received systemic therapy for advanced or metastatic cancer diagnosed starting in 2011 and died within 4 years between 2015 and 2019. We assessed use of EOL systemic treatment at 30 and 14 days before death. We divided treatments into three subcategories: chemotherapy alone, chemotherapy and immunotherapy in combination, and immunotherapy (with/without targeted therapy), and estimated conditional odds ratios (ORs) and 95% CIs for patient and practice factors using multivariable mixed-level logistic regression.

RESULTS

Among 57,791 patients from 150 practices, 19,837 received systemic treatment within 30 days of death. We observed 36.6% of White patients, 32.7% of Black patients, 43.3% of commercially insured patients, and 37.0% of Medicaid patients received EOL systemic treatment. White patients and those with commercial insurance were more likely to receive EOL systemic treatment than Black patients or those with Medicaid. Treatment at community practices was associated with higher odds of receiving 30-day systemic EOL treatment than treatment at academic centers (adjusted OR, 1.51). We observed large variations in EOL systemic treatment rates across practices.

CONCLUSION

In a large real-world population, EOL systemic treatment rates were related to patient race, insurance type, and practice setting. Future work should examine factors that contribute to this usage pattern and its impact on downstream care.

[Media: see text].

Quality and Satisfaction With Advance Care Planning Conversations Among English- and Spanish-Speaking Older Adults

Background: Little is known about the patient-reported quality of and satisfaction with advance care planning (ACP) conversations with surrogates and clinicians among English- and Spanish-speaking older adults, or the potential disparities associated with ACP communication satisfaction. Objectives: To determine patients' perceived quality of and satisfaction with ACP surrogate/clinician conversations and associated patient characteristics. Design: Cross-sectional baseline data were used from two ACP trials, 2013-2017. Outcomes included self-reported ACP conversation quality ("general" vs. "detailed") and communication satisfaction (5-point Likert scale). Associations were determined by chi-squared and t-tests. Setting/Subjects: Subjects were primary care patients ≥55 years with chronic/serious illness in the United States. Results: Of 1398 patients, mean age was 65.6 years (±7.7), 46% women, 32% Spanish speaking, 34% had limited health literacy, and 589 (42%) reported conversations with surrogates and 216 (15%) with clinicians. Of these, less than half rated the conversations as detailed high quality (clinician: 43%; surrogate: 37%). Five-point communication satisfaction scores were higher with detailed versus general conversations (e.g., surrogates: 4.4 vs. 4.1, p = 0.001; clinicians: 4.4 vs. 4.2, p = 0.18) and more often reported by men versus women [(4.4 (0.8) vs. 4.0 (1.0), p = 0.003]; those with adequate versus limited health literacy [4.4 (0.8) vs. 4.0 (0.9), p = 0.002]; and English versus Spanish speakers [4.5 (0.7) vs. 3.5 (0.9), p < 0.001]. Conclusions: Among English- and Spanish-speaking older adults, ACP conversations were infrequent and most were general in quality. Higher quality detailed conversations resulted in greater communication satisfaction. Interventions are needed to improve conversation quality, particularly for Spanish-speaking patients and those with limited health literacy. Trial Registrations: ClinicalTrials.gov identifiers: "Improving Advance Care Planning by Preparing Diverse Seniors for Decision Making (PREPARE)" NCT01990235 and "Preparing Spanish-Speaking Older Adults for Advance Care Planning and Medical Decision Making (PREPARE)" NCT02072941.

Perceived Barriers and Social Cultural Factors Associated With Advance Care Planning Conversations Among Chinese American Older Adults

Despite the well-documented benefits of advance care planning (ACP), persistent racial and ethnic disparities continue to exist in ACP engagement. Guided by a social ecological model, this study examined perceived barriers and sociocultural factors associated with informal ACP conversations among Chinese American older adults. A purposive sample of 281 community-dwelling older Chinese Americans aged 55 years or older in Arizona and Maryland completed a survey in 2018. Hierarchical logistic regression models were conducted. There were 26.5% of participants who engaged in advance care planning. Lower perceived barriers and sociocultural factors (i.e., length of stay in the U.S. and English language proficiency) were positively associated with ACP conversations. Social support had a significant moderation effect. Findings highlighted the importance of language services and social support in facilitating ACP discussions among older Chinese immigrants. Effective strategies are needed to reduce the barriers to ACP at various levels for older Chinese American populations.

