African American bereaved family members' perceptions of the quality of hospice care: lessened disparities, but opportunities to improve remain

Roles of Chaplains and Clergy in Spiritual Care for African Americans in Hospice: A Pilot Study

CONTEXT

Spiritual care is recognition of patient and caregiver spiritual/religious needs and attention to those needs. Caregivers of African American hospice patients are more likely to report worse emotional/religious support. Yet, spiritual care delivery and roles of community clergy and chaplains for African American hospice patients are not well understood.

OBJECTIVES

Examine who provides spiritual care to African American hospice patients and caregivers.

METHODS

Partnering with large, urban/suburban community hospice, we interviewed caregivers of deceased African American hospice patients (n = 12), their clergy (n = 3) and chaplains (n = 5). Using a phenomenological qualitative study design, we coded transcripts and deceased patient chart data and conducted thematic analysis to identify themes.

RESULTS

Community clergy and chaplains tend to not interact and provide different aspects of emotional, religious and spiritual support to hospice patients and families. Clergy and chaplains agreed that rapport and openness of the patient were main factors in meeting spiritual care needs. Clergy provided interaction with a trusted person and connection to church, congregational support, religious beliefs/theology, and practices. Chaplains focused on present needs and issues of death and dying.

CONCLUSION

Clergy and chaplains have distinct, complementary roles in providing spiritual care to African American hospice patients and families. Both are needed to provide desired spiritual care for African American hospice patients and their caregivers. Robust spiritual care programs need to ensure chaplains have sufficient time to spend with patients and families and incorporate collaboration, handoffs and integrated processes for clergy and chaplains. Research is needed on effectively including clergy in hospice spiritual care delivery.

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.

Some Reflections on the 50th Anniversary of Hospice Care in America

This article celebrates the 50th anniversary of hospice care in America. It also offers a brief recounting of one person's reflections on some aspects of the history, achievements, and current status of American hospice care.

Black Caregivers' Symptom Management, Cultural, and Religious Experiences With Home Hospice Care

CONTEXT

Informal Black or African American (Black/AA) caregivers are at high risk for caregiver burden due to both greater caregiving responsibilities and unmet needs. However, there has been minimal research on the challenges Black/AA caregivers face after hospice enrollment.

OBJECTIVES

This study seeks to address this knowledge gap by applying qualitative methods to understand Black/AA caregivers' experiences around symptom management, cultural, and religious challenges during home hospice care.

METHODS

Data from small group discussions with 11 bereaved Black/AA caregivers of patients who received home hospice care were qualitatively analyzed.

RESULTS

Caregivers struggled most with managing patients' pain, lack of appetite, and decline near end of life (EoL). Cultural needs (e.g., knowing their language, having familiarity with foods) were perceived as not on top of mind for many Black/AA caregivers. However, there was a concern of stigma around mental health preventing care recipients from sharing their mental health concerns and seeking resources. Many caregivers relied on their personal religious networks rather than services provided by hospice chaplains. Lastly, caregivers reported increased burden during this phase of caregiving but were satisfied with the overall hospice experience.

CONCLUSION

Our results suggest that tailored approaches that target mental health stigma in the Black/AA community and reduce caregiver distress around end of life symptoms may improve hospice outcomes among Black/AA hospice caregivers. Hospice spiritual services should consider offering services complementary to caregivers' existing religious networks. Future qualitative and quantitative studies should examine the clinical implications of these results in terms of patient, caregiver, and hospice outcomes.

Characteristics, ICU Interventions, and Clinical Outcomes of Patients With Palliative Care Triggers in a Mixed Community-Based Intensive Care Unit

Objective: Integration of palliative care initiatives in the intensive care unit (ICU) benefit patients and improve outcomes. Palliative care triggers (PCTs) is a screening tool that aides in stratifying patients who would benefit most from an early palliative care approach. There is no consensus on PCT selection or best timing for implementation. We evaluated the clinical characteristics, ICU and palliative care interventions, and clinical outcomes of critically ill patients with PCT in a community-based mixed ICU. Methods: This retrospective study was conducted in a 44-bed adult, mixed ICU in a 407-bed community-based teaching hospital in Florida. Eleven PCTs were used as a screening tool during multidisciplinary rounds (MDRs). Patients were analyzed based on presence or absence of PCT as well as having met high (>2) versus low (<2) PCT. Data collected included patient demographics, ICU resource utilization and clinical outcomes. We considered a two-sided P value of less than .05 to indicate statistical significance with a 95% confidence interval. Results: Of 388 ICU patients, 189 (48.7%) met at least 1 PCT and 199 (51.3%) did not. The trigger group had higher Acute Physiology and Chronic Evaluation (APACHE) and Sequential Organ Failure Assessment (SOFA) scores within 24 h of ICU admission. The most common PCTs identified were ICU length of stay greater than 7 days or readmission to ICU, terminal prognosis and assisting family in transitioning goals of care. There were statistically significant differences in ICU resource utilization, palliative care interventions, and overall worse clinical outcomes in the trigger-detected group. Similar findings were seen in the cohort with high PCT (>2). Conclusions: Our study supports the implementation of a tailored 11-item palliative care screening tool to effectively identify ICU patients with high ICU and palliative care interventions and worse clinical outcomes.

Hospice Enrollment, Future Hospitalization, and Future Costs Among Racially and Ethnically Diverse Patients Who Received Palliative Care Consultation

BACKGROUND

Palliative care consultation to discuss goals-of-care ("PCC") may mitigate end-of-life care disparities.

OBJECTIVE

To compare hospitalization and cost outcomes by race and ethnicity among PCC patients; identify predictors of hospice discharge and post-discharge hospitalization utilization and costs.

METHODS

This secondary analysis of a retrospective cohort study assessed hospice discharge, do-not-resuscitate status, 30-day readmissions, days hospitalized, ICU care, any hospitalization cost, and total costs for hospitalization with PCC and hospitalization(s) post-discharge among 1,306 Black/African American, Latinx, White, and Other race PCC patients at a United States academic hospital.

RESULTS

In adjusted analyses, hospice enrollment was less likely with Medicaid (AOR = 0.59, P = 0.02). Thirty-day readmission was less likely among age 75+ (AOR = 0.43, P = 0.02); more likely with Medicaid (AOR = 2.02, P = 0.004), 30-day prior admission (AOR = 2.42, P < 0.0001), and Black/African American race (AOR = 1.57, P = 0.02). Future days hospitalized was greater with Medicaid (Coefficient = 4.49, P = 0.001), 30-day prior admission (Coefficient = 2.08, P = 0.02), and Black/African American race (Coefficient = 2.16, P = 0.01). Any future hospitalization cost was less likely among patients ages 65-74 and 75+ (AOR = 0.54, P = 0.02; AOR = 0.53, P = 0.02); more likely with Medicaid (AOR = 1.67, P = 0.01), 30-day prior admission (AOR = 1.81, P = 0.0001), and Black/African American race (AOR = 1.40, P = 0.02). Total future hospitalization costs were lower for females (Coefficient = -3616.64, P = 0.03); greater with Medicaid (Coefficient = 7388.43, P = 0.01), 30-day prior admission (Coefficient = 3868.07, P = 0.04), and Black/African American race (Coefficient = 3856.90, P = 0.04). Do-not-resuscitate documentation (48%) differed by race.

