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Hauschildt KE, Vick JB, Ashana DC. Racial, Ethnic, and Socioeconomic Differences in Critical Care Near the End of Life: A Narrative Review. Crit Care Clin 2024; 40:753-766. [PMID: 39218484 DOI: 10.1016/j.ccc.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
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.
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Affiliation(s)
- Katrina E Hauschildt
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, #520, Baltimore, MD 21205, USA
| | - Judith B Vick
- Durham VA Health Care System; Department of Medicine, Duke University School of Medicine; National Clinician Scholars Program, Duke Clinical and Translational Science Institute, 701 West Main Street, Durham, NC 27701, USA
| | - Deepshikha Charan Ashana
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; Department of Population Health Sciences, Duke University, Hanes House, 315 Trent Drive, Durham, NC 27705, USA.
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Lenko RA, Hoffman GJ, Robinson-Lane SG, Silveira MJ, Voepel-Lewis T. Achieving goal-concordant care: Formal and informal advance care planning for White, Black, and Hispanic older adults. J Am Geriatr Soc 2024; 72:2412-2422. [PMID: 38760957 PMCID: PMC11323214 DOI: 10.1111/jgs.18971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/15/2024] [Accepted: 04/21/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION Advance care planning (ACP) aims to ensure that patients receive goal-concordant care (GCC), which is especially important for racially or ethnically minoritized populations at greater risk of poor end-of-life outcomes. However, few studies have evaluated the impact of advance directives (i.e., formal ACP) or goals-of-care conversations (i.e., informal ACP) on such care. This study aimed to examine the relationship between each of formal and informal ACP and goal-concordant end-of-life care among older Americans and to determine whether their impact differed between individuals identified as White, Black, or Hispanic. METHODS We conducted a retrospective cohort study using 2012-2018 data from the biennial Health and Retirement Study. We examined the relationships of interest using two, separate multivariable logistic regression models. Model 1 regressed a proxy report of GCC on formal and informal ACP and sociodemographic and health-related covariates. Model 2 added interaction terms between race/ethnicity and the two types of ACP. RESULTS Our sample included 2048 older adults. There were differences in the proportions of White, Black, and Hispanic decedents who received GCC (83.1%, 75.3%, and 71.3%, respectively, p < 0.001) and in the use of each type of ACP by racial/ethnic group. In model 1, informal compared with no informal ACP was associated with higher odds of GCC (adjusted odds ratio = 1.38 [95% confidence interval, 1.05-1.82]). In model 2, Black decedents who had formal ACP were more likely to receive GCC than those who did not, but there were no statistically significant differences between decedents of different racial/ethnic groups who had no ACP, informal ACP only, or both types of ACP. CONCLUSIONS Our results build on previous work by indicating the importance of incorporating goals-of-care conversations into routine healthcare for older adults and encouraging ACP usage among racially and ethnically minoritized populations who use ACP tools at lower rates.
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Affiliation(s)
- Rachel A Lenko
- Department of Nursing, Calvin University School of Health, Grand Rapids, Michigan, USA
| | - Geoffrey J Hoffman
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Sheria G Robinson-Lane
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Maria J Silveira
- Palliative Care Program, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Terri Voepel-Lewis
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
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3
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De Souza J, Gillett K, Salifu Y, Walshe C. Living and dying between cultural traditions in African & Caribbean Heritage families: a constructivist grounded theory. BMC Palliat Care 2024; 23:176. [PMID: 39026241 PMCID: PMC11256641 DOI: 10.1186/s12904-024-01503-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 07/08/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Ethnic differences influence end-of-life health behaviours and use of palliative care services. Use of formal Advance care planning is not common in minority ethnic heritage communities. Older adults expect and trust their children to be their decision makers at the end of life. The study aim was to construct a theory of the dynamics that underpin end-of-life conversations within families of African and Caribbean heritage. This is a voice not well represented in the current debate on improving end-of-life outcomes. METHODS Using Charmaz's constructivist grounded theory approach, a purposive sample of elders, adult-children, and grandchildren of African and Caribbean Heritage were recruited. In-person and online focus groups were conducted and analysed using an inductive, reflexive comparative analysis process. Initial and axial coding facilitated the creation of categories, these categories were abstracted to constructs and used in theory construction. RESULTS Elders (n = 4), adult-children (n = 14), and adult grandchildren (n = 3) took part in 5 focus groups. A grounded theory of living and dying between cultural traditions in African and Caribbean heritage families was created. The constructs are (a) Preparing for death but not for dying (b) Complexity in traditions crosses oceans (c) Living and dying between cultures and traditions (d) There is culture, gender and there is personality (e) Watching the death of another prompts conversations. (f) An experience of Hysteresis. DISCUSSION African and Caribbean cultures celebrate preparation for after-death processes resulting in early exposure to and opportunities for discussion of these processes. Migration results in reforming of people's habitus/ world views shaped by a mixing of cultures. Being in different geographical places impacts generational learning-by-watching of the dying process and related decision making. CONCLUSIONS Recognising the impact of migration on the roles of different family members and the exposure of those family members to previous dying experiences is important. This can provide a more empathetic and insightful approach to partnership working between health care professionals and patients and families of minority ethic heritage facing serious illness. A public health approach focusing on enabling adult-children to have better end of life conversations with their parents can inform the development of culturally competent palliative care.
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Affiliation(s)
- Joanna De Souza
- International Observatory on End-of-Life Care, Division of Health Research, Lancaster University, Lancaster, UK.
- King's College London, Nursing, Midwifery & Palliative Care, London, UK.
| | - Karen Gillett
- King's College London, Nursing, Midwifery & Palliative Care, London, UK
| | - Yakubu Salifu
- International Observatory on End-of-Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - Catherine Walshe
- International Observatory on End-of-Life Care, Division of Health Research, Lancaster University, Lancaster, UK
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McCleskey SG, Vargas Bustamante A, Ahluwalia SC, Nuckols TK, Kominski GF, Chuang E. Racial Differences in Treatment Intensity at the End of Life Among Older Adults with Heart Failure: Evidence from the Health and Retirement Study. J Palliat Med 2024; 27:854-860. [PMID: 38546482 DOI: 10.1089/jpm.2023.0369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2024] Open
Abstract
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.
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Affiliation(s)
- Sara G McCleskey
- Behavioral and Policy Sciences, RAND, Santa Monica, California, USA
| | - Arturo Vargas Bustamante
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | | | - Teryl K Nuckols
- Behavioral and Policy Sciences, RAND, Santa Monica, California, USA
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gerald F Kominski
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Emmeline Chuang
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
- School of Social Welfare, University of California, Berkeley, Berkeley, California, USA
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DeCourcey DD, Bernacki RE, Nava-Coulter B, Lach S, Xiong N, Wolfe J. Feasibility of a Serious Illness Communication Program for Pediatric Advance Care Planning. JAMA Netw Open 2024; 7:e2424626. [PMID: 39058485 PMCID: PMC11282445 DOI: 10.1001/jamanetworkopen.2024.24626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2024] Open
Abstract
Importance Pediatric advance care planning (ACP), which aims to ensure care is aligned with family goals and values, is associated with better end-of-life outcomes; however, ACP in pediatrics remains uncommon. Objectives To determine the feasibility and acceptability of the Pediatric Serious Illness Communication Program (PediSICP) and explore family-centered outcomes. Design, Setting, and Participants This cohort study was a single-group pilot study of the PediSICP in adolescents and young adults (AYAs; age ≥13 y) with serious illness, parents of seriously ill children, and interprofessional clinicians from April 2021 to March 2023 in a quaternary care pediatric hospital. Duration of follow-up was 1 month. Data were analyzed from January 2022 to March 2023. Exposure The PediSICP includes clinician training preceding an ACP communication occasion supported by communication guides and a template for electronic medical record documentation. Main Outcomes and Measures Outcomes of interest were parent, patient, and clinician experiences with and perceptions of the PediSICP. Feasibility was defined a priori as at least 70% clinician intervention completion rates. Results A total of 10 virtual trainings were conducted among 40 clinicians, including 27 physicians, 7 nurse practitioners, 5 nurses, and 1 respiratory therapist, and 30 trained clinicians (75%) conducted and documented 42 ACP conversations with 33 parents (median [IQR] age, 43 [35-51] years; 25 [76%] female) and 5 AYAs (median [IQR] age, 19 [17-19] years; 3 [60%] female) who completed the intervention. The median (IQR) conversation duration was 27 (10-45) minutes. Most clinicians (29 clinicians [97%]) agreed that they felt prepared for the conversation, and all clinicians recommended the PediSICP. Parents reported participation was worthwhile (27 parents [84%]), they felt listened to (31 parents [94%]), and would recommend the PediSICP (28 parents [85%]). Parents endorsed higher therapeutic alliance after the PediSICP intervention compared with before (The Human Connection scale mean [SD] score, 57.6 [6.4] vs 55.3 [7.8]; P = .03) and decreased anxiety immediately after the intervention (Generalized Anxiety Disorder-7-item mean [SD] score, 10.1 [7.3] vs 8.4 [6.9]; P = .003), which persisted at the 1-month follow-up (mean [SD] score, 7.7 [6.8]; P = .03). Conclusions and Relevance This pilot cohort study found that the PediSICP was feasible, acceptable, and highly valued by clinicians and parents of children with serious illness. These findings suggest that the PediSICP may empower interprofessional clinicians and improve ACP with families of children and AYAs who are seriously ill.
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Affiliation(s)
- Danielle D DeCourcey
- Department of Pediatrics, Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Rachelle E Bernacki
- Division of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Brett Nava-Coulter
- Department of Pediatrics, Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Sithya Lach
- Department of Pediatrics, Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Niya Xiong
- Department of Data Science, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Joanne Wolfe
- Division of Supportive and Palliative Care, Mass General for Children, Boston, Massachusetts
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Izumi S(S, Garcia E, Kualaau A, Sloan DE, DeSanto-Madeya S, Candrian C, Anderson E, Sanders J. Advance care planning as perceived by marginalized populations: Willing to engage and facing obstacles. PLoS One 2024; 19:e0301426. [PMID: 38557983 PMCID: PMC10984538 DOI: 10.1371/journal.pone.0301426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 03/17/2024] [Indexed: 04/04/2024] Open
Abstract
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.