Predictors of Advance Care Planning Engagement Among Muslim Americans

Advance care planning (ACP) enables people to discuss their physical, psychological, social, and spiritual needs before nearing death. Most literature examining the determinants of ACP engagement is limited and does not include minority faith communities in the United States, including Muslim communities. The purpose of this cross-sectional correlational study was to examine ACP engagement determinants among Muslims in the United States. Using the Social Ecological Model, we conceptualized the determinants of ACP engagement into intrapersonal, interpersonal, and community factors. The study self-administered questionnaires were distributed using convenience and snowball techniques. Multiple linear regression was used to predict ACP engagement. The total sample was 148 Muslim adults. The age range was 18 to 79 years. Among all tested factors, being Asian American, knowing a deceased person who had received aggressive or minimal medical treatments near death, being born in the United States, having knowledge and awareness about ACP, and being accepting of the American culture were the determinants of ACP engagement. Engagement in ACP is a multifactorial behavior. Several intrapersonal and interpersonal factors, but none of the community factors, were associated with ACP engagement among Muslim adults. Future ACP interventions targeted toward Muslim Americans should be planned with an understanding of the multifactorial nature of ACP engagement.

Experiences and preferences for advance care planning following a diagnosis of dementia: Findings from a cross-sectional survey of carers

BACKGROUND

Future medical and financial planning is important for persons with dementia given the impact of the disease on capacity for decision making.

AIMS

To explore from the perspective of carers of persons with dementia: (1) Participation in future medical and financial planning by the person they care for, including when planning was undertaken and the characteristics associated with having an advance care directive completed; (2) The type of healthcare providers who discussed advance care planning following diagnosis; and (3) Preferences for timing of discussions about advance care planning following diagnosis.

METHODS

Recruitment and data collection took place between July 2018 and June 2020. Carers of persons with dementia aged 18 years and older were mailed a survey. Participants completed questions regarding completion of various future planning documents by the person they support, including time of completion and who discussed advance care planning following diagnosis. Participants were presented with information about the benefits and consequences of early and late discussions of advance care planning and asked when discussions about advance care planning were best initiated.

RESULTS

198 carers participated. Most participants were female (74%) and had been a carer for more than 2 years (82%). Most participants reported that the person with dementia they support had made a Will (97%) and appointed an Enduring Guardian (93%) and Enduring Power of Attorney (89%). Only 47% had completed an advance care directive. No significant associations were found between characteristics of persons with dementia and completion of an advance care directive. Geriatricians (53%) and GPs (51%) most often discussed advance care planning following diagnosis. Most carers thought that discussions about advance care planning should occur in the first few weeks or months following diagnosis (32%), at the healthcare provider's discretion (31%), or at the time of diagnosis (25%).

CONCLUSIONS

More than half of persons with dementia do not have an advance care directive. There is variability in preferences for timing of discussions following dementia diagnosis.

Social workers' perspectives about advance directives: A qualitative study

OBJECTIVES

The study explores medical social workers' perceptions on the importance of and purpose for documenting Advance Directives (ADs) in the United States and their views of the benefits for engaging patients and families in dialogue about ADs and Advance Care Planning (ACP).

METHODS

We conducted a qualitative study using free-text responses from a survey of 142 social workers who work in the medical field in various in-patient hospital and out-patient medical/healthcare settings. Participants were asked, "What is the purpose of documenting an advance directive?" and "Why do you think advance directives are important?" and "What benefits have you experienced in educating patients about advance directives?" Thematic analysis informed themes about the purpose, importance, and benefits of supporting patients in completing an AD.

RESULTS

Four themes emerged: 1) The purpose of documenting an AD, 2) Facilitating communication, 3) Creating a plan involves relationship building, and 4) Having an AD reduces suffering and uncertainty.

CONCLUSION

Social workers have expertise in relationship building which is an essential element of the partnering process with patients and their support systems towards AD completion.

PRACTICE IMPLICATIONS

Social workers who work in medical settings provide ACP education for patients and families and create interprofessional linkages to support patient care. It is clear that social workers add value to care provision to improve communication and provide assistance towards AD completion.