CONCLUSIONS

Among PCC patients, Black/African American race and social determinants of health were risk factors for future hospitalization utilization and costs. Medicaid use predicted hospice discharge. Social support interventions are needed to reduce future hospitalization disparities.

Racial Disparities in the Provision of Pediatric Psychosocial End-of-Life Services: A Systematic Review

Background: When compared with White patients, racial and ethnic minorities experience greater barriers to quality end-of-life care. Each year, approximately 52,000 children die in the United States, yet little is known about the disparities in pediatric palliative care, especially when looking at psychosocial palliative care services such as those provided by child life specialists, social workers, and pediatric psychologists. Objectives: In an effort to consolidate and synthesize the literature on this topic for psychosocial professionals working with children and families confronting a life-threatening diagnosis, a review was conducted. Design: This work was a systematic review of several academic databases that were searched from January 2000 to December 2020 for studies exploring disparities in pediatric end-of-life services and written in English. Setting/Subjects: This review was conducted in the United States. The search yielded 109 articles, of which 16 were included for review. Measurements: Three psychosocial researchers independently reviewed, critically appraised, and synthesized the results. Results: Emerging themes from the literature (n = 16) include service enrollment, decision making, and communication. Results highlight a lack of research discussing psychosocial variables and the provision of psychosocial services. Despite this gap, authors were able to extract recommendations relevant to psychosocial providers from the medical-heavy literature. Conclusions: Recommendations call for more research specific to possible disparities in psychosocial care as this is vital to support families of all backgrounds who are confronting the difficulties of pediatric loss.

Does ethnicity affect pain management for people with advanced disease? A mixed methods cross-national systematic review of 'very high' Human Development Index English-speaking countries

BACKGROUND

Racial disparities in pain management have been observed in the USA since the 1990s in settings such as the emergency department and oncology. However, the palliative care context is not well described, and little research has focused outside of the USA or on advanced disease. This review takes a cross-national approach to exploring pain management in advanced disease for people of different racial and ethnic groups.

METHODS

Mixed methods systematic review. The primary outcome measure was differences in receiving pain medication between people from different racial and ethnic groups. Five electronic databases were searched. Two researchers independently assessed quality using JBI checklists, weighted evidence, and extracted data. The quantitative findings on the primary outcome measure were cross-tabulated, and a thematic analysis was undertaken on the mixed methods studies. Themes were formulated into a conceptual/thematic matrix. Patient representatives from UK ethnically diverse groups were consulted. PRISMA 2020 guidelines were followed.

RESULTS

Eighteen papers were included in the primary outcome analysis. Three papers were rated 'High' weight of evidence, and 17/18 (94%) were based in the USA. Ten of the eighteen (56%) found no significant difference in the pain medication received between people of different ethnic groups. Forty-six papers were included in the mixed methods synthesis; 41/46 (89%) were based in the USA. Key themes: Patients from different ethnically diverse groups had concerns about tolerance, addiction and side effects. The evidence also showed: cultural and social doctor-patient communication issues; many patients with unmet pain management needs; differences in pain assessment by racial group, and two studies found racial and ethnic stereotyping.

CONCLUSIONS

There was not enough high quality evidence to draw a conclusion on differences in receiving pain medication for people with advanced disease from different racial and ethnic groups. The mixed methods findings showed commonalities in fears about pain medication side effects, tolerance and addiction across diverse ethnic groups. However, these fears may have different foundations and are differently prioritised according to culture, faith, educational and social factors. There is a need to develop culturally competent pain management to address doctor-patient communication issues and patients' pain management concerns.

TRIAL REGISTRATION

PROSPERO- CRD42020167890 .

Anxiety, Depression, Quality of Life, Caregiver Burden, and Perceptions of Caregiver-Centered Communication among Black and White Hospice Family Caregivers

Background: Anxiety, depression, and reduced quality of life (QOL) are common problems for hospice family caregivers, but it is unknown if disparities in these experiences exist among Black and White caregivers. Objectives: To compare anxiety, depression, QOL, caregiver burden, and perceptions of caregiver-centered hospice team communication between Black and White hospice family caregivers. Design: Secondary analysis of baseline data from two randomized clinical trials. Setting/Subjects: Seven hundred twenty-two Black and White hospice family caregivers ages 18+ from Midwestern and Northeastern United States. Measurements: Measures included the Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire (PHQ-9), Caregiver Quality-of-Life Index-Revised (CQLI-R), Zarit Burden Interview (ZBI-7), and Caregiver-Centered Communication Questionnaire (CCCQ). Results: Black and White caregivers differed across demographic and socioeconomic variables. Nearly one-third of hospice family caregivers reported moderate-to-severe anxiety (32.1%) and moderate-to-severe depressive symptoms (32.0%). White caregivers reported lower QOL than Black caregivers (p = 0.04), specifically in emotional (p = 0.02) and social (p = 0.0005) domains. In multiple regression analyses controlling for caregiver and patient factors, we found no racial differences in depression, anxiety, QOL, caregiver burden, or perceptions of caregiver-centered hospice communication. Conclusions: Despite demographic and socioeconomic differences, Black and White hospice family caregivers experience similarly high levels of anxiety, depression, burden, and perceptions of hospice communication. Interventions to support hospice family caregivers across racial groups and research that identifies factors that mediate social determinants of health in this population are needed. The development and validation of culture-concordant mental health screening tools in racially diverse populations is recommended. Trial registration: ClinicalTrials.gov NCT02929108 and ClinicalTrials.gov NCT01444027.

Top Ten Tips Palliative Care Clinicians Should Know About Delivering Antiracist Care to Black Americans

Racial disparities, including decreased hospice utilization, lower quality symptom management, and poor-quality end-of-life care have been well documented in Black Americans. Improving health equity and access to high-quality serious illness care is a national palliative care (PC) priority. Accomplishing these goals requires clinician reflection, engagement, and large-scale change in clinical practice and health-related policies. In this article, we provide an overview of key concepts that underpin racism in health care, discuss common serious illness disparities in Black Americans, and propose steps to promote the delivery of antiracist PC.