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Affiliation(s)
- Shigeko (Seiko) Izumi
- School of Nursing, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Ellen Garcia
- School of Nursing, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Andrew Kualaau
- School of Nursing, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Danetta E. Sloan
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Susan DeSanto-Madeya
- College of Nursing, University of Rhode Island, Providence, Rhode Island, United States of America
| | - Carey Candrian
- School of Medicine, University of Colorado, Aurora, Colorado, United States of America
| | - Elizabeth Anderson
- Pacific Institute for Research and Evaluation, Louisville, Kentucky, United States of America
| | - Justin Sanders
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
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Shen MJ, Prigerson HG, Maciejewski PK, Daly B, Adelman R, McConnell Trevino KM. A communication intervention to improve prognostic understanding and engagement in advance care planning among diverse advanced cancer patient-caregiver dyads: A pilot study. Palliat Support Care 2024; 22:10-18. [PMID: 37526150 PMCID: PMC10901460 DOI: 10.1017/s1478951523000901] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
OBJECTIVES Accurate prognostic understanding among patients with advanced cancer and their caregivers is associated with greater engagement in advance care planning (ACP) and receipt of goal-concordant care. Poor prognostic understanding is more prevalent among racial and ethnic minority patients. The purpose of this study was to examine the feasibility, acceptability, and impact of a patient-caregiver communication-based intervention to improve prognostic understanding, engagement in ACP, and completion of advance directives among a racially and ethnically diverse, urban sample of patients and their caregivers. METHODS Patients with advanced cancer and their caregivers (n = 22 dyads) completed assessments of prognostic understanding, engagement in ACP, and completion of advance directives at baseline and post-intervention, Talking About Cancer (TAC). TAC is a 7-session intervention delivered remotely by licensed social workers that includes distress management and communication skills, review of prognosis, and information on ACP. RESULTS TAC met a priori benchmarks for feasibility, acceptability, and fidelity. Prognostic understanding and engagement in ACP did not change over time. However, patients showed increases in completion of advance directives. SIGNIFICANCE OF RESULTS TAC was feasible, acceptable, and delivered with high fidelity. Involvement of caregivers in TAC may provide added layers of support to patients facing advanced cancer diagnoses, especially among racial and ethnic minorities. Trends indicated greater completion of advance directives but not in prognostic understanding or engagement in ACP. Future research is needed to optimize the intervention to improve acceptability, tailor to diverse patient populations, and examine the efficacy of TAC in a randomized controlled trial.
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Affiliation(s)
- Megan J Shen
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Holly G Prigerson
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Paul K Maciejewski
- Department of Radiology, Weill Cornell Medical College, New York, NY, USA
| | - Bobby Daly
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ronald Adelman
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Kelly M McConnell Trevino
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Andersson S, Granat L, Baxter R, Reimertz H, Modéus C, Pusa S, Sandgren A. Translation, Adaptation, and Validation of the Swedish Serious Illness Conversation Guide. J Palliat Care 2024; 39:21-28. [PMID: 37886797 PMCID: PMC10687820 DOI: 10.1177/08258597231210136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Objective: To translate and adapt the Serious Illness Conversation Guide for use within the Swedish healthcare setting and examine the validity and acceptability of the Swedish Serious Illness Conversation Guide. Methods: Three rounds of cognitive interviews were conducted (T1-3); patients (T1 n = 11; T2 n = 10; T3 n = 8), family members (T1 n = 5; T2 n = 2; T3 n = 2), and healthcare professionals (T1 n = 6; T2 n = 6; T3 n = 5). The guide was iteratively adapted based on interview feedback, clinical experience, and the literature. The guide was tested on training days with physicians and nurses. Results: The Swedish Serious Illness Conversation Guide was found to be useful in supporting serious illness conversations. Clinicians reported that some questions were emotionally challenging. Explicit questions about prognosis and timing were excluded. Instead, the dual approach of "hoping for the best and preparing for the worst" was used to explore patients' thoughts about the future. Conclusions: Patients, family members, and healthcare professionals found the Swedish Serious Illness Conversation Guide to be appropriate, sensitive, and responsive to their needs. The Swedish Serious Illness Conversation Guide may facilitate a more health-promoting approach to serious illness conversations. Further research is needed to understand the impact of these conversations on person-centered and goal-concordant care.
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Affiliation(s)
- Sofia Andersson
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Sweden
| | - Lisa Granat
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| | - Rebecca Baxter
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Sweden
| | - Helene Reimertz
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Unit of Palliative Care, Region Kronoberg, Växjö, Sweden
| | - Carina Modéus
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Unit of Palliative Care, Region Kronoberg, Växjö, Sweden
| | - Susanna Pusa
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Sweden
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
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Seevaratnam B, Wang S, Fong R, Hui F, Callahan A, Chobot S, Gensheimer MF, Li RC, Nguyen D, Ramchandran K, Shah NH, Shieh L, Zeng JGQ, Teuteberg W. Lessons Learned from a Multi-Site, Team-Based Serious Illness Care Program Implementation at an Academic Medical Center. J Palliat Med 2024; 27:83-89. [PMID: 37935036 DOI: 10.1089/jpm.2023.0254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Background: Patients with serious illness benefit from conversations to share prognosis and explore goals and values. To address this, we implemented Ariadne Labs' Serious Illness Care Program (SICP) at Stanford Health Care. Objective: Improve quantity, timing, and quality of serious illness conversations. Methods: Initial implementation followed Ariadne Labs' SICP framework. We later incorporated a team-based approach that included nonphysician care team members. Outcomes included number of patients with documented conversations according to clinician role and practice location. Machine learning algorithms were used in some settings to identify eligible patients. Results: Ambulatory oncology and hospital medicine were our largest implementation sites, engaging 4707 and 642 unique patients in conversations, respectively. Clinicians across eight disciplines engaged in these conversations. Identified barriers that included leadership engagement, complex workflows, and patient identification. Conclusion: Several factors contributed to successful SICP implementation across clinical sites: innovative clinical workflows, machine learning based predictive algorithms, and nonphysician care team member engagement.
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Affiliation(s)
- Briththa Seevaratnam
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Samantha Wang
- Division of Hospital Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Rebecca Fong
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Felicia Hui
- Section of Palliative Care, Stanford University School of Medicine, Stanford, California, USA
| | - Alison Callahan
- Biomedical Informatics, Stanford University School of Medicine, Stanford, California, USA
| | | | - Michael F Gensheimer
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Ron C Li
- Division of Hospital Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Duy Nguyen
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Kavitha Ramchandran
- Section of Palliative Care, Stanford University School of Medicine, Stanford, California, USA
- Division of Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Nigam H Shah
- Biomedical Informatics, Stanford University School of Medicine, Stanford, California, USA
| | - Lisa Shieh
- Division of Hospital Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jack Guo-Qing Zeng
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Winifred Teuteberg
- Section of Palliative Care, Stanford University School of Medicine, Stanford, California, USA
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Fromme EK, Nisotel L, Mendoza K, Thacker A, Lowery K, Sihlongonyane B, DeBartolo KO, Roessner J, Margo JN. Testing the What Matters to Me workbook in a diverse sample of seriously ill patients and caregivers. PEC INNOVATION 2023; 3:100216. [PMID: 37771460 PMCID: PMC10523264 DOI: 10.1016/j.pecinn.2023.100216] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 09/30/2023]
Abstract
Objectives We evaluated the What Matters to Me Workbook, a patient-facing version of the Serious Illness Conversation Guide co-created by Ariadne Labs and The Conversation Project. Methods We purposively recruited diverse seriously ill patients and caregivers in the US. Participants completed the Workbook, a survey, and a semi-structured in-depth interview about their experience. Qualitative analysis of interviews and notes was employed to extract themes. Simple descriptive statistics were employed to analyze eight investigator authored questions. Results Twenty-nine study participants completed twenty-one interviews and twenty-five surveys. Ratings for safety (3.87/4, SD = 0.43) and acceptability (3.59/4, SD = 0.956) were higher than ratings for ease of use (3.30/4, SD = 0.97) and usefulness (3.24/4, SD = 0.80). Qualitative analysis identified that while the workbook was safe, acceptable, easy to use, and useful, it is more important who is recommending it and how they are explaining it. Conclusion If presented in the right way by a trustworthy person, the What Matters to Me Workbook can be an easy to use, useful, and safe resource for patients with serious illness and their caregivers. Innovation The Workbook focuses on serious illness rather than end-of-life and meshes with a clinician-facing conversation guide and a health-system level intervention.