Advance care planning among older adults of Moroccan origin: An interview-based study

OBJECTIVE

To explore advance care planning (ACP)-related knowledge, experience, views, facilitators and barriers among older Moroccan adults in Belgium.

METHOD

General practitioners (GPs) recruited participants for semi-structured interviews. Data were analysed using the constant comparative method.

RESULTS

The 25 interviewees (average age, 74 years) lacked ACP knowledge and had not discussed it with healthcare professionals. After a brief explanation, most interviewees did not find ACP useful. After more explanation with a specific example, they had fewer religious objections and were more willing to have discussions with their GPs and/or relatives. ACP barriers were a lack of knowledge, current good health, potential harm of talking about death, trust in one's children to make care decisions and fear of worrying one's children. Facilitators were GPs' information provision, children's involvement in ACP discussions and the desire to not depend on children.

CONCLUSION

Many older Moroccan adults lacked familiarity, but were willing to discuss ACP after receiving understandable concrete information. GPs should facilitate ACP discussions for these patients, ideally with adult children involved, with consideration of barriers, individual preferences and generally low educational levels.

PRACTICE IMPLICATIONS

GPs should provide comprehensible ACP information with case examples and consider potential barriers and facilitators in this group.

How does ethnicity affect presence of advance care planning in care records for individuals with advanced disease? A mixed-methods systematic review

BACKGROUND

Advance care planning (ACP) is the process supporting individuals with life-limiting illness to make informed decisions about their future healthcare. Ethnic disparities in ACP have been widely highlighted, but interpretation is challenging due to methodological heterogeneity. This review aims to examine differences in the presence of documented ACP in individuals' care records for people with advanced disease by ethnic group, and identify patient and clinician related factors contributing to this.

METHODS

Mixed-methods systematic review. Keyword searches on six electronic databases were conducted (01/2000-04/2022). The primary outcome measure was statistically significant differences in the presence of ACP in patients' care records by ethnicity: quantitative data was summarised and tabulated. The secondary outcome measures were patient and clinician-based factors affecting ACP. Data was analysed qualitatively through thematic analysis; themes were developed and presented in a narrative synthesis. Feedback on themes was gained from Patient and Public Involvement (PPI) representatives. Study quality was assessed through Joanna Briggs Institute Critical Appraisal tools and Gough's Weight of Evidence.

RESULTS

N=35 papers were included in total; all had Medium/High Weight of Evidence. Fifteen papers (comparing two or more ethnic groups) addressed the primary outcome measure. Twelve of the fifteen papers reported White patients had statistically higher rates of formally documented ACP in their care records than patients from other ethnic groups. There were no significant differences in the presence of informal ACP between ethnic groups. Nineteen papers addressed the secondary outcome measure; thirteen discussed patient-based factors impacting ACP presence with four key themes: poor awareness and understanding of ACP; financial constraints; faith and religion; and family involvement. Eight papers discussed clinician-based factors with three key themes: poor clinician confidence around cultural values and ideals; exacerbation of institutional constraints; and pre-conceived ideas of patients' wishes.

CONCLUSIONS

This review found differences in the presence of legal ACP across ethnic groups despite similar presence of informal end of life conversations. Factors including low clinician confidence to deliver culturally sensitive, individualised conversations around ACP, and patients reasons for not wishing to engage in ACP (including, faith, religion or family preferences) may begin to explain some documented differences.

TRIAL REGISTRATION

PROSPERO-CRD42022315252.

Impact of Chronic Conditions, Healthcare Utilization, and Demographics on Advance Care Planning

Context: Unraveling the intricacies of what factors influence advance care planning (ACP) is an ongoing research challenge. Research shows much ACP is crisis-based and takes place at the end of life. Complicating this late-stage approach may be demographic differences based on race, ethnicity and socioeconomic status. Objective: We examined the relationship between demographic factors, chronic health conditions, and healthcare utilization in predicting who was most likely to engage in ACP activities, including designating a durable power of attorney for healthcare (DPOAHC), having a living will, and discussing wishes with family or others. Methods: We conducted a secondary analysis using 2018 Health and Retirement Study (HRS) exit data provided by a proxy for the deceased participant that matched the 2016 survey participant data (N = 884). Generalized linear mixed models were used for the analysis. Results: The number of chronic health conditions and healthcare utilization were not associated with ACP activities, but several of the demographic variables showed strong associations. Participants who were female, white, older, and from a higher socioeconomic status were more likely to have engaged in ACP. Conclusion: People continue to defer ACP discussions and documentation end of life or when facing medical crises. More needs to be done to reach out to younger adults, racial minorities, and those with lower socioeconomic status to encourage them to engage in ACP.