Care processes and racial/ethnic differences in family reports of end-of-life care among Veterans: A mediation analysis

BACKGROUND

Bereaved family members of racial/ethnic minority Veterans are less likely than families of White Veterans to provide favorable overall ratings of end-of-life (EOL) care quality; however, the underlying mechanisms for these differences have not been explored. The objective of this study was to examine whether a set of EOL care process measures mediated the association between Veteran race/ethnicity and bereaved families' overall rating of the quality of EOL care in VA medical centers (VAMCs).

METHODS

A retrospective, cross-sectional analysis of linked Bereaved Family Survey (BFS), administrative and clinical data was conducted. The sample included 17,911 Veterans (mean age: 73.7; SD: 11.6) who died on an acute or intensive care unit across 121 VAMCs between October 2010 and September 2015. Mediation analyses were used to assess whether five care processes (potentially burdensome transitions, high-intensity EOL treatment, and the BFS factors of Care and Communication, Emotional and Spiritual Support, and Death Benefits) significantly affected the association between Veteran race/ethnicity and a poor/fair BFS overall rating.

RESULTS

Potentially burdensome transitions, high-intensity EOL treatment, and the three BFS factors of Care and Communication, Emotional and Spiritual Support, and Death Benefits did not substantially mediate the relationship between Veteran race/ethnicity and poor/fair overall ratings of quality of EOL care by bereaved family members.

CONCLUSIONS

The reasons underlying poorer ratings of quality of EOL care among bereaved family members of racial/ethnic minority Veterans remain largely unexplained. More research on identifying potential mechanisms, including experiences of racism, and the unique EOL care needs of racial and ethnic minority Veterans and their families is warranted.

Preparedness for Serious Illnesses: Impact of Ethnicity, Mistrust, Perceived Discrimination, and Health Communication

BACKGROUND

Increasing severity of serious illness requires individuals to prepare and make decisions to mitigate adverse consequences of their illness. In a racial and ethnically diverse sample, the current study examined preparedness for serious illness among adults in California.

METHODS

This cross-sectional study used data from the Survey of California Adults on Serious Illness and End-of-Life 2019. Participants included 542 non-Hispanic White (52%), non-Hispanic Black (28%), and Hispanic (20%) adults who reported at least one chronic medical condition that they perceived to be a serious illness. Race/ethnicity, socio-demographic factors, health status, discrimination, mistrust, and communication with provider were measured. To perform data analysis, we used logistic regression models.

RESULTS

Our findings revealed that 19%, 24%, and 34% of non-Hispanic White, non-Hispanic Blacks, and Hispanic believed they were not prepared if their medical condition gets worse, respectively. Over 60% indicated that their healthcare providers never engaged them in discussions of their feelings of fear, stress, or sadness related to their illnesses. Results of bivariate analyses showed that race/ethnicity was associated with serious illness preparedness. However, multivariate analysis uncovered that serious illness preparedness was only lower in the presence of medical mistrust in healthcare providers, perceived discrimination, less communication with providers, and poorer quality of self-rated health.

CONCLUSION

This study draws attention to the need for healthcare systems and primary care providers to engage in effective discussions and education regarding serious illness preparedness with their patients, which can be beneficial for both individuals and family members and increase quality of care.

Front-Line Hospice Staff Perceptions of Barriers and Opportunities to Discussing Advance Care Planning With Hospice Patients and Their Families

OBJECTIVES

To understand the facilitators and barriers to hospice staff engagement of patients and surrogates in advance care planning (ACP) conversations.

DESIGN

Qualitative study conducted with purposive sampling and semistructured interviews using ATLAS.ti software to assist with template analysis.

SETTINGS AND PARTICIPANTS

Participants included 51 hospice professionals (31 clinicians, 13 leaders, and 7 quality improvement administrators) from 4 geographically distinct nonprofit US hospices serving more than 2700 people.

MEASURES

Interview domains were derived from the implementation science framework of Capability, Opportunity, Motivation, and Behavior (COM-B), with additional questions soliciting recommendations for behavior change. Differences in themes were reconciled by consensus. The facilitator, barrier, and recommendation themes were organized within the COM-B framework.

RESULTS

Capability was facilitated by interdisciplinary teamwork and specified clinical staff roles and inhibited by lack of self-perceived skill in engaging in ACP conversations. Opportunities for ACP occurred during admission to hospice, acute changes, or deterioration in patient condition. Opportunity-related environmental barriers included time constraints such as short patient stay in hospice and workload expectations that prevented clinicians from spending more time with patients and families. Motivation to discuss ACP was facilitated by the employee's goal of providing personalized, patient-centered care. Implicit assumptions about patients' and families' preferences reduced staff's motivation to engage in ACP. Hospice staff made recommendations to improve ACP discussions, including training and modeling practice sessions, earlier introduction of ACP concepts by clinicians in prehospice settings, and increasing workforce diversity to reflect the patient populations the organizations want to reach and cultural competency.

CONCLUSIONS AND IMPLICATIONS

Even hospice staff can be uncomfortable discussing death and dying. Yet staff were able to identify what worked well. Solutions to increase behavior of ACP engagement included staff training and modeling practice sessions, introducing ACP prior to hospice, and increasing workforce diversity to improve cultural competency.

Disparities in Palliative and Hospice Care and Completion of Advance Care Planning and Directives Among Non-Hispanic Blacks: A Scoping Review of Recent Literature

OBJECTIVES

Published research in disparities in advance care planning, palliative, and end-of-life care is limited. However, available data points to significant barriers to palliative and end-of-life care among minority adults. The main objective of this scoping review was to summarize the current published research and literature on disparities in palliative and hospice care and completion of advance care planning and directives among non-Hispanc Blacks.

METHODS

The scoping review method was used because currently published research in disparities in palliative and hospice cares as well as advance care planning are limited. Nine electronic databases and websites were searched to identify English-language peer-reviewed publications published within last 20 years. A total of 147 studies that addressed palliative care, hospice care, and advance care planning and included non-Hispanic Blacks were incorporated in this study. The literature review include manuscripts that discuss the intersection of social determinants of health and end-of-life care for non-Hispanic Blacks. We examined the potential role and impact of several factors, including knowledge regarding palliative and hospice care; healthcare literacy; communication with providers and family; perceived or experienced discrimination with healthcare systems; mistrust in healthcare providers; health care coverage, religious-related activities and beliefs on palliative and hospice care utilization and completion of advance directives among non-Hispanic Blacks.

DISCUSSION

Cross-sectional and longitudinal national surveys, as well as local community- and clinic-based data, unequivocally point to major disparities in palliative and hospice care in the United States. Results suggest that national and community-based, multi-faceted, multi-disciplinary, theoretical-based, resourceful, culturally-sensitive interventions are urgently needed. A number of practical investigational interventions are offered. Additionally, we identify several research questions which need to be addressed in future research.