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Affiliation(s)
- Erik K. Fromme
- Serious Illness Care Program, Ariadne Labs, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | | | - Kurt Lowery
- Serious Illness Care Program, Ariadne Labs, Boston, MA, USA
| | | | | | - Jane Roessner
- The Conversation Project, Institute for Healthcare Improvement, Boston, MA, USA
| | - Judy N. Margo
- Science & Technology Platform, Ariadne Labs, Boston, MA, USA
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Davila C, Chan SH, Gosline A, Arenas Z, Kavanagh J, Feltz B, McCarthy E, Pitts T, Ritchie C. Online Forums as a Tool for Broader Inclusion of Voices on Health Care Communication Experiences and Serious Illness Care: Mixed Methods Study. J Med Internet Res 2023; 25:e48550. [PMID: 38055311 PMCID: PMC10733833 DOI: 10.2196/48550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 09/10/2023] [Accepted: 09/28/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Existing health care research, including serious illness research, often underrepresents individuals from historically marginalized communities. Capturing the nuanced perspectives of individuals around their health care communication experiences is difficult. New research strategies are needed that increase engagement of individuals from diverse backgrounds. OBJECTIVE The aim of this study was to develop a mixed methods approach with qualitative online forums to better understand health communication experiences of individuals, including people from groups historically marginalized such as Black and Latino individuals; older adults; and people with low income, disability, or serious illness. METHODS We used a multiphase mixed methods, community-informed research approach to design study instruments and engage participants. We engaged a diverse group of collaborators with lived experience of navigating the health care system who provided feedback on instruments, added concepts for testing, and offered guidance on creating a safe experience for participants (phase 1). We conducted a national quantitative survey between April and May 2021 across intrapersonal, interpersonal, and systems-level domains, with particular focus on interpersonal communication between patients and clinicians (phase 2). We conducted two asynchronous, qualitative online forums, a technique used in market research, between June and August 2021, which allowed us to contextualize the learnings and test concepts and messages (phase 3). Using online forums allowed us to probe more deeply into results and hypotheses from the survey to better understand the "whys" and "whats" that surfaced and to test public messages to encourage action around health. RESULTS We engaged 46 community partners, including patients and clinicians from a Federally Qualified Health Center, to inform study instrument design. In the quantitative survey, 1854 adults responded, including 50.5% women, 25.2% individuals over 65 years old, and 51.9% individuals with low income. Nearly two-thirds identified as non-Hispanic white (65.7%), 10.4% identified as non-Hispanic Black, and 15.5% identified as Hispanic/Latino. An additional 580 individuals participated in online forums, including 60.7% women, 17.4% individuals over 65 years old, and 49.0% individuals with low income. Among the participants, 70.3% identified as non-Hispanic white, 16.0% as non-Hispanic Black, and 9.5% as Hispanic/Latino. We received rich, diverse input from our online forum participants, and they highlighted satisfaction and increased knowledge with engagement in the forums. CONCLUSIONS We achieved modest overrepresentation of people who were over 65 years old, identified as non-Hispanic Black, and had low income in our online forums. The size of the online forums (N=580) reflected the voices of 93 Black and 55 Hispanic/Latino participants. Individuals who identify as Hispanic/Latino remained underrepresented, likely because the online forums were offered only in English. Overall, our findings demonstrate the feasibility of using the online forum qualitative approach in a mixed methods study to contextualize, clarify, and expound on quantitative findings when designing public health and clinical communications interventions.
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Affiliation(s)
- Carine Davila
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Stephanie H Chan
- Massachusetts Coalition for Serious Illness Care, Boston, MA, United States
- Blue Cross Blue Shield of Massachusetts, Boston, MA, United States
| | - Anna Gosline
- Massachusetts Coalition for Serious Illness Care, Boston, MA, United States
- Blue Cross Blue Shield of Massachusetts, Boston, MA, United States
| | | | - Jane Kavanagh
- Massachusetts Coalition for Serious Illness Care, Boston, MA, United States
- Ariadne Labs, Boston, MA, United States
| | - Brian Feltz
- Flowetik, Boston, MA, United States
- 3D Research Partners LLC, Harvard, MA, United States
| | - Elizabeth McCarthy
- Flowetik, Boston, MA, United States
- Elizabeth M McCarthy Consulting, Boston, MA, United States
| | - Tyrone Pitts
- The Coalition to Transform Advanced Care, Washington, DC, United States
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
- Center for Aging in Serious Illness, Mongan Institute, Boston, MA, United States
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12
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McLeod-Sordjan R. Death Preparedness: Development and Initial Validation of the Advance Planning Preparedness Scale. OMEGA-JOURNAL OF DEATH AND DYING 2023:302228231212998. [PMID: 37922539 DOI: 10.1177/00302228231212998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
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.
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Affiliation(s)
- Renee McLeod-Sordjan
- Division of Medical Ethics, Department of Medicine, Northwell Health, Manhasset, NY, USA
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13
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Kemp CL, Skipper AD, Bender AA, Perkins MM. Turning It Over to God: African American Assisted Living Residents' End-of-Life Preferences and Advance Care Planning. J Gerontol B Psychol Sci Soc Sci 2023; 78:1747-1755. [PMID: 37466307 PMCID: PMC10561881 DOI: 10.1093/geronb/gbad100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES Assisted living (AL), a popular long-term care setting for older Americans, increasingly is a site for end-of-life care. Although most residents prefer AL to be their final home, relatively little is known about end-of-life preferences and advance care planning, especially among African American residents. Our research addresses this knowledge gap. METHODS Informed by grounded theory, we present an analysis of qualitative data collected over 2 years in a 100-bed AL community catering to African American residents. Data consisted of field notes from participant observation conducted during 310 site visits and 818 observation hours, in-depth interviews with 25 residents, and a review of their AL records. RESULTS Residents varied in their end-of-life preferences and advance care planning, but united in the belief that God was in control. We identified "Turning it over to God" as an explanatory framework for understanding how this group negotiated end-of-life preferences and advance care planning. Individual-level resident factors (e.g., age, pain, and function) and factors reflecting broader cultural and societal influences, including health literacy and care experiences, were influential. DISCUSSION Contradictions arose from turning it over to God, including those between care preferences, planning, and anticipated or actual end-of-life outcomes.
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Affiliation(s)
- Candace L Kemp
- The Gerontology Institute, Georgia State University, Atlanta, Georgia, USA
- Department of Sociology, Georgia State University, Atlanta, Georgia, USA
| | - Antonius D Skipper
- The Gerontology Institute, Georgia State University, Atlanta, Georgia, USA
| | - Alexis A Bender
- Division of Geriatrics & Gerontology, Department of Medicine, Emory School of Medicine, Atlanta, Georgia, USA
| | - Molly M Perkins
- Division of Geriatrics & Gerontology, Department of Medicine, Emory School of Medicine, Atlanta, Georgia, USA
- Department of Sociology, Emory University, Atlanta, Georgia, USA
- Birmingham/Atlanta VA Geriatric Research, Education, and Clinical Center, Atlanta, Georgia, USA
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14
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Sanders JJ, Durieux BN, Cannady K, Johnson KS, Ford DW, Block SD, Paladino J, Sterba KR. Acceptability of a Serious Illness Conversation Guide to Black Americans: Results from a focus group and oncology pilot study. Palliat Support Care 2023; 21:788-797. [PMID: 36184937 DOI: 10.1017/s1478951522001298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Serious illness conversations (SICs) can improve the experience and well-being of patients with advanced cancer. A structured Serious Illness Conversation Guide (SICG) has been shown to improve oncology patient outcomes but was developed and tested in a predominantly White population. To help address disparities in advanced cancer care, we aimed to assess the acceptability of the SICG among African Americans with advanced cancer and their clinicians. METHODS A two-phase study conducted in Charleston, SC, included focus groups to gather perspectives on the SICG in Black Americans and a single-arm pilot study of a revised SICG with surveys and qualitative exit interviews to evaluate patient and clinician perspectives. We used descriptive analysis of survey results and thematic analysis of qualitative data. RESULTS Community-based and patient focus group participants (N = 20) reported that a simulated conversation using an adapted SICG built connection, promoted control, and fostered consideration of religious faith and family. Black patients with advanced cancer (N = 23) reported that SICG-guided conversations were acceptable, helpful, and promoted conversations with loved ones. Oncologists found conversations feasible to implement and skill-building, and also identified opportunities for training and implementation that could support meeting the needs of their patients with low health literacy. An adapted SICG includes language to assess the strength and affirm the clinician-patient relationship. SIGNIFICANCE OF RESULTS An adapted structured communication tool to facilitate SIC, the SICG, appears acceptable to Black Americans with advanced cancer and seems feasible for use by oncology clinicians working with this population. Further testing in other marginalized populations may address disparities in advanced cancer care.
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Affiliation(s)
- Justin J Sanders
- Department of Family Medicine, McGill University, Montreal, QC, Canada
- Ariadne Labs, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Brigitte N Durieux
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kimberly Cannady
- Department of Medicine (Ford) Department of Public Health Sciences (Cannady and Sterba), Medical University of South Carolina, Charleston, SC, USA
| | - Kimberly S Johnson
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA
- Geriatrics Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Dee W Ford
- Department of Medicine (Ford) Department of Public Health Sciences (Cannady and Sterba), Medical University of South Carolina, Charleston, SC, USA
| | - Susan D Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Joanna Paladino
- Ariadne Labs, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Katherine R Sterba
- Department of Medicine (Ford) Department of Public Health Sciences (Cannady and Sterba), Medical University of South Carolina, Charleston, SC, USA
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15
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Zhang P, Sun F, Hirsch J. Perceived Barriers and Social Cultural Factors Associated With Advance Care Planning Conversations Among Chinese American Older Adults. J Appl Gerontol 2023; 42:2110-2118. [PMID: 37204849 DOI: 10.1177/07334648231176142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023] Open
Abstract
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.