Associations Between Patient-Perceived Cancer Curability and Advance Directive Completion

Background: Despite Advance Care Planning recommendations for patients with cancer, many lack Advance Directives (ADs). AD disparities persist among Black, Indigenous, or People of Color (BIPOC) patients. Based on a hypothesized correlation, we examined the association between patient-perceived cancer incurability and AD completion. Methods: This cross-sectional study obtained self-reported AD completion and incurability perception from routine care surveys. AD completion by incurability perception was estimated using modified Poisson regression. Subgroup analyses examined patients who were BIPOC, White, and had solid organ malignancies. Results: Our sample (N = 1209) was predominantly female (70%), White (73%) with early-stage disease (60%), and solid organ malignancies (82%). AD completion was 42%, and 40% of patients reported their cancer incurable. Patient-perceived incurability was not associated with increased AD completion (likelihood ratio 0.94, 95% confidence interval 0.78-1.13) in overall or subgroup analyses. Conclusion: Patient-perceived cancer incurability was not associated with AD completion, even accounting for race/ethnicity and cancer type.

"We are Human too.": The Challenges of Being an End-of-Life Doula

End-of-life (EOL) doulas are emerging professionals who provide an intimate approach to the death process by focusing on the psychological, social, spiritual, and emotional needs of dying individuals. EOL doula work is stressful; it exposes individuals to recurring stressors such as suffering and grief. Trained professionals are needed to help advocate for the dying individual and their families. Despite the growing literature on EOL doulas, information regarding the challenges of being an EOL doula is underrepresented in the literature. This paper is one of the first to address this concept. Twelve in-depth, semi-structured interviews regarding the EOL doula experience were conducted as a part of a larger exploratory study. Three overarching themes emerged from the larger project: motivations to become an EOL doula, roles of an EOL doula, and challenges of an EOL doula. In this article, only challenges of EOL are discussed, along with subsequent subordinate themes.

Effects of advance care planning training on advanced practice nurse students' knowledge, confidence, and perception of end-of-life care: A mixed-method study

AIMS

This study aimed to assess how an advance care planning training program affected advanced practice nursing students' knowledge, confidence and perception of end-of-life care in South Korea.

BACKGROUND

Effective communication between healthcare providers, patients and their families is one of the most important components of quality end-of-life care. However, nurses in South Korea may feel uncomfortable helping patients and families with advance care planning because of the cultural taboo against talking about dying.

DESIGN

A mixed-method design was used with data obtained from self-administered questionnaires at the onset and end of the advance care planning training program and qualitative data from participant feedback after the program.

METHODS

Data collected from 65 advanced practice nursing students who participated in advance care planning training programs in June-July 2020 and 2021, conducted as part of a graduate clinical practice course, were analyzed. Data were originally collected to examine students' course outcomes. A training program was provided to advanced practice nursing students to improve their knowledge, confidence and perception in advance care planning conversations with their patients. The program comprised three sessions: online lectures, face-to-face simulations and discussions on advance care planning and ethical issues. Changes in advance care planning knowledge, confidence in supporting patients' advance directives, perceived nursing roles in end-of-life treatment decisions and perception of a good death were examined before and after the training.

RESULTS

There were statistically significant increases in participants' advance care planning knowledge, confidence in supporting patients' advance directives and perception of the active role of nurses in patients' end-of-life treatment decisions after the training.

CONCLUSIONS

The results indicate the effects of training programs on advanced practice nursing students' knowledge, confidence and perception of advance care planning communication. They also provide evidence about what contents and methods can be helpful in developing end-of-life care training for advanced practice nursing students.

Factors Associated With Advance Care Planning by Race

OBJECTIVE

This study aims to quantify and interpret Black-White differences in the factors associated with advance care planning (ACP), with specific attention to self-reported presence of chronic conditions and healthcare stereotype threat (HCST) in medical settings.