LIGHT: A Church-Based Curriculum for Training African American Lay Health Workers to Support Advance Care Planning and End-of-Life Decision-Making

Purpose: African Americans with life-limiting illnesses experience significant health inequities. Lay health workers (LHWs) may help overcome existing challenges of communicating with African Americans about advance care planning (ACP) and end-of-life decision-making. Church-based LHWs have some advantages over other LHWs but no curriculum exists to fully prepare them. This article describes the development, content, format, and implementation of a curriculum designed to meet this need. Methods: We created a church-based curriculum to train African American, LHWs as communications-facilitators who can support persons with life-limiting illnesses, not only with ACP but also with issues that arise as illnesses progress. Learners are church members whom we call comfort care supporters. The curriculum organizes the LHW interactions with clients by the mnemonic LIGHT: Listening, Identifying, Guiding, Helping, and Translating. Results: The final curriculum consists of three parts: (1) a 26-h classroom component delivered in nine modules organized around eight themes: meaning and prognosis of a life-limiting illness, spirituality and the meaning of death, understanding the dying process, major decisions and choices, goals of care, end-of-life services, and resources, intrafamily communication, and role and activities of the LHW; (2) a visit component; and (3) experiential, case-based discussions during monthly meetings. Conclusions: LHWs may improve quality of care and thus reduce health inequities at the end-of-life. Preparing LHWs for conversations about ACP is necessary but insufficient. This curriculum also prepares LHWs to attend to the spiritual needs of clients and to support clients with their other needs as their illness progresses.

Cultivating Cultural Competence: How Are Hospice Staff Being Educated to Engage Racially and Ethnically Diverse Patients?

BACKGROUND

Compared to Whites, racial/ethnic minorities are less likely to enroll in hospice and if they enroll, more likely to experience poor quality care. Building cultural competence (CC) among hospice staff is a strategy that may reduce disparities.

OBJECTIVE

To describe the state of CC training across hospices.

DESIGN

National survey of hospices' practices to promote CC.

RESULTS

A total of 197 hospices participated; most were not-for-profit (80%) with an average daily census less than 100 (47%); 73% offered staff cultural competence training (CCT). There were no differences in characteristics of hospices who offered CCT and those that did not. Of hospices offering CCT, 61% held it annually. Most trainings were 1 hour (60%); content was delivered via web (58%) and/or lecture (58%). While over 90% of staff (i.e., nurses, social workers, chaplains) completed CCT, a smaller proportion of medical directors (64%), senior leaders (71%) and board members (26%) did so. Most common topics were: cross-cultural communication, death/illness beliefs, spirituality's role, and healthcare disparities. The majority focused on African-Americans (83%), Hispanics (76%), and Asians (62%)-the most common U.S. minority groups. Almost 30% reported no effectiveness assessment of CCT, while 51% reported a quiz at the end of training. Most hospices offered some CCT.

CONCLUSIONS

CCT has been shown to improve healthcare providers' knowledge and skills in caring for diverse patients and it is associated with increased patient satisfaction. Future research should evaluate effectiveness of CCT in improving the ability of hospices to deliver high quality end-of-life care to diverse groups of older adults.

Racial Differences in Pain Management for Patients Receiving Hospice Care

OBJECTIVES

To investigate racial differences in implementation of 11 evidence-based cancer pain management strategies in a matched sample of patients in hospice.

SAMPLE & SETTING

32 African American and 32 Caucasian American older adults (aged 65 years or older) with cancer pain receiving hospice care in the midwestern United States.

METHODS & VARIABLES

Matched cohort secondary data analysis of postintervention data in a cluster randomized controlled trial was used. Main outcomes are the summative and individual Cancer Pain Practice Index scores.

RESULTS

There were few statistically significant or clinically meaningful differences in implementation of individual best practices for pain management by race. Assessment of primary pain characteristics and management of opioid-induced constipation with a bowel regimen was significantly lower in African Americans than in Caucasian Americans.

IMPLICATIONS FOR NURSING

African American older adults receiving hospice care at the end of life received pain management that was, overall, comparable to matched Caucasian American older adults. Hospice and oncology nurses play a critical role in effective pain management and should continue to implement evidence-based guidelines for pain management into daily practice. Diffusing the hospice model and principles of pain and symptom management into other settings and specialty care areas may reduce widespread pain disparities.

Improving End-of-Life Care for Diverse Populations: Communication, Competency, and System Supports

BACKGROUND

While disparities in end-of-life care have been well-documented, explanations for the persistence of disparities are less clear. This study sought to examine diverse perceptions of end-of-life care, especially regarding how medical professionals can better serve all populations.

OBJECTIVE

To investigate similarities and differences in end-of-life care preferences, across racial and ethnic groups.

DESIGN

This work consists of a qualitative study utilizing in-depth focus group discussions.

SETTING/PARTICIPANTS

Six community-based focus groups were conducted with a total of 39 participants. Two groups were composed of African American participants, 2 had Latino participants, and 2 groups had white participants.

RESULTS

Analysis produced 3 major themes: (1) clear, comprehensive, and culturally relevant provider-patient communication regarding serious illness; (2) provider characteristics and competency; and (3) health system supports and barriers. Although all groups had individuals who expressed a strong preference for direct communication, individuals varied within groups. All groups discussed concerns that the costs of care are high and that financial considerations are given more importance than high-quality care. Groups diverged in their focus on provider characteristics and feelings of marginalization. African American and Latino groups emphasized a desire to match characteristics with providers, and African American groups discussed that their marginalization in the health-care system requires hypervigilance to receive high-quality care.

CONCLUSIONS

Improvements in care would come from acknowledging diversity within groups, provider demonstration of comfort and competence, more effective care coordination, and recruitment of providers who share similar characteristics with the communities they serve.

Understanding Underuse of Advance Care Planning Among a Cohort of African American Patients With Advanced Cancer: Formative Research That Examines Gaps in Intent to Discuss Options for Care

BACKGROUND

Advance care planning (ACP), palliative care (PC), and hospice are often underutilized by African Americans (AAs). This study assessed the impact of stage of intent to discuss ACP options as key potential barriers.

METHODS

We examined intent to discuss completion of ACP, PC, and hospice among 22 AA patients with cancer admitted to a local safety net hospital. Participants were asked about intent to discuss an advanced directive or living will (AD/LW), medical power of attorney (MPOA), PC, and hospice with their doctors. Intent to discuss these ACP components was based on the transtheoretical model. Electronic health records were reviewed at various intervals to assess completion of ACP behaviors and survival.