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Affiliation(s)
- Peiyuan Zhang
- School of Social Work, University of Maryland, Baltimore, MD, USA
| | - Fei Sun
- School of Social Work, Michigan State University, East Lansing, MI, USA
| | - Jen Hirsch
- School of Social Work, Michigan State University, East Lansing, MI, USA
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16
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Saeed F, Eneanya A, Allen RJ, Tamura MK, Fiscella KA. Addressing Racial Injustice, Developing Cultural Humility, and Fostering Rapport-Building Communication Skills to Improve Disparities in End-of-Life Planning. J Pain Symptom Manage 2023; 66:e451-e453. [PMID: 37355055 DOI: 10.1016/j.jpainsymman.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 05/30/2023] [Indexed: 06/26/2023]
Affiliation(s)
- Fahad Saeed
- Departments of medicine and Public Health, Divisions of Nephrology and Palliative Care (F.S.), University of Rochester Medical Center, Rochester, New York, USA.
| | - Amaka Eneanya
- Fresenius Medical Care, Global Medical Office (A.E.), Philadelphia, Pennsylvania, USA
| | - Rebecca J Allen
- School of Behavior and Natural Science (R.J. A.), Mount St. Joseph University, Cincinnati, Ohio, USA
| | - Manjula K Tamura
- Division of Nephrology (M.K.T.), Stanford University and Geriatric Research and Education Clinical Center Veterans Affairs Palo Alto, Palo Alto, California, USA
| | - Kevin A Fiscella
- Department of Family Medicine and Center for Center for Communication and Disparities Research (K.A.F.), University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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17
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Nouri S, Quinn M, Doyle BN, McKissack M, Johnson N, Wertz M, Tan C, Pantilat SZ, Lyles CR, Ritchie CS, Sudore RL. "We've Got to Bring Information to Where People Are Comfortable": Community-Based Advance Care Planning with the Black Community. J Gen Intern Med 2023; 38:2478-2485. [PMID: 36894819 PMCID: PMC9998020 DOI: 10.1007/s11606-023-08134-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/01/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND People identifying as Black/African American are less likely to engage in advance care planning (ACP) compared to their White peers, despite the association of ACP with improved patient and caregiver outcomes. OBJECTIVES Assess facilitators/barriers to ACP in the San Francisco (SF) Black community and co-design/implement/test community-based ACP pilot events. DESIGN Community-based participatory research, including qualitative research, intervention development, and implementation. PARTICIPANTS In partnership with the SF Palliative Care Workgroup (which includes health system, city, and community-based organizations), we formed an African American Advisory Committee (n = 13). We conducted 6 focus groups with Black older adults (age ≥ 55), caregivers, and community leaders (n = 29). The Advisory Committee then selected 5 community-based organizations through a widespread request for proposal. These community-based organizations designed and implemented community-based pilot events to support ACP engagement. MAIN MEASURES Two authors analyzed recorded focus group transcripts using thematic analysis. We assessed pre- vs post-event readiness to engage in ACP (validated ACP Engagement Survey; 1-4 scale, 4 = most ready) using Wilcoxon signed rank tests and assessed event acceptability with open-ended questions. KEY RESULTS Themes included the importance of ACP to the Black community (sub-themes: strengthens families; preserves dignity, particularly for sexual/gender minorities; is tied to financial planning) and facilitators for increasing ACP engagement (sub-themes: culturally relevant materials; events in trusted community spaces including Black-owned businesses). A total of 114 participants attended 5 events; 74% identified as Black, and 16% as sexual/gender minorities. Readiness to engage in ACP was similar pre- vs post-events; 98% would recommend the events to others. CONCLUSIONS Community-based ACP events designed and led by and for the Black community are highly acceptable. Novel insights underscored the importance of financial planning as part of ACP and the role of Black-owned businesses as trusted spaces for ACP-related discussions.
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Affiliation(s)
- Sarah Nouri
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Mara Quinn
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Natalya Johnson
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Molly Wertz
- Molly Wertz Consulting, San Francisco, CA, USA
| | - Charissa Tan
- John A. Burns School of Medicine, University of Hawai'I at Mānoa, Honolulu, HI, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Courtney R Lyles
- Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Christine S Ritchie
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, USA
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18
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Ben-Moshe S, Curseen KA. Advance Care Planning in the Geriatrics Clinic. Clin Geriatr Med 2023; 39:407-416. [PMID: 37385692 DOI: 10.1016/j.cger.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Advance care planning (ACP) is a process that allows individuals to express their health-care preferences and make decisions about their future medical care. Clinicians practicing in a Geriatrics clinic or with many patients who are aged 65 years or older have a unique opportunity to discuss patients' goals of care. ACP is particularly important for older adults, who may be facing serious health issues and/or end-of-life decisions. This review article will provide an overview of the importance of ACP in the geriatrics clinic, discuss the barriers to implementation, and explore strategies for successful integration..
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Affiliation(s)
- Sivan Ben-Moshe
- Department of Medicine, Division of General Medicine and Geriatrics, Emory University School of Medicine, Geriatrics Clinic, Emory Healthcare, 1525 Clifton Road Northeast, Atlanta, GA 30322, USA.
| | - Kimberly A Curseen
- Division of Palliative Medicine, Emory Palliative Care Center, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30322, USA.
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19
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Gazaway S, Chuang E, Thompson M, White-Hammond G, Elk R. Respecting Faith, Hope, and Miracles in African American Christian Patients at End-of-Life: Moving from Labeling Goals of Care as "Aggressive" to Providing Equitable Goal-Concordant Care. J Racial Ethn Health Disparities 2023; 10:2054-2060. [PMID: 35947300 PMCID: PMC10026148 DOI: 10.1007/s40615-022-01385-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 10/15/2022]
Abstract
In this article, we demonstrate first how the term "aggressive care," used loosely by clinicians to denote care that can negatively impact quality of life in serious illness, is often used to inappropriately label the preferences of African American patients, and discounts, discredits, and dismisses the deeply held beliefs of African American Christians. This form of biased communication results in a higher proportion of African Americans than whites receiving care that is non-goal-concordant and contributes to the prevailing lack of trust the African American community has in our healthcare system. Second, we invite clinicians and health care centers to make the perspectives of socially marginalized groups (in this case, African American Christians) the central axis around which we find solutions to this problem. Based on this, we provide insight and understanding to clinicians caring for seriously ill African American Christian patients by sharing their beliefs, origins, and substantive importance to the African American Christian community. Third, we provide recommendations to clinicians and healthcare systems that will result in African Americans, regardless of religious affiliation, receiving equitable levels of goal-concordant care if implemented. KEY MESSAGE: Labeling care at end-of-life as "aggressive" discounts the deeply held beliefs of African American Christians. By focusing on the perspectives of this group clinicians will understand the importance of respecting their religious values. The focus on providing equitable goal-concordant care is the goal.
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Affiliation(s)
- Shena Gazaway
- Department of Family, School of Nursing, University of Alabama Birmingham, Community, and Health Systems 1720 2nd Avenue South, AB, N485C,35294-1210, Birmingham, USA.
| | | | | | | | - Ronit Elk
- School of Medicine, UAB, Birmingham, AL, USA
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20
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Brown CE, Marshall AR, Snyder CR, Cueva KL, Pytel CC, Jackson SY, Golden SH, Campelia GD, Horne DJ, Doll KM, Curtis JR, Young BA. Perspectives About Racism and Patient-Clinician Communication Among Black Adults With Serious Illness. JAMA Netw Open 2023; 6:e2321746. [PMID: 37405773 PMCID: PMC10323709 DOI: 10.1001/jamanetworkopen.2023.21746] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/15/2023] [Indexed: 07/06/2023] Open
Abstract
Importance Black patients with serious illness experience higher-intensity care at the end of life. Little research has used critical, race-conscious approaches to examine factors associated with these outcomes. Objective To investigate the lived experiences of Black patients with serious illness and how various factors may be associated with patient-clinician communication and medical decision-making. Design, Setting, and Participants In this qualitative study, one-on-one, semistructured interviews were conducted with 25 Black patients with serious illness hospitalized at an urban academic medical center in Washington State between January 2021 and February 2023. Patients were asked to discuss experiences with racism, how those experiences affected the way they communicated with clinicians, and how racism impacted medical decision-making. Public Health Critical Race Praxis was used as framework and process. Main Outcomes and Measures The experience and of racism and its association, as described by Black patients who had serious illness, with patient-clinician communication and medical decision-making within a racialized health care setting. Results A total of 25 Black patients (mean [SD] age, 62.0 [10.3] years; 20 males [80.0%]) with serious illness were interviewed. Participants had substantial socioeconomic disadvantage, with low levels of wealth (10 patients with 0 assets [40.0%]), income (annual income <$25 000 among 19 of 24 patients with income data [79.2%]), educational attainment (mean [SD] 13.4 [2.7] years of schooling), and health literacy (mean [SD] score in the Rapid Estimate of Adult Literacy in Medicine-Short Form, 5.8 [2.0]). Participants reported high levels of medical mistrust and high frequency of discrimination and microaggressions experienced in health care settings. Participants reported epistemic injustice as the most common manifestation of racism: silencing of their own knowledge and lived experiences about their bodies and illness by health care workers. Participants reported that these experiences made them feel isolated and devalued, especially if they had intersecting, marginalized identities, such as being underinsured or unhoused. These experiences were associated with exacerbation of existing medical mistrust and poor patient-clinician communication. Participants described various mechanisms of self-advocacy and medical decision-making based on prior experiences with mistreatment from health care workers and medical trauma. Conclusions and Relevance This study found that Black patients' experiences with racism, specifically epistemic injustice, were associated with their perspectives on medical care and decision-making during serious illness and end of life. These findings suggest that race-conscious, intersectional approaches may be needed to improve patient-clinician communication and support Black patients with serious illness to alleviate the distress and trauma of racism as these patients near the end of life.