METHOD

Black and White individuals aged 50 and older (N = 499) were recruited from community centers and assisted living facilities in southern California and on Amazon Mechanical Turk. Six sequential logistic regressions assessed the effect of age, presence of chronic conditions, income, and HCST on predicting 3 components of ACP by race.

RESULTS

Findings suggest that the awareness of ongoing chronic conditions predicts all 3 aspects of ACP for Whites, but not for Blacks. HCST positively predicts the appointment of a durable power of attorney, but only for Black respondents.

DISCUSSION

These findings offer a novel perspective on racial disparities in ACP that may inform health care providers and community practices.

Advance care planning among African Americans: A review and synthesis of theory application

OBJECTIVES

Theoretical and conceptual frameworks are often underutilized in research, which may diminish understanding of the phenomena and contribute to the under-development of interventions. The topic of low/disparate rates of Advance Care Planning (ACP) among African Americans has been researched extensively; however, the use of theoretical and/or conceptual frameworks has not been reported. The purpose of this review is to describe theoretical and/or conceptual frameworks utilized in studies that investigated factors affecting perceptions of ACP or ACP rates among African Americans.

METHODS

Utilizing a narrative, literature review process, themes were generated, applied, and described with frequencies across broad categories of study characteristics, framework categories and key constructs, mode of framework application, and quality of framework reporting.

RESULTS

Four main types of frameworks were found with behavioral frameworks dominating the collection of studies. Complex, systems theoretical frameworks were less common. Framework use and reporting quality findings are described.

SIGNIFICANCE OF RESULTS

The problem of disparate rates of ACP among African Americans is nuanced and varied, stemming from both internal (e.g., personal, behavioral) and external factors (e.g., living conditions). While important and necessary to focus on internal, psychological factors, it is also vital to incorporate systems' theories such as the Cumulative Disadvantage Theory to better understand and demonstrate inherent complexities. Recommendations for framework use are discussed for research and clinical application. Incorporating complexity science approaches and multi-systems theories may support multi-level modeling needed to understand this problem and reduce ACP disparities in this population.

The affordable care act and do-not-resuscitate orders: Differences by race and ethnicity

BACKGROUND

The Affordable Care Act (ACA) created new payment rules that provided reimbursement for physicians to engage in advance care planning (ACP) conversations with patients. This reimbursement policy has the potential to increase ACP participation, including among racial and ethnic minority groups that have had lower ACP participation.

OBJECTIVES

To examine whether the ACP payment rules were associated with an increase in use of do-not-resuscitate (DNR) orders, particularly among racial and ethnic minority groups, among patients diagnosed with heart failure (HF) in California.

METHODS

The California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Data Set was used to identify a cohort of elderly patients with a principal diagnosis of HF. This study included 432,520 hospital admissions of patients over the age of 65 with a primary diagnosis of HF between 2012 and 2018. DNR status was identified using International Classification of Diseases, Clinical Modification Ninth and Tenth Revision, codes.

RESULTS

There was a small increase in the utilization of DNR orders overall after the ACA reimbursement policy, but the change was not significantly different for all racial and ethnic groups when compared to white non-Hispanic patients.

CONCLUSIONS

ACP payment rules provided in the ACA were associated with increased utilization of DNR, but the effect was not significantly different for racial and ethnic minorities hospitalized with HF in CA. Additional efforts are needed to increase ACP participation among racial and ethnic minorities.

Health inequalities for older people from minority ethnic groups receiving palliative care and end of life care: A scoping review protocol

OBJECTIVE

The proposed scoping review aims to explore international literature on how older people from minority ethnic groups engage with and utilise palliative and end of life care, investigate the barriers and facilitators, and compare how this varies between ethnicities and health conditions.

INTRODUCTION

Minority ethnic groups make up substantial parts of the populations of many countries around the world. Research has found that there are disparities in access to palliative care and end of life care among minority ethnic groups. Language barriers, cultural values, and socio-demographic factors have been cited as preventing access to quality palliative and end of life care. However, it is unclear how these barriers and inequalities differ across different minority ethnic groups in different countries, and across different health conditions within these groups.

INCLUSION CRITERIA

The population will be older people of different minority ethnic groups who are receiving palliative or end of life care, family caregivers, and health and social care professionals. The sources of information will include quantitative, qualitative and mixed methods research, and sources that focus on minority ethnic groups' interactions with palliative and end of life care.