RESULTS

Participants had colorectal (33%), breast (44%), and lung (23%) cancer, and 82% had stage III/IV disease. Low percentages of patients were in the precontemplation stage for AD/LW completion (4.6%), MPOA completion (13.6%), and PC discussions (27.2%), but 77.2% were in the precontemplation stage for hospice discussions. At 1 year, only 5% completed an AD/LW, 36.4% appointed an MPOA, 42.9% were referred to PC, and 12.5% were referred to hospice. More than half (54.6%) were deceased by the study's conclusion. Most (81%) of these died within 6 months of their baseline study assessment.

CONCLUSIONS

Despite being hospitalized with advanced cancer and having poor prognosis, intent to discuss ACP options, PC, and hospice in this population was variable, and completion of these activities was low. This formative research is needed to develop education and counseling interventions for this high-risk, vulnerable population.

Black And Hispanic Patients Receive Hospice Care Similar To That Of White Patients When In The Same Hospices

Little is known about racial and ethnic variation in the quality of hospice care. We used data on 292,516 respondents for 2015-16 from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey to assess how the patient and family experience of hospice care differed among black, Hispanic, and white patients. We found that, on average, black and Hispanic patients received care from poorer quality hospices. Within a given hospice, we found that friends and relatives who served as caregivers of black and Hispanic patients reported significantly better hospice care experiences than their peers serving as caregivers of white patients on five of seven outcomes. However, caregivers of black and Hispanic patients reported receiving their desired level of emotional and religious support less often than caregivers of white patients did. As more black and Hispanic patients enroll in hospice care, it is critical to ensure that they have access to high-quality, culturally competent hospice services.

Measuring the quality of end-of-life care: Development, testing, and cultural validation of the Danish version of Views of Informal Carers' Evaluation of Services-Short Form

BACKGROUND

The perspectives of patients and relatives are important in the improvement of the quality of health care. However, the quality of end-of-life care has not been systematically evaluated in Scandinavia.

AIM

To develop or adapt and subsequently validate a questionnaire assessing the quality of end-of-life care in Denmark. The questionnaire was intended for bereaved relatives in order to assess the quality of care in the last 3 months of the patient's life and the circumstances surrounding death.

DESIGN AND DATA SOURCES

Based on the literature and interviews with 15 bereaved relatives and 17 healthcare professionals, relevant topics to include in a questionnaire were identified. The topics were prioritized by 100 bereaved relatives and subsequently compared to existing questionnaires. The chosen questionnaire was tested by cognitive interviews with 36 bereaved relatives.

RESULTS

Most of the important topics were covered by the Views of Informal Carers' Evaluation of Services-Short Form, but not all Danish settings (e.g. home care by a palliative team) were covered. These settings were added to the Views of Informal Carers' Evaluation of Services-Short Form, and a few adaptations were made before a Danish version of the Views of Informal Carers' Evaluation of Services-Short Form was tested by cognitive interviews. This cultural validation showed that the slightly adapted Danish version was perceived as relevant, understandable, and acceptable. Furthermore, the cognitive interviews gave insight in the comprehension and interpretation of Views of Informal Carers' Evaluation of Services-Short Form items.

CONCLUSION

With a few adaptations, the British Views of Informal Carers' Evaluation of Services-Short Form was relevant in a Danish setting.

Hispanic Hospice Patients' Experiences of End-Stage Restlessness

End-stage restlessness, or terminal agitation, is experienced by some patients during their final days and is characterized by physical, emotional, or spiritual distress, agitation or anxiety. End-stage restlessness negatively affects the patient's death experience and can be distressing to the family and care team. Using the 2007 National Home and Hospice Care survey, this study examined factors associated with experiencing end-stage restlessness among non-Hispanic white and Hispanic hospice patients deceased at time of discharge. Results showed that being Hispanic/Latino, experiencing dyspnea, pain, and receiving palliative sedation treatment were risk factors for experiencing end-stage restlessness. The association between pain and restlessness was stronger for Hispanics compared with non-Hispanic whites. The Hispanic population remains underrepresented and little is known about the patient-centered experiences of Hispanic hospice users. Findings indicated that dying Hispanic patients continue to experience pain and other negative symptoms, even when hospice care is in place. Thus, it is important that social workers provide education to interdisciplinary team members about culturally competent practices, and advocate for a patient-centered approach to care.

Patient- and Caregiver-Reported Assessment Tools for Palliative Care: Summary of the 2017 Agency for Healthcare Research and Quality Technical Brief

CONTEXT

Assessment tools are data collection instruments that are completed by or with patients or caregivers and which collect data at the individual patient or caregiver level.

OBJECTIVES

The objectives of this study are to 1) summarize palliative care assessment tools completed by or with patients or caregivers and 2) identify needs for future tool development and evaluation.

METHODS

We completed 1) a systematic review of systematic reviews; 2) a supplemental search of previous reviews and Web sites, and/or 3) a targeted search for primary articles when no tools existed in a domain. Paired investigators screened search results, assessed risk of bias, and abstracted data. We organized tools by domains from the National Consensus Project Clinical Practice Guidelines for Palliative Care and selected the most relevant, recent, and highest quality systematic review for each domain.

RESULTS

We included 10 systematic reviews and identified 152 tools (97 from systematic reviews and 55 from supplemental sources). Key gaps included no systematic review for pain and few tools assessing structural, cultural, spiritual, or ethical/legal domains, or patient-reported experience with end-of-life care. Psychometric information was available for many tools, but few studies evaluated responsiveness (sensitivity to change) and no studies compared tools.

CONCLUSION

Few to no tools address the spiritual, ethical, or cultural domains or patient-reported experience with end-of-life care. While some data exist on psychometric properties of tools, the responsiveness of different tools to change and/or comparisons between tools have not been evaluated. Future research should focus on developing or testing tools that address domains for which few tools exist, evaluating responsiveness, and comparing tools.

Measuring Patient-Centeredness of Care for Seriously Ill Individuals: Challenges and Opportunities for Accountability Initiatives

Patient- and family-centeredness of care is particularly important for individuals with serious illness. In this article, we describe methodological challenges of using measures of patient- and family-centeredness in accountability initiatives such as public reporting and pay for performance. We begin with background on measuring patient- and family-centered care using standardized surveys, describe evidence of the use of these measures for quality improvement, and highlight methodological challenges in the development and implementation of these measures for use in accountability. To ensure that patient- and family-centeredness is the cornerstone of public and private accountability initiatives designed to promote high-quality care to seriously ill patients, we recommend development of (1) a nationally endorsed survey instrument that assesses patient and family experiences of serious illness care across the full range of patient trajectories and care settings in which this care is provided; (2) administrative data infrastructure that allows for identification and outreach to the most knowledgeable respondents for the survey, regardless of the patient's setting of care; and (3) a broad toolkit of quality improvement approaches to ensure that as the emphasis on accountability grows, providers across settings have access to tools that can help them improve patient- and family-centeredness of care for the seriously ill.