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Affiliation(s)
- Crystal E. Brown
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle
| | - Arisa R. Marshall
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Cyndy R. Snyder
- Department of Family Medicine, Center for Health Workforce Studies, School of Medicine, University of Washington, Seattle
| | | | - Christina C. Pytel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | | | - Sherita H. Golden
- Division of Endocrinology, Diabetes, and Metabolism, John Hopkins University, Baltimore, Maryland
| | - Georgina D. Campelia
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle
| | - David J. Horne
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Kemi M. Doll
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle
| | - J. Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Bessie A. Young
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
- Justice, Equity, Diversity, and Inclusion Center for Transformational Research, University of Washington, Seattle
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21
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Fennell G, Hoe D, Zelinski E, Enguídanos S. Factors Associated With Advance Care Planning by Race. Am J Hosp Palliat Care 2023; 40:164-172. [PMID: 35469436 DOI: 10.1177/10499091221094779] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Gillian Fennell
- Leonard Davis School of Gerontology, 5116University of Southern California, Los Angeles, CA, USA
| | - Deborah Hoe
- Leonard Davis School of Gerontology, 5116University of Southern California, Los Angeles, CA, USA
| | - Elizabeth Zelinski
- Leonard Davis School of Gerontology, 5116University of Southern California, Los Angeles, CA, USA
| | - Susan Enguídanos
- Leonard Davis School of Gerontology, 5116University of Southern California, Los Angeles, CA, USA
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22
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Advance care planning among African Americans: A review and synthesis of theory application. Palliat Support Care 2023; 21:118-126. [PMID: 36814150 DOI: 10.1017/s1478951521001863] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Elbaum A, Kinsey L, Mariano J. Decision-Making Across Cultures. Cancer Treat Res 2023; 187:85-104. [PMID: 37851221 DOI: 10.1007/978-3-031-29923-0_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
This chapter surveys the range of different orientations toward decision-making, common clinical scenarios, and considerations to bear in mind when caring for culturally diverse patients at the end of life. While this chapter draws on the cultural competency literature, its primary goal is to articulate an approach to end-of-life care that is rooted in cultural humility and structural competency. Medical providers, as representatives of the social institution of medicine, have their own cultural values that often come into conflict with patients' cultural values, especially when patients and providers have different unspoken visions of the "good death," or when patients wish to receive interventions that their providers deem futile. In the final section of the chapter, we seek to move away from this confrontational paradigm by analyzing two case studies of decision-making across cultures in order to empower providers to engage in value-based shared decision-making and thereby achieve goal-concordant care.
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Affiliation(s)
- Alan Elbaum
- University of California San Francisco, San Francisco, USA.
| | | | - Jeffrey Mariano
- Department of Geriatrics, Palliative Medicine and Continuing Care, Kaiser Permanente Bernard J. Tyson School of Medicine, Southern California Permanente Medical Group, Kaiser Permanente West Los Angeles, Pasadena, USA
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Martina D, Kustanti CY, Dewantari R, Sutandyo N, Putranto R, Shatri H, Effendy C, van der Heide A, Rietjens JAC, van der Rijt C. Opportunities and challenges for advance care planning in strongly religious family-centric societies: a Focus group study of Indonesian cancer-care professionals. Palliat Care 2022; 21:110. [PMID: 35729537 PMCID: PMC9215088 DOI: 10.1186/s12904-022-01002-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/14/2022] [Indexed: 11/21/2022] Open
Abstract
Background Most studies on advance care planning in Asia originate in high-income Asian countries. Indonesia is a middle-income Asian country characterized by its religious devoutness and strong family ties. This study aims to explore the perspectives and experiences of Indonesian healthcare professionals on advance care planning for cancer patients. Methods Focus-group discussions were conducted in July and August 2019 and were analysed using thematic content analysis enhanced by dual coding and exploration of divergent views. Purposive sampling of physicians and nurses actively engaged in cancer care in a national cancer centre and a national general hospital. Results We included 16 physicians and 16 nurses. These participants were open to the idea of advance care planning. We further identified four aspects of this planning that the participants considered to be important: 1) the family’s role in medical decision-making; 2) sensitivity to communication norms; 3) patients’ and families’ religious beliefs regarding the control and sanctity of life; and 4) the availability of a support system for advance care planning (healthcare professionals’ education and training, public education, resource allocation, and formal regulation). Participants believed that, although family hierarchical structure and certain religious beliefs may complicate patients’ engagement in advance care planning, a considerate approach to involving family and patients’ religious perspectives in advance care planning may actually facilitate their engagement in it. Conclusion Indonesian healthcare professionals believed that, for culturally congruent advance care planning in Indonesia, it was essential to respect the cultural aspects of collectivism, communication norms, and patients’ religious beliefs. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-01002-6.
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Affiliation(s)
- Diah Martina
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands. .,Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands. .,Division of Psychosomatic and Palliative Medicine, Department of Internal Medicine, Universitas Indonesia, Jakarta, Indonesia. .,Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia.
| | | | - Rahajeng Dewantari
- Department of Neuro-Psychiatry, Dharmais National Cancer Center, Jakarta, Indonesia
| | - Noorwati Sutandyo
- Department of Hematology and Medical Oncology, Dharmais National Cancer Center, Jakarta, Indonesia
| | - Rudi Putranto
- Division of Psychosomatic and Palliative Medicine, Department of Internal Medicine, Universitas Indonesia, Jakarta, Indonesia.,Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Hamzah Shatri
- Division of Psychosomatic and Palliative Medicine, Department of Internal Medicine, Universitas Indonesia, Jakarta, Indonesia.,Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Christantie Effendy
- School of Nursing, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Judith A C Rietjens
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Carin van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
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Gazaway S, Bakitas MA, Elk R, Eneanya ND, Dionne-Odom JN. Engaging African American family Caregivers in Developing a Culturally-responsive Interview Guide: A Multiphase Process and Approach. J Pain Symptom Manage 2022; 63:e705-e711. [PMID: 35247583 PMCID: PMC9133041 DOI: 10.1016/j.jpainsymman.2022.02.331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/11/2022] [Accepted: 02/18/2022] [Indexed: 11/21/2022]
Abstract
Qualitatively eliciting historically marginalized populations' beliefs, values, and preferences is critical to capturing information that authentically characterizes their experiences and can be used to develop culturally-responsive interventions. Eliciting these rich perspectives requires researchers to have highly effective qualitative interviewing guides, which can be optimized through community engagement. However, researchers have had little methodological guidance on how community member engagement can aid development of interview guides. The purpose of this article is to provide a series of steps, each supported by a case example from our work with African American family caregivers, for developing an interview guide through community engagement. We conclude by highlighting how involving historically marginalized community members in these early stages of research study development can build trust, research partnerships, and acknowledge their contribution to the development of new knowledge.
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Affiliation(s)
- Shena Gazaway
- School of Nursing (S.G., M.A.B., J.N.D.-O.), University of Alabama at Birmingham, Birmingham, Alabama, USA; Center for Palliative and Supportive Care (S.G., M.A.B., R.E., J.N.D.-O.), University of Alabama at Birmingham, Birmingham, Alabama, USA.
| | - Marie A Bakitas
- School of Nursing (S.G., M.A.B., J.N.D.-O.), University of Alabama at Birmingham, Birmingham, Alabama, USA; Center for Palliative and Supportive Care (S.G., M.A.B., R.E., J.N.D.-O.), University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ronit Elk
- Center for Palliative and Supportive Care (S.G., M.A.B., R.E., J.N.D.-O.), University of Alabama at Birmingham, Birmingham, Alabama, USA; School of Medicine (R.E.), Division of Geriatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nwamaka D Eneanya
- Perelman School of Medicine (N.D.E.), University of Pennsylvania, Philadelphia, Pennsylvania, USA; Palliative and Advanced Illness Research (PAIR) Center (N.D.E.), University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J Nicholas Dionne-Odom
- School of Nursing (S.G., M.A.B., J.N.D.-O.), University of Alabama at Birmingham, Birmingham, Alabama, USA; Center for Palliative and Supportive Care (S.G., M.A.B., R.E., J.N.D.-O.), University of Alabama at Birmingham, Birmingham, Alabama, USA
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Gelfand SL, Fitchett G, Moss AH. Recognizing the Potential Importance of Religion and Spirituality in the Care of Black Americans with Kidney Failure. J Am Soc Nephrol 2022; 33:1255-1257. [PMID: 35304429 PMCID: PMC9257821 DOI: 10.1681/asn.2021101367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Samantha L Gelfand
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts .,Harvard Medical School, Boston, Massachusetts.,Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - George Fitchett
- Department of Religion, Health and Human Values, Rush University Medical Center, Chicago, Illinois
| | - Alvin H Moss
- Section of Nephrology, West Virginia University School of Medicine, Morgantown, West Virginia.,Section of Geriatrics and Palliative Medicine, West Virginia University School of Medicine, Morgantown, West Virginia.,Center for Health Ethics and Law, West Virginia University Health Sciences Center, Morgantown, West Virginia
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Jones KF, Laury E, Sanders JJ, Starr LT, Rosa WE, Booker SQ, Wachterman M, Jones CA, Hickman S, Merlin JS, Meghani SH. Top Ten Tips Palliative Care Clinicians Should Know About Delivering Antiracist Care to Black Americans. J Palliat Med 2022; 25:479-487. [PMID: 34788577 PMCID: PMC9022452 DOI: 10.1089/jpm.2021.0502] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2021] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
| | - Esther Laury
- Louise Fitzpatrick College of Nursing, Villanova University, Villanova, Pennsylvania, USA
| | - Justin J. Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren T. Starr
- New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - William E. Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Staja Q. Booker
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, Gainesville, Florida, USA
| | - Melissa Wachterman
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Christopher A. Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Susan Hickman
- Department of Community and Health Systems, Indiana University School of Nursing, Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Jessica S. Merlin
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Salimah H. Meghani
- Department of Biobehavioral Health Sciences, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- New Courtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Affiliation(s)
- Juliet Jacobsen
- Harvard Medical School, Boston, Massachusetts
- Lund University Institute for Palliative Care, Lund, Sweden
| | - Rachelle Bernacki
- Harvard Medical School, Boston, Massachusetts
- Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joanna Paladino
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
- Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
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Aaron SP, Gazaway SB, Harrell ER, Elk R. Disparities and Racism Experienced Among Older African Americans Nearing End of Life. CURRENT GERIATRICS REPORTS 2021; 10:157-166. [PMID: 34956825 PMCID: PMC8685164 DOI: 10.1007/s13670-021-00366-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 11/23/2022]
Abstract
Purpose of Review The purpose of this review is to examine racism in healthcare as it relates to older African American adults. We focus on health disparities in old age and medical mismanagement throughout their lifespan. Recent Findings In the United States there have been extensive medical advances over the past several decades. Individuals are living longer, and illnesses that were deemed terminal in the past are now considered chronic illnesses. While most individuals living with chronic illness have experienced better quality of life, this is not the case for many African American older adults. Summary Older African American adults are less likely to have their chronic illness sufficiently managed and are more likely to die from chronic illnesses that are well controlled in Whites. African American older adults also continue to suffer from poorer healthcare outcomes throughout the lifespan to end-of-life.