METHODS

A scoping review guided by the Joanna Briggs Institute Manual for Evidence Synthesis. Searches of MEDLINE, Embase, PsycInfo, CINAHL, Scopus, Web of Science, Assia, and the Cochrane Library will be conducted. Citation tracking, reference list checking and grey literature searches will be undertaken. Data will be extracted, charted and summarised descriptively.

IMPLICATIONS

This review will highlight the health inequalities present in palliative and end of life care, the research gaps in understudied minority ethnic populations, locations where further study is required, and how barriers and facilitators differ across different ethnic groups and health conditions. The results of this review will be shared with stakeholders and will provide evidence-based recommendations for inclusive palliative and end of life care.

Insurance Status and Ethnicity Impact Health Disparities in Rates of Advance Directives in Trauma

INTRODUCTION

Advanced directives (ADs) provide a framework from which families may understand patient's wishes. However, end-of-life planning may not be prioritized by everyone. This analysis aimed to determine what populations have ADs and how they affected trauma outcomes.

METHODS

Adult trauma patients recorded in the American College of Surgeons Trauma Quality Improvement Program (TQIP) from 2013-2015 were included. The primary outcome was presence of an AD. Secondary outcomes included mortality, length of stay (LOS), mechanical ventilation, ICU admission/LOS, withdrawal of life-sustaining measures, and discharge disposition. Multivariable logistic regression models were developed for outcomes.

RESULTS

44 705 patients were included in the analyses. Advanced directives were present in 1.79% of patients. The average age for patients with ADs was 77.8 ± 10.7. African American (odds ratio (OR) .53, confidence intervals [CI] .36-.79) and Asian (OR .22, CI .05-.91) patients were less likely to have ADs. Conversely, Medicaid (OR 1.70, CI 1.06-2.73) and Medicare (OR 1.65, CI 1.25-2.17) patients were more likely to have ADs as compared to those with private insurance. The presence of ADs was associated with increased hospital mortality (OR 2.84, CI 2.19-3.70), increased transition to comfort measures (OR 2.87, CI 2.08-3.95), and shorter LOS (CO -.74, CI -1.26-.22). Patients with ADs had an increased odds of hospice care (OR 4.24, CI 3.18-5.64).

CONCLUSION

Advanced directives at admission are uncommon, particularly among African Americans and Asians. The presence of ADs was associated with increased mortality, use of mechanical ventilation, admission to the ICU, withdrawal of life-sustaining measures, and hospice. Future research should target expansion of ADs among minority populations to alleviate disparities in end-of-life treatment.

African American Recruitment in Early Heart Failure Palliative Care Trials: Outcomes and Comparison With the ENABLE CHF-PC Randomized Trial

BACKGROUND

Palliative care trial recruitment of African Americans (AAs) is a formidable research challenge.

OBJECTIVES

Examine AA clinical trial recruitment and enrollment in a palliative care randomized controlled trial (RCT) for heart failure (HF) patients and compare patient baseline characteristics to other HF palliative care RCTs.

METHODS

This is a descriptive analysis the ENABLE CHF-PC (Educate, Nurture, Advise, Before Life Ends: Comprehensive Heartcare for Patients and Caregivers) RCT using bivariate statistics to compare racial and patient characteristics and differences through recruitment stages. We then compared the baseline sample characteristics among three palliative HF trials.

RESULTS

Of 785 patients screened, 566 eligible patients with NYHA classification III-IV were approached; 461 were enrolled and 415 randomized (AA = 226). African Americans were more likely to consent than Caucasians (55%; P FDR = .001), were younger (62.7 + 8; P FDR = .03), had a lower ejection fraction (39.1 + 15.4; PFDR = .03), were more likely to be single (P FDR = .001), and lack an advanced directive (16.4%; P FDR < .001). AAs reported higher goal setting (3.3 + 1.3; P FDR = .007), care coordination (2.8 + 1.3; P FDR = .001) and used more "denial" coping strategies (0.8 + 1; P FDR = .001). Compared to two recent HF RCTs, the ENABLE CHF-PC sample had a higher proportion of AAs and higher baseline KCCQ clinical summary scores.