Race/Ethnicity and End-of-Life Care Among Veterans

BACKGROUND

Few studies have examined comprehensively racial/ethnic variations in quality of end-of-life care.

OBJECTIVE

Examine end-of-life care quality received by Veterans and their families, comparing racial/ethnic minorities to nonminorities.

RESEARCH DESIGN

This is a retrospective, cross-sectional analysis of chart review and survey data.

SUBJECTS

Nearly all deaths in 145 Veterans Affairs Medical Centers nationally (n=94,697) in addition to Bereaved Family Survey (BFS) data (n=51,859) from October 2009 to September 2014.

MEASURES

Outcomes included 15 BFS items and 4 indicators of high-quality end-of-life care, including receipt of a palliative care consult, chaplain visit, bereavement contact, and death in hospice/palliative care unit. Veteran race/ethnicity was measured via chart review and defined as non-Hispanic white, non-Hispanic black, Hispanic, or other.

RESULTS

In adjusted models, no differences were observed by race/ethnicity in receipt of a palliative care consult or death in a hospice unit. Although black Veterans were less likely than white Veterans to receive a chaplain visit, Hispanic Veterans were more likely than white Veterans to receive a chaplain visit and to receive a bereavement contact. Less favorable outcomes for racial/ethnic minorities were noted on several BFS items. In comparison with family members of white Veterans, families of minority Veterans were less likely to report excellent overall care, and this difference was largest for black Veterans (48% vs. 62%).

CONCLUSIONS

Bereaved family members of minority Veterans generally rate the quality of end-of-life care less favorably than those of white Veterans. Family perceptions are critical to the evaluation of equity and quality of end-of-life care.

Family Functioning Predicts End-of-Life Care Quality in Patients With Cancer: Multicenter Prospective Cohort Study

BACKGROUND

Treating patients with cancer within a family setting is the accepted standard of care and a hallmark of end-of-life (EoL) quality of care (QoC).

OBJECTIVE

The aim of this study was to determine whether family caregiver functioning predicts EoL QoC received by terminally ill patients with cancer.

METHODS

Family caregivers of terminally ill patients with cancer (n = 264) were enrolled from oncology inpatient and outpatient units of 12 large hospitals located in different regions throughout South Korea. Caregivers were administered self-reported questionnaires about family functioning and EoL QoC at the time of an incurable cancer diagnosis, 4 to 6 weeks later, and again 2 to 3 months later. Family functioning and QoC were measured using the family Apgar and Quality Care Questionnaire-End of Life scales, respectively.

RESULTS

Improved adaptability to resource sharing and attention received predicted improved family relationships for the 3 time points. Increased participation in decision making and communication predicted improved individualized care and family relationships for the 3 time points. Increased affection predicted improvements in dignity-conserving care and family relationships for the 3 time points. Improved resolution regarding sharing time and satisfaction with commitments predicted increases in all QoC domains for the 3 time points, including dignity-conserving care, care by healthcare professionals, individualized care, and family relationships.

CONCLUSIONS

Family functioning may contribute to improved EoL QoC of patients with terminal cancer.

IMPLICATIONS FOR PRACTICE

Patients' family caregivers are a valued source of affection and communicative support, improving EoL QoC. More family-oriented cancer support systems can better maintain the effectiveness of QoC until EoL.

Are Hospice Admission Practices Associated With Hospice Enrollment for Older African Americans and Whites?

CONTEXT

Hospices that enroll patients receiving expensive palliative therapies may serve more African Americans because of their greater preferences for aggressive end-of-life care.

OBJECTIVES

Examine the association between hospices' admission practices and enrollment of African Americans and whites.

METHODS

This was a cross-sectional study of 61 North and South Carolina hospices. We developed a hospice admission practices scale; higher scores indicate less restrictive practices, that is, greater frequency with which hospices admitted those receiving chemotherapy, inotropes, and so forth. In separate multivariate analyses for each racial group, we examined the relationship between the proportion of decedents (age ≥ 65) served by a hospice in their service area (2008 Medicare Data) and admission practices while controlling for health care resources (e.g., hospital beds) and market concentration in the area, ownership, and budget.

RESULTS

Nonprofit hospices and those with larger budgets reported less restrictive admission practices. In bivariate analyses, hospices with less restrictive admission practices served a larger proportion of patients in both racial groups (P < 0.001). However, in the multivariate models, nonprofit ownership and larger budgets but not admission practices predicted the outcome.

CONCLUSION

Hospices with larger budgets served a greater proportion of African Americans and whites in their service area. Although larger hospices reported less restrictive admission practices, they also may have provided other services that may be important to patients regardless of race, such as more in-home support or assistance with nonmedical expenses, and participated in more outreach activities increasing their visibility and referral base. Future research should explore factors that influence decisions about hospice enrollment among racially diverse older adults.

The Desires of Their Hearts: The Multidisciplinary Perspectives of African Americans on End-of-Life Care in the African American Community

BACKGROUND

Studies have identified racial differences in advance care planning and use of hospice for care at the end of life. Multiple reasons for underuse among African American patients and their families have been proposed and deserve further exploration.

OBJECTIVE

The goal of this study was to examine perceptions of advance care planning, palliative care, and hospice among a diverse sample of African Americans with varying degrees of personal and professional experience with end-of-life care and use these responses to inform a culturally sensitive intervention to promote awareness of these options.

METHODS

Semistructured interviews and focus groups were conducted with African Americans who had varying degrees of experience and exposure to end-of-life care both personally and professionally. We conducted in-depth qualitative analyses of these interviews and focus group transcripts and determined that thematic saturation had been achieved.

RESULTS

Several themes emerged. Participants felt that advance care planning, palliative care, and hospice can be beneficial to African American patients and their families but identified specific barriers to completion of advance directives and hospice enrollment, including lack of knowledge, fear that these measures may hasten death or cause providers to deliver inadequate care, and perceived conflict with patients' faith and religious beliefs. Providers described approaches they use to address these barriers in their practices.

CONCLUSION

Findings, which are consistent with and further elucidate those identified from previous research, will inform design of a culturally sensitive intervention to increase awareness and understanding of advance care planning, palliative care, and hospice among members of the African American community.

Unique Correlates of Heart Failure and Cancer Caregiver Satisfaction With Hospice Care

CONTEXT

Heart failure patients, along with their informal caregivers are increasingly enrolling in hospice care. Caregiver satisfaction with hospice care is a key quality indicator. The role that diagnosis plays in shaping satisfaction is unclear.