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Affiliation(s)
- Siobhan P Aaron
- College of Nursing, University of Utah, 10 2000 E, Salt Lake City, UT 84112 U.S.A
| | - Shena B Gazaway
- School of Nursing, University of Alabama Birmingham, Birmingham, AL U.S.A
| | - Erin R Harrell
- Department of Psychology, University of Alabama, Tuscaloosa, AL U.S.A
| | - Ronit Elk
- Department of Medicine, University of Alabama Birmingham, Birmingham, AL U.S.A
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Bazargan M, Cobb S, Assari S. Completion of advance directives among African Americans and Whites adults. PATIENT EDUCATION AND COUNSELING 2021; 104:2763-2771. [PMID: 33840551 PMCID: PMC8481344 DOI: 10.1016/j.pec.2021.03.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 03/24/2021] [Accepted: 03/25/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The primary purpose of this study was to analyze the completion of advance directives among African American and White adults and examine related factors, including demographics, socio-economic status, health conditions, and experiences with health care providers. METHODS This study used data from the Survey of California Adults on Serious Illness and End-of-Life 2019. We compared correlates of completion of advance directives among a sample of 1635 African American and White adults. Multivariate analysis was conducted. RESULTS Whites were 50% more likely to complete an advance directive than African Americans. The major differences between African Americans and Whites were mainly explained by the level of mistrust and discrimination experienced by African Americans and partially explained by demographic characteristics. Our study showed that at both bivariate and multivariate levels, participation in religious activities was associated with higher odds of completion of an advance directive for both African Americans and Whites. CONCLUSION Interventional studies needed to address the impact of mistrust and perceived discrimination on advance directive completion. PRACTICAL IMPLICATIONS Culturally appropriate multifaceted, theoretical- and religious-based interventions are needed that include minority health care providers, church leaders, and legal counselors to educate, modify attitudes, provide skills and resources for communicating with health care providers and family members.
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Affiliation(s)
- Mohsen Bazargan
- Department of Family Medicine, College of Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA, USA; Department of Family Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA; Department of Public Health, CDU, Los Angeles, CA, USA; Physician Assistant Program, CDU, Los Angeles, CA, USA.
| | - Sharon Cobb
- School of Nursing, CDU, Los Angeles, CA, USA
| | - Shervin Assari
- Department of Family Medicine, College of Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA, USA; Department of Public Health, CDU, Los Angeles, CA, USA
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Bazargan M, Cobb S, Assari S, Bazargan-Hejazi S. Preparedness for Serious Illnesses: Impact of Ethnicity, Mistrust, Perceived Discrimination, and Health Communication. Am J Hosp Palliat Care 2021; 39:461-471. [PMID: 34476995 PMCID: PMC10173884 DOI: 10.1177/10499091211036885] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Mohsen Bazargan
- Department of Family Medicine, Charles R. Drew University of Medicine and Science & University of California at Los Angeles (UCLA), Los Angeles, CA, USA.,Department of Public Health, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA.,Physician Assistant Program, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA.,Department of Family Medicine, UCLA, Los Angeles, CA, USA
| | - Sharon Cobb
- School of Nursing, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | - Shervin Assari
- Department of Family Medicine, Charles R. Drew University of Medicine and Science & University of California at Los Angeles (UCLA), Los Angeles, CA, USA.,Department of Public Health, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | - Shahrzad Bazargan-Hejazi
- Department of Psychiatry, Charles R. Drew University of Medicine and Science & University of California at Los Angeles (UCLA), Los Angeles, CA, USA
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Kumar P, Yasmin F, Khan MS, Shahid I, Diwan MN, Leiter RE, Warraich HJ. Place of death in Parkinson's disease: trends in the USA. BMJ Support Palliat Care 2021:bmjspcare-2021-003016. [PMID: 34475135 DOI: 10.1136/bmjspcare-2021-003016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/28/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Parkinson's disease (PD) is a significant cause of mortality but little is known about the place of death for patients with PD in the USA, a key metric of end-of-life care. METHODOLOGY A trend analysis was conducted for years 2003-2017 using aggregated death certificate data from the Centers for Disease Control and Prevention Wide-ranging OnLine Data for Epidemiologic Research) database, with individual-level mortality data from the Mortality Multiple Cause-of-Death Public Use Record available between 2013 and 2017. All natural deaths for which PD was identified as an underlying cause of death were identified. Place of death was categorised as hospital, decedent home, hospice facility, nursing home/long-term care and other. RESULTS Between 2003 and 2017, 346141 deaths were attributed to PD (59% males, 93.7% White). Most deaths occurred in patients aged 75-84 years (43.9%), followed by those aged ≥85 years (40.9 %). Hospital and nursing home deaths decreased from 18% (n=3240) and 52.6% (n=9474) in 2003 to 9.2% (n=2949) and 42% (n=13 429) in 2017, respectively. Home deaths increased from 21.1% (n=3804) to 32.4% (n=10 347) and hospice facility deaths increased from 0.3% (n=47) in 2003 to 8.6% (n=2739) in 2017. Female sex, being married and college education were associated with increased odds of home deaths while Hispanic ethnicity and non-white race were associated with increased odds of hospital deaths. CONCLUSION Home and hospice facility deaths are gradually increasing in patients with PD. Particular attention should be provided to vulnerable socioeconomic groups that continue to have higher rates of hospital deaths and decreased usage of hospice facilities.
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Affiliation(s)
- Pankaj Kumar
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Farah Yasmin
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Shahzeb Khan
- Department of Cardiovascular Medicine, Duke University Hospital, Durham, North Carolina, USA
| | - Izza Shahid
- Department of Internal Medicine, Ziauddin Medical University, Karachi, Pakistan
| | | | - Richard E Leiter
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Haider J Warraich
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Cardiology Section, VA Boston Healthcare System, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Front-Line Hospice Staff Perceptions of Barriers and Opportunities to Discussing Advance Care Planning With Hospice Patients and Their Families. J Am Med Dir Assoc 2021; 23:1205-1214.e2. [PMID: 34391713 DOI: 10.1016/j.jamda.2021.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/20/2021] [Accepted: 07/14/2021] [Indexed: 11/21/2022]
Abstract
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.
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Jacobsen J, Schelin MEC, Fürst CJ. Too much too late? Optimizing treatment through conversations over years, months, and days. Acta Oncol 2021; 60:957-960. [PMID: 34214016 DOI: 10.1080/0284186x.2021.1945680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Juliet Jacobsen
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Maria E. C. Schelin
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
- Department of Clinical Sciences Lund, Division of Palliative Care, Lund University, Lund, Sweden
- Department of Research and Development, Skåne University Hospital, Lund, Sweden
| | - Carl Johan Fürst
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
- Department of Clinical Sciences Lund, Division of Palliative Care, Lund University, Lund, Sweden
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Bazargan M, Bazargan-Hejazi S. Disparities in Palliative and Hospice Care and Completion of Advance Care Planning and Directives Among Non-Hispanic Blacks: A Scoping Review of Recent Literature. Am J Hosp Palliat Care 2021; 38:688-718. [PMID: 33287561 PMCID: PMC8083078 DOI: 10.1177/1049909120966585] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Mohsen Bazargan
- Department of Family Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA, USA
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shahrzad Bazargan-Hejazi
- Department of Psychiatry, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA, USA
- Department of Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Bell LF, Livingston J, Arnold RM, Schenker Y, Kelsey RC, Ivonye C, October TW. Lack of Exposure to Palliative Care Training for Black Residents: A Study of Schools With Highest and Lowest Percentages of Black Enrollment. J Pain Symptom Manage 2021; 61:1023-1027. [PMID: 33189856 DOI: 10.1016/j.jpainsymman.2020.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/16/2020] [Accepted: 11/06/2020] [Indexed: 01/03/2023]
Abstract
CONTEXT The palliative medicine workforce lacks racial diversity with <5% of specialty Hospice and Palliative Medicine (HPM) fellows identifying as black. Little is known about black trainees' exposure to palliative care during their medical education. OBJECTIVES To describe palliative care training for black students during medical school, residency, and fellowship training. METHODS We conducted a cross-sectional descriptive study using Internet searches and phone communication in September 2019. We evaluated 24 medical schools in three predetermined categories: historically black colleges and universities (HBCUs; N = 4) and non-under-represented minority-serving institutions with the highest (N = 10) and lowest (N = 10) percentages of black medical students. Training opportunities were determined based on the presence of a course, clerkship, or rotation in the medical school and residency curricula, a specialty HPM fellowship program, and specialty palliative care consult service at affiliated teaching hospitals. RESULTS None of the four HBCUs with a medical school offered a palliative care course or clerkship, rotation during residency, or specialty HPM fellowship program. Three of four HBCUs were affiliated with a hospital that had a palliative care consult service. Institutions with the highest black enrollment were less likely to offer palliative care rotations during internal medicine (P = 0.046) or family medicine (P = 0.019) residency training than those with the lowest black enrollment. CONCLUSION Residents at schools with the highest black medical student enrollment lack access to palliative care training opportunities. Efforts to reduce health disparities and underrepresentation in palliative care must begin with providing palliative-focused training to physicians from under-represented minority backgrounds.