CONCLUSION

ENABLE CHF-PC has the highest reported recruitment rate and proportion of AAs in a palliative clinical trial to date. Community-based recruitment partnerships, recruiter training, ongoing communication with recruiters and clinician co-investigators, and recruiter racial concordance likely contributed to successful recruitment of AAs. These important insights provide guidance for design of future HF palliative RCTs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02505425.

Racial and ethnic variation in COVID-19 care, treatment, and outcomes: A retrospective cohort study from the MiCOVID-19 registry

BACKGROUND

Racial and ethnic disparities in COVID-19 outcomes exist, but whether in-hospital care explains this difference is not known. We sought to determine racial and ethnic differences in demographics, comorbidities, in-hospital treatments, and in-hospital outcomes of patients hospitalized with COVID-19.

METHODS AND FINDINGS

This was a cohort study using MiCOVID-19, a multi-center, retrospective, collaborative quality improvement registry, which included data on patients hospitalized with COVID-19 across 38 hospitals in the State of Michigan. 2,639 adult patients with COVID-19 hospitalized at a site participating in the MiCOVID-19 Registry were randomly selected. Outcomes included in-hospital mortality, age at death, intensive care unit admission, and need for invasive mechanical ventilation by race and ethnicity. Baseline comorbidities differed by race and ethnicity. In addition, Black patients had higher lactate dehydrogenase, erythrocyte sedimentation rate, C-reactive protein, creatine phosphokinase, and ferritin levels. Black patients were less likely to receive dexamethasone and remdesivir compared with White patients (4.2% vs 14.3% and 2.2% vs. 11.8%, p < 0.001 for each). Black (18.7%) and White (19.6%) patients experienced greater mortality compared with Asian (13.0%) and Latino (5.9%) patients (p < 0.01). The mean age at death was significantly lower by 8 years for Black patients (69.4 ± 13.3 years) compared with White (77.9 ± 12.6), Asian (77.6 ± 6.6), and Latino patients (77.4 ± 15.5) (p < 0.001).

CONCLUSIONS

COVID-19 mortality appears to be driven by both pre-hospitalization clinical and social factors and potentially in-hospital care. Policies aimed at population health and equitable application of evidence-based medical therapy are needed to alleviate the burden of COVID-19.

A Qualitative Exploration of End-of-Life Care Planning With Korean Americans: Awareness, Attitudes, Barriers, and Preferences

This study aimed to explore how Korean American older adults viewed and anticipated engaging in end-of-life (EOL) care planning. An exploratory qualitative research design was adopted for the study, and data were collected through 3 focus group interviews. A total of 30 Korean American older adults 65 years or older participated in the study. A total of 10 themes emerged and were organized into 5 categories: (1) awareness (varying experience in EOL care planning and insufficient understanding about advance directives), (2) attitudes (comfort with talking about EOL and favorable views toward EOL planning), (3) barriers (concerns about noncompliance and concerns about change of mind), (4) preference for natural dying (life-sustaining treatment as added pain and suffering and no meaning of life when relying on life-sustaining treatment), and (5) preference for EOL planning process (EOL planning initiated by physicians and involvement of close family members). This exploratory study provides crucial insights into awareness and concerns regarding EOL care planning among Korean American older adults, updating existing evidence about their EOL needs. These findings support a culturally grounded approach to promote EOL planning for ethnic/racial minority groups.

Lessons learned from a social worker's approach to advance care planning discussions with Chinese-immigrant oncology outpatients

PURPOSE

To examine Chinese-immigrant cancer patients' openness to advance care planning (ACP) in an outpatient oncology setting.

DESIGN

Retrospective review of social work assessment data.

SAMPLE

150 Chinese-immigrant patient charts were reviewed (55% Cantonese, 45% Mandarin).

METHODS

Data were summarized descriptively and with logistic regression analyses.

FINDINGS

Sixteen percent of patients had completed ACP prior to meeting with the oncology social worker (OSW). Twenty percent of patients agreed to complete a health care proxy (HCP) after receiving culturally-tailored education in their language of origin from the OSW, while 75% remained open to ongoing consideration of ACP and HCP completion.

CONCLUSIONS

This study illuminates how Chinese immigrants engage in ACP discussions in an oncology setting.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDER

OSWs can play an integral role in advocating, educating, and intervening with this population and can assist the interdisciplinary team in understanding the importance of the cultural differences, even if the OSW's primary language differs from that of a patient's.