OBJECTIVES

Our aim was to identify unique correlates of caregiver satisfaction in heart failure and cancer caregivers and explore whether the identified correlates differ between the two diagnosis groups.

METHODS

This was a retrospective cohort study of national data collected in 2011 by the National Hospice and Palliative Care Organization using the 61-item Family Evaluation of Hospice Care survey. We used complete Family Evaluation of Hospice Care responses of adult heart failure (n = 7324) and cancer (n = 23,871) caregivers. Multiple logistic regression was used to examine the relationship between possible correlates and caregiver satisfaction. Correlates examined included caregiver and patient demographics, patient clinical characteristics, and hospice characteristics.

RESULTS

Caregiver-reported patient dyspnea was associated with global and symptom management satisfaction in the heart failure cohort, whereas caregiver race was associated with global and symptom management satisfaction in the cancer cohort. Nursing home placement was associated with lower satisfaction odds in both cancer and heart failure cohorts, but heart failure patients were twice as likely as cancer patients to receive care in a nursing home.

CONCLUSION

This study generated hypotheses about unique factors related to caregiver satisfaction among two diagnosis cohorts that require further study, particularly the impact of race on satisfaction in the cancer cohort and the management of dyspnea in heart failure hospice patients.

Does Diagnosis Make a Difference? Comparing Hospice Care Satisfaction in Matched Cohorts of Heart Failure and Cancer Caregivers

BACKGROUND

Half of heart failure patients will die within five years of diagnosis, making them an ideal population for hospice to reach. Yet hospice originated in oncology, and problems have been noted with the enrollment of heart failure patients. Whether caregiver satisfaction, a key quality measure in hospice, differs between heart failure and cancer caregivers is unknown.

OBJECTIVE

We aimed to determine whether diagnosis makes a difference in satisfaction with hospice care in matched cohorts of heart failure caregivers and cancer caregivers.

METHODS

This was a national cohort study, using caregiver responses to the Family Evaluation of Hospice Care (FEHC) survey. Heart failure and cancer caregivers were matched via propensity scoring. The relationship between diagnosis and caregiver satisfaction was examined across the domains of symptom management, emotional support, caregiver teaching, coordination of care, and global satisfaction, both before and after matching via logistic regression.

RESULTS

One-to-one matching with calipers yielded 7730 matched pairs out of an original sample of 8175 heart failure caregivers and 24,972 cancer caregivers. Significant differences were found in caregiver teaching, emotional support, coordination of care, and global satisfaction prior to matching, but the effect sizes were small. All differences disappeared after matching. High rates of dissatisfaction with caregiver teaching (42%) and emotional support (30%) were found in both cohorts.

CONCLUSIONS

The diagnosis of heart failure, in and of itself, does not appear to make a difference in informal caregiver satisfaction with hospice care. Hospice provides high-quality care for patients, but improvements are needed in caring for the caregiver.

Quality of hospice care: comparison between rural and urban residents

Discrepancies between needed and received hospice care exist, especially in rural areas. Hospice care quality ratings for 743 rural and urban patients and their families were compared. Rural participants reported higher overall satisfaction and with pain/symptom management. Regardless of geographic location, satisfaction was higher when patients were informed and emotionally supported. Patients and family ratings did not differ. Findings support prior reports using retrospective rather than our study's point-of-care surveys.

Measuring Experience With End-of-Life Care: A Systematic Literature Review

CONTEXT

Increasing interest in end-of-life care has resulted in many tools to measure the quality of care. An important outcome measure of end-of-life care is the family members' or caregivers' experiences of care.

OBJECTIVES

To evaluate the instruments currently in use to inform next steps for research and policy in this area.

METHODS

We conducted a systematic review of PubMed, PsycINFO, and PsycTESTS(®) for all English-language articles published after 1990 using instruments to measure adult patient, family, or informal caregiver experiences with end-of-life care. Survey items were abstracted and categorized into content areas identified through an iterative method using three independent reviewers. We also abstracted information from the most frequently used surveys about the identification of proxy respondents for after-death surveys, the timing and method of survey administration, and the health care setting being assessed.

RESULTS

We identified 88 articles containing 51 unique surveys with available content. We characterized 14 content areas variably present across the 51 surveys. Information and care planning, provider care, symptom management, and overall experience were the most frequent areas addressed. There was also considerable variation across the surveys in the identification of proxy respondents, the timing of survey administration, and in the health care settings and services being evaluated.

CONCLUSION

This review identified several comprehensive surveys aimed at measuring the experiences of end-of-life care, covering a variety of content areas and practical issues for survey administration. Future work should focus on standardizing surveys and administration methods so that experiences of care can be reliably measured and compared across care settings.

Organizational Barriers to Cultural Competence in Hospice

This national mixed method study with directors of 207 hospices identified major barriers to cultural competence, including (1) lack of funding for additional staff for community outreach or development of culturally competent programs, (2) lack of applications from diverse professionals, and (3) lack of knowledge about diverse cultures and what cultural groups in the community are not being served. Qualitative results indicated that elements of an organizational culture, which create barriers to access included (1) failure to prioritize cultural competence, (2) failure to budget for culturally competent services, and (3) a staff that does not value awareness of cultural differences, is uncomfortable with diversity, and stereotypes diverse individuals. In phase 2, an interactive session with a 100-symposium audience provided strategies to address the barriers.

Racial and ethnic disparities in palliative care

Racial and ethnic disparities in health care access and quality are well documented for some minority groups. However, compared to other areas of health care, such as disease prevention, early detection, and curative care, research in disparities in palliative care is limited. Given the rapidly growing population of minority older adults, many of whom will face advanced serious illness, the availability of high-quality palliative care that meets the varied needs of older adults of all races and ethnicities is a priority. This paper reviews existing data on racial and ethnic disparities in use of and quality of palliative care and outlines priorities for future research.

African American client satisfaction with hospice: a comparison of primary caregiver experiences within and outside of hospice

This study, conducted within a larger participatory action research project, explored satisfaction with end-of-life care among African Americans in a rural southeastern community. Researchers collaborated with practitioners and the African American community, conducting qualitative interviews with 1 African American hospice patient, 9 primary caregivers of terminally ill patients within hospice, and 10 family caregivers outside of hospice. Results indicated a more positive experience for hospice patients, and that most nonhospice participants preferred hospice after learning about it through the study. Participants made recommendations for public information efforts, the referral and intake process, and developing a relationship with the African American community. Implications for practice are to include the reasons found for African American preference for hospice in public information sessions with the African American community.