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Affiliation(s)
- Lindsay F Bell
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics and Palliative Research Center (PaRC), University of Pittsburgh, Pennsylvania, USA.
| | - Jessica Livingston
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Robert M Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics and Palliative Research Center (PaRC), University of Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics and Palliative Research Center (PaRC), University of Pittsburgh, Pennsylvania, USA
| | - Riba C Kelsey
- Department of Family Medicine, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Chinedu Ivonye
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Tessie W October
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, USA; The George Washington School of Medicine and Health Sciences, Washington, District of Columbia, USA
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Kuczmarski TM, Odejide OO. Goal of a "Good Death" in End-of-Life Care for Patients with Hematologic Malignancies-Are We Close? Curr Hematol Malig Rep 2021; 16:117-125. [PMID: 33864180 DOI: 10.1007/s11899-021-00629-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW The medical field has a critical role not only in prolonging life but also in helping patients achieve a good death. Early studies assessing end-of-life quality indicators to capture if a good death occurred demonstrated low rates of hospice use and high rates of intensive healthcare utilization near death among patients with hematologic malignancies, raising concerns about the quality of death. In this review, we examine trends in end-of-life care for patients with hematologic malignancies to determine if we are close to the goal of a good death. RECENT FINDINGS Several cohort studies show that patients with blood cancers are often inadequately prepared for the dying process due to late goals of care discussions and they experience low rates of palliative and hospice care. More recent analyses of population-based data demonstrate some improvements over time, with significantly more patients receiving palliative care, enrolling in hospice, and having the opportunity to die at home compared to a decade ago. These encouraging trends are paradoxically accompanied by concomitant increases in late hospice enrollment and intensive healthcare utilization near death. Although we are closer to the goal of a good death for patients with hematologic malignancies, there is ample room for growth. To close the gap between the current state of care and a good death, we need research that engages patients, caregivers, hematologic oncologists, and policy-makers to develop innovative interventions that improve timeliness of goals of care discussions, expand palliative care integration, and increase hospice use.
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Affiliation(s)
- Thomas M Kuczmarski
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Oreofe O Odejide
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
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Ashana DC, D’Arcangelo N, Gazarian PK, Gupta A, Perez S, Reich AJ, Tjia J, Halpern SD, Weissman JS, Ladin K. "Don't Talk to Them About Goals of Care": Understanding Disparities in Advance Care Planning. J Gerontol A Biol Sci Med Sci 2021; 77:339-346. [PMID: 33780534 PMCID: PMC8824574 DOI: 10.1093/gerona/glab091] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Structurally marginalized groups experience disproportionately low rates of advance care planning (ACP). To improve equitable patient-centered end-of-life care, we examine barriers and facilitators to ACP among clinicians as they are central participants in these discussions. METHOD In this national study, we conducted semi-structured interviews with purposively selected clinicians from 6 diverse health systems between August 2018 and June 2019. Thematic analysis yielded themes characterizing clinicians' perceptions of barriers and facilitators to ACP among patients, and patient-centered ways of overcoming them. RESULTS Among 74 participants, 49 (66.2%) were physicians, 16.2% were nurses, and 13.5% were social workers. Most worked in primary care (35.1%), geriatrics (21.1%), and palliative care (19.3%) settings. Clinicians most frequently expressed difficulty discussing ACP with certain racial and ethnic groups (African American, Hispanic, Asian, and Native American) (31.1%), non-native English speakers (24.3%), and those with certain religious beliefs (Catholic, Orthodox Jewish, and Muslim) (13.5%). Clinicians were more likely to attribute barriers to ACP completion to patients (62.2%), than to clinicians (35.1%) or health systems (37.8%). Three themes characterized clinicians' difficulty approaching ACP (preconceived views of patients' preferences, narrow definitions of successful ACP, and lack of institutional resources), while the final theme illustrated facilitators to ACP (acknowledging bias and rejecting stereotypes, mission-driven focus on ACP, and acceptance of all preferences). CONCLUSIONS Most clinicians avoided ACP with certain racial and ethnic groups, those with limited English fluency, and persons with certain religious beliefs. Our findings provide evidence to support development of clinician-level and institutional-level interventions and to reduce disparities in ACP.
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Affiliation(s)
- Deepshikha Charan Ashana
- Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA,Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Noah D’Arcangelo
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, Massachusetts, USA
| | - Priscilla K Gazarian
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Avni Gupta
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA,Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, USA
| | - Stephen Perez
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Amanda J Reich
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jennifer Tjia
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, USA
| | - Scott D Halpern
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA,Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Keren Ladin
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, Massachusetts, USA,Department of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts, USA,Address correspondence to: Keren Ladin, PhD, MSc, Department of Community Health, Tufts University, 574 Boston Avenue, Suite 216, Medford, MA 02155, USA. E-mail:
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Siler S, Arora K, Doyon K, Fischer SM. Spirituality and the Illness Experience: Perspectives of African American Older Adults. Am J Hosp Palliat Care 2021; 38:618-625. [PMID: 33461330 DOI: 10.1177/1049909120988280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Disparities in hospice and palliative care (PC) for African Americans have been linked to mistrust toward the healthcare system, racial inequalities, and cultural preferences. Spirituality has been identified as important to African Americans in general. Less is known about the influence of spirituality on African American illness experiences. OBJECTIVE The goal of this study was to understand older African Americans' perspectives on how spirituality influences chronic illness experiences to inform the development of a culturally tailored PC intervention. METHODS In partnership with 5 churches in the Denver metropolitan area, we conducted focus groups with African American older adults (n = 50) with chronic health conditions and their family caregivers. Transcripts were analyzed using a deductive approach. The theoretical framework for this study draws on psychology of religion research. RESULTS Themes referenced participants' spiritual orienting systems, spiritual coping strategies, and spiritual coping styles. Psycho-spiritual struggles, social struggles, and sources of social support were also identified. Findings suggest African Americans' spirituality influences chronic illness experiences. Participants relied on their spirituality and church community to help them cope with illness. In addition, social struggles impacted the illness experience. Social struggles included mistrust toward the healthcare system and not being connected to adequate resources. Participants expressed a need to advocate for themselves and family members to receive better healthcare. Churches were referred to as a trusted space for health resources, as well as spiritual and social support.
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Affiliation(s)
- Shaunna Siler
- School of Medicine, 12225University of Colorado, Anschutz Medical Campus, CO, USA
| | - Kelly Arora
- University of Colorado, Anschutz Medical Campus, CO, USA
| | - Katherine Doyon
- School of Medicine, 12225University of Colorado, Anschutz Medical Campus, CO, USA
| | - Stacy M Fischer
- Division of General Internal Medicine, Department of Medicine, 12225University of Colorado, Anschutz Medical Campus, CO, USA
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Catlett L, Campbell C. Advance Care Planning and End of Life Care Literacy Initiatives in African American Faith Communities: A Systematic Integrative Review. Am J Hosp Palliat Care 2020; 38:719-730. [PMID: 33297716 DOI: 10.1177/1049909120979164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
African Americans (AA) experience health inequalities that affect their utilization of advance care planning (ACP) and hospice and palliative care at end of life (EOL). Faith-based health promotion models may be applicable to ACP and EOL care literacy for this population. The purpose of this integrative review was to examine the literature highlighting participant responses to ACP and EOL care literacy initiatives in AA faith communities. An integrative literature review was conducted using the following databases: PubMed, CINAHL, Web of Science, and PsychINFO. Eight primary sources met inclusion criteria. Findings from these studies indicate that integration of AA religious beliefs and practices into ACP and EOL care educational programs may enhance the efficacy of these efforts in promoting ACP, advance directive completion, and hospice use. Building trust, creating community partnerships, and involving church leadership in ACP and EOL care literacy promotion efforts serve as important elements to inform future initiatives.
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Affiliation(s)
- Lauren Catlett
- 2358University of Virginia School of Nursing, Charlottesville, VA, USA
| | - Cathy Campbell
- 2358University of Virginia School of Nursing, Charlottesville, VA, USA
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Johnson KA, Quest T, Curseen K. Will You Hear Me? Have You Heard Me? Do You See Me? Adding Cultural Humility to Resource Allocation and Priority Setting Discussions in the Care of African American Patients With COVID-19. J Pain Symptom Manage 2020; 60:e11-e14. [PMID: 32889037 PMCID: PMC7462785 DOI: 10.1016/j.jpainsymman.2020.08.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/15/2020] [Accepted: 08/28/2020] [Indexed: 11/02/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has refocused our attention on health care disparities affecting patients of color, with a growing body of literature focused on the etiology of these disparities and strategies to eliminate their effects. In considering the unique impact COVID-19 is having on African American communities, added measure must be given to ensure for sensitivity, empathy, and supportive guidance in medical decision making among African American patients faced with critical illness secondary to COVID-19. In this article, we explore the applications of cultural humility over cultural competency in optimizing the care we provide to African American patients faced with critical health care decisions during this pandemic. In turn, we charge one another as health care providers to consider how ethical principles and guidance can be applied to honor African American patients' unique stories and experiences.
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Affiliation(s)
- Khaliah A Johnson
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA; Pediatric Palliative Care, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.
| | - Tammie Quest
- Department of Family and Preventative Medicine, Emory University, Atlanta, Georgia, USA
| | - Kimberly Curseen
- Palliative Care, Emory University Hospital, Atlanta, Georgia, USA
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Communication Tools to Support Advance Care Planning and Hospital Care During the COVID-19 Pandemic: A Design Process. Jt Comm J Qual Patient Saf 2020; 47:127-136. [PMID: 33191165 PMCID: PMC7584878 DOI: 10.1016/j.jcjq.2020.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/18/2022]
Abstract
The COVID-19 pandemic has exposed the medical and social vulnerability of an unprecedented number of people. Consequently, there has never been a more important time for clinicians to engage patients in advance care planning (ACP) discussions about their goals, values, and preferences in the event of critical illness. An evidence-based communication tool-the Serious Illness Conversation Guide-was adapted to address COVID-related ACP challenges using a user-centered design process: convening relevant experts to propose initial guide adaptations; soliciting feedback from key clinical stakeholders from multiple disciplines and geographic regions; and iteratively testing language with patient actors. With feedback focused on sharing risk about COVID-19-related critical illness, recommendations for treatment decisions, and use of person-centered language, the team also developed conversation guides for inpatient and outpatient use. These tools consist of open-ended questions to elicit perception of risk, goals, and care preferences in the event of critical illness, and language to convey prognostic uncertainty. To support use of these tools, publicly available implementation materials were also developed for clinicians to effectively engage high-risk patients and overcome challenges related to the changed communication context, including video demonstrations, telehealth communication tips, and step-by-step approaches to identifying high-risk patients and documenting conversation findings in the electronic health record. Well-designed communication tools and implementation strategies can equip clinicians to foster connection with patients and promote shared decision making. Although not an antidote to this crisis, such high-quality ACP may be one of the most powerful tools we have to prevent or ameliorate suffering due to COVID-19.