Psychosocial, cultural, and spiritual health disparities in end-of-life and palliative care: where we are and where we need to go

Although health disparities are well documented, the extent to which they affect end-of-life care is unknown. Limited research funding leads to sparse and often contradictory palliative care literature, with few studies on causal mechanisms. This article explores the psychosocial, cultural, and spiritual health disparities existing in palliative and end-of-life care with the goal of identifying future research needs. This article reports efforts to determine knowledge gaps related to health disparities in psychosocial, cultural, and spiritual aspects of end-of-life care in which the authors draw upon recent literature from multiple databases. Although few data are available, studies show that minorities make little use of hospice, often because of lack of knowledge about hospice or palliative care, family-centered cultures, and preferences for more aggressive end-of-life care than hospice allows. The authors conclude that future research should include a search for theoretical and causal mechanisms; prospective longitudinal investigations; diverse patients, conditions, contexts, and settings; methodological diversity and rigor; and interdisciplinary, culturally sensitive interventions.

African American bereaved family members' perceptions of hospice quality: do hospices with high proportions of African Americans do better?

BACKGROUND

Research suggests that racial differences in end-of-life care persist even among patients enrolled in hospice.

OBJECTIVE

The objective of the study was to examine the association between bereaved family members' satisfaction with hospice services and the proportion of African American (AA) patients in hospice.

METHODS

The 2007 and 2008 Family Evaluation of Hospice Care (FEHC) Survey examined family members' perceptions of the quality of care on several dimensions including: unmet need for pain, dyspnea, and emotional support; being informed about the patient's condition and what to expect as the patient was dying; being informed about medications and treatments for symptoms; coordination of care; and overall satisfaction with care. We examined the association between family members' perception along each domain and the proportion of AAs served by hospices surveyed.

RESULTS

Of the 11,892 AA decedents in 678 hospice programs, 53.7% were female. The leading cause of death was cancer (51.6%). On univariate analysis, family members of decedents who died in hospices that had higher proportions of AAs were less likely to have concerns about unmet pain needs (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.72-0.98), more likely to have concerns about coordination of care (1.28, 1.17-1.40), and less likely to perceive care as excellent or very good (0.73, 0.63-0.84). Coordination-of-care concerns and lower overall rating of care persisted in multivariable analyses. There were no other significant associations between family perceptions and proportions of AAs in hospice.

CONCLUSIONS

Among hospices with higher proportions of AAs, family members have more concerns about coordination of care and have lower overall perceptions of quality.

Racial/ethnic perspectives on the quality of hospice care

Diversity in the US population is increasing, and evaluating the quality of culturally sensitive hospice care is important. A survey design was used to collect data from 743 patients enrolled in hospice or their family members or caregivers. Race/ethnicity was not significantly associated with any of the hospice interventions or outcomes. Patients were less likely to be satisfied with the overall hospice care (OR = 0.23, 95% CI = 0.065-0.796, P = .021) compared to other type of respondents.  Satisfaction with emotional support was substantially associated with the increased likelihood of satisfaction with pain management (OR = 3.82, 95% CI = 1.66-8.83, P = .002), satisfaction with other symptom management (OR = 6.17, 95% CI = 2.80-13.64, P < .001), and of overall satisfaction with hospice care (OR = 20.22, 95% CI = 8.64-47.35, P < .001).

Disparity in hospice utilization by African American patients with cancer

Patients with cancer represent the largest group of hospice users, making this population critically important in hospice research studies. Despite the potential benefits of hospice, many studies have noted lower levels of utilization among African Americans. The goal of this literature review was to determine whether this disparity exists within this population of patients with cancer. The largest studies focusing on multiple cancers found lower hospice use among African American patients with cancer. Disparities also existed after entry into hospice. Age, gender, geographic location, preference for aggressive care, and knowledge of hospice influenced hospice use by these patients. Since African American patients with cancer evidently use hospice at a lower rate, future studies should explore potential barriers to participation by this patient population and methods to remove these obstacles.

Racial differences in end-of-life planning: why don't Blacks and Latinos prepare for the inevitable?

I evaluate the extent to which ethnic disparities in advance care planning reflect cultural and religious attitudes and experience with the painful deaths of loved ones. Data are from a sample of 293 chronically ill older adults who are seeking care at one of two large medical centers in urban New Jersey. Blacks and Hispanics are significantly less likely than Whites to have a living will, a durable power of attorney for health care (DPAHC), and to have discussed their end of life treatment preferences. Multivariate analyses reveal that the Black-White gap in advance care planning is largely accounted for by Blacks' belief that God controls the timing and nature of death. The Hispanic-White gap is partially accounted for by the belief that one's illness negatively affects one's family. Ethnic disparities are starkest for living will and DPAHC use, and less pronounced for discussions. Implications for policy and practice are discussed.

Developing a pediatric palliative care program: addressing the lack of baseline expenditure information

An estimated 500 000 children annually cope with life-limiting conditions expected to lead to premature death, but little is known about their health care expenditures at the end of life. This information is crucial for health planners to propose pediatric palliative care programs. This study aims to estimate predicted health care expenditures for Medicaid-eligible infants and children across several health service categories. Across these categories, infants and children were predicted to spend about US$110 000 and US$62 000 at the end of life, respectively. About 5% of infants and 8% of children incurred hospice expenditures. Results from the multivariate models suggest that black, non-Hispanic children are less likely than white, non-Hispanic children to use hospice care. Baseline expenditure information from this study can be used to develop integrated pediatric palliative care models. Our findings also suggest that many more children could potentially benefit by using hospice care at the end of life.

What explains racial differences in the use of advance directives and attitudes toward hospice care?

Cultural beliefs and values are thought to account for differences between African Americans and whites in the use of advance directives and beliefs about hospice care, but few data clarify which beliefs and values explain these differences. Two hundred five adults aged 65 and older who received primary care in the Duke University Health System were surveyed. The survey included five scales: Hospice Beliefs and Attitudes, Preferences for Care, Spirituality, Healthcare System Distrust, and Beliefs About Dying and Advance Care Planning. African Americans were less likely than white subjects to have completed an advance directive (35.5% vs 67.4%, P<.001) and had less favorable beliefs about hospice care (Hospice Beliefs and Attitudes Scale score, P<.001). African Americans were more likely to express discomfort discussing death, want aggressive care at the end of life, have spiritual beliefs that conflict with the goals of palliative care, and distrust the healthcare system. In multivariate analyses, none of these factors alone completely explained racial differences in possession of an advance directive or beliefs about hospice care, but when all of these factors were combined, race was no longer a significant predictor of either of the two outcomes. These findings suggest that ethnicity is a marker of common cultural beliefs and values that, in combination, influence decision-making at the end of life. This study has implications for the design of healthcare delivery models and programs that provide culturally sensitive end-of-life care to a growing population of ethnically diverse older adults.