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Bazargan M, Cobb S, Assari S. End-of-Life Wishes Among Non-Hispanic Black and White Middle-Aged and Older Adults. J Racial Ethn Health Disparities 2020; 8:1168-1177. [PMID: 33078334 PMCID: PMC10173885 DOI: 10.1007/s40615-020-00873-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/11/2020] [Accepted: 09/14/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Although some research has been done on end-of-life (EOL) preferences and wishes, our knowledge of racial differences in the EOL wishes of non-Hispanic White and non-Hispanic Black middle-aged and older adults is limited. Previous studies exploring such racial differences have focused mainly on EOL decision-making as reflected in advance healthcare directives concerning life-sustaining medical treatment. In need of examination are aspects of EOL care that are not decision-based and therefore not normally covered by written advance healthcare directives. This study focuses on racial differences in non-decision-based aspects of EOL care, that is, EOL care that incorporates patients' beliefs, culture, or religion. AIM To test the combined effects of race, socioeconomic status, health status, spirituality, perceived discrimination and medical mistrust on the EOL non-decision-based desires and wishes of a representative sample of non-Hispanic White and non-Hispanic Black older California adults. METHODS This cross-sectional study used data from the Survey of California Adults on Serious Illness and End-of-Life 2019. To perform data analysis, we used multiple logistic regression models. RESULTS Non-Hispanic Blacks reported more EOL non-decision-based desires and wishes than non-Hispanic Whites. In addition to gender, age, and education other determinants of EOL non-decision-based medical desires and wishes included perceived and objective health status, spirituality, and medical trust. Poverty level, perceived discrimination did not correlate with EOL medical wishes. CONCLUSION Non-Hispanic Blacks desired a closer relationship with their providers as well as a higher level of respect for their cultural beliefs and values from their providers compared with their White counterparts. Awareness, understanding, and respecting the cultural beliefs and values of older non-Hispanic Black patients, that usually are seen by non-Hispanic Black providers, is the first step for meaningful relationship between non-Hispanic Black patients and their providers that directly improve the end-of-life quality of life for this segment of our population.
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Affiliation(s)
- Mohsen Bazargan
- Department of Family Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA, USA.
- Department of Family Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA.
| | - Sharon Cobb
- School of Nursing, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA, USA
| | - Shervin Assari
- Department of Family Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA, USA
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Mack JW, Uno H, Twist CJ, Bagatell R, Rosenberg AR, Marachelian A, Granger MM, Glade Bender J, Baker JN, Park JR, Cohn SL, Fernandez JH, Diller LR, Shusterman S. Racial and Ethnic Differences in Communication and Care for Children With Advanced Cancer. J Pain Symptom Manage 2020; 60:782-789. [PMID: 32360991 PMCID: PMC7523916 DOI: 10.1016/j.jpainsymman.2020.04.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/17/2020] [Accepted: 04/21/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Racial and ethnic disparities in end-of-life care are well documented among adults with advanced cancer. OBJECTIVES To examine the extent to which communication and care differ by race and ethnicity among children with advanced cancer. METHODS We conducted a prospective cohort study at nine pediatric cancer centers enrolling 95 parents (42% racial/ethnic minorities) of children with poor prognosis cancer (relapsed/refractory high-risk neuroblastoma). Parents were surveyed about whether prognosis was discussed; likelihood of cure; intent of current treatment; and primary goal of care. Medical records were used to identify high-intensity medical care since the most recent recurrence. Logistic regression evaluated differences between white non-Hispanic and minority (black, Hispanic, and Asian/other race) parents. RESULTS About 26% of parents recognized the child's low likelihood of cure. Minority parents were less likely to recognize the poor prognosis (odds ratio [OR] = 0.19; 95% CI = 0.06-0.63; P = 0.006) and the fact that current treatment was unlikely to offer cure (OR = 0.07; 95% CI = 0.02-0.27; P < 0.0001). Children of minority parents were more likely to experience high-intensity medical care (OR = 3.01; 95% CI = 1.29-7.02; P = 0.01). After adjustment for understanding of prognosis, race/ethnicity was no longer associated with high-intensity medical care (adjusted odds ratio = 2.14; 95% CI = 0.84-5.46; P = 0.11), although power to detect an association was limited. CONCLUSION Parental understanding of prognosis is limited across racial and ethnic groups; racial and ethnic minorities are disproportionately affected. Perhaps as a result, minority children experience higher rates of high-intensity medical care. Work to improve prognostic understanding should include focused work to meet needs of minority populations.
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Affiliation(s)
- Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - Hajime Uno
- Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Clare J Twist
- Roswell Park Cancer Institute Buffalo, New York, New York, USA
| | - Rochelle Bagatell
- Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Abby R Rosenberg
- Department of Pediatric Hematology/Oncology, University of Washington School of Medicine, Seattle, Washington, USA; Pediatric Bioethics/Palliative Care, University of Washington School of Medicine, Seattle, Washington, USA; Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA
| | - Araz Marachelian
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - M Meaghan Granger
- Hematology and Oncology Center, Cook Children's Hospital, Fort Worth, Texas, USA
| | - Julia Glade Bender
- Department of Pediatric Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Julie R Park
- Department of Pediatric Hematology/Oncology, University of Washington School of Medicine, Seattle, Washington, USA; Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA
| | - Susan L Cohn
- Department of Pediatrics, Comer Children's Hospital, University of Chicago, Chicago, Illinois, USA
| | - Jorge H Fernandez
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lisa R Diller
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Suzanne Shusterman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
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De Souza J, Gillett K, Froggatt K, Walshe C. Perspectives of elders and their adult children of Black and minority ethnic heritage on end-of-life conversations: A meta-ethnography. Palliat Med 2020; 34:195-208. [PMID: 31965907 PMCID: PMC7000852 DOI: 10.1177/0269216319887070] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND People of Black and minority ethnic heritage are more likely to die receiving life supporting measures and less likely to die at home. End-of-life care decision making often involves adult children as advance care planning is uncommon in these communities. Physicians report family distress as being a major factor in continuing with futile care. AIM To develop a deeper understanding of the perspectives of elders of Black and minority ethnic heritage and their children, about end-of-life conversations that take place within the family, using a meta-ethnographic approach. DESIGN Systematic interpretive exploration using the process of meta-ethnography was utilised. DATA SOURCES CINAHL, MEDLINE, PubMed and PsycINFO databases were searched. Inclusion criteria included studies published between 2005 and 2019 and studies of conversations between ethnic minority elders and family about end-of-life care. Citation snowballing was used to ensure all appropriate references were identified. A total of 13 studies met the inclusion criteria and required quality level using Critical Appraisal Skills Programme. RESULTS The following four storylines were constructed: 'My family will carry out everything for me; it is trust'; 'No Mum, don't talk like that'; 'I leave it in God's hands'; and 'Who's going to look after us?' The synthesis reflected the dichotomous balance of trust and burden avoidance that characterises the perspectives of Black and minority ethnic elders to end-of-life care planning with their children.
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Affiliation(s)
- Joanna De Souza
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, UK.,Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Karen Gillett
- Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Katherine Froggatt
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, UK
| | - Catherine Walshe
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, UK
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Lyon ME, Squires L, D'Angelo LJ, Benator D, Scott RK, Greenberg IH, Tanjutco P, Turner MM, Weixel TE, Cheng YI, Wang J. FAmily-CEntered (FACE) Advance Care Planning Among African-American and Non-African-American Adults Living With HIV in Washington, DC: A Randomized Controlled Trial to Increase Documentation and Health Equity. J Pain Symptom Manage 2019; 57:607-616. [PMID: 30472318 PMCID: PMC6382515 DOI: 10.1016/j.jpainsymman.2018.11.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/09/2018] [Accepted: 11/14/2018] [Indexed: 12/25/2022]
Abstract
CONTEXT No prospective studies address disease-specific advance care planning (ACP) for adults living with HIV/AIDS. OBJECTIVE To examine the efficacy of FAmily-CEntered (FACE) ACP in increasing ACP and advance directive documentation in the medical record. METHODS Longitudinal, two-arm, randomized controlled trial with intent-to-treat design recruited from five hospital-based outpatient HIV clinics in Washington, DC. Adults living with HIV and their surrogate decision-makers (N = 233 dyads) were randomized to either an intensive facilitated two-session FACE ACP (Next Steps: Respecting Choices goals of care conversation and Five Wishes advance directive) or healthy living control (conversations about developmental/relationship history and nutrition). RESULTS Patients (n = 223) mean age: 51 years, 56% male, 86% African-American. One hundred ninety-nine dyads participated in the intervention. At baseline, only 13% of patients had an advance directive. Three months after intervention, this increased to 59% for the FACE ACP group versus 17% in the control group (P < 0.0001). Controlling for race, the odds of having an advance directive in the medical record in the FACE ACP group was approximately seven times greater than controls (adjusted odds ratio = 6.58, 95% CI: 3.21-13.51, P < 0.0001). Among African-Americans randomized to FACE, 58% had completed/documented advance directives versus 20% of controls (P < 0.0001). CONCLUSIONS The FACE ACP intervention significantly improved ACP completion and advance directive documentation in the medical record among both African-American and non-African-American adults living with HIV in Washington, DC, providing health equity in ACP, which can inform best practices.
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Affiliation(s)
- Maureen E Lyon
- Division of Adolescent and Young Adult Medicine, Children's National, Center for Translational Science/Children's Research Institute, Washington, DC, USA; George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Leah Squires
- Washington DC Veterans Affairs Medical Center, Washington, DC
| | - Lawrence J D'Angelo
- Division of Adolescent and Young Adult Medicine, Children's National, Center for Translational Science/Children's Research Institute, Washington, DC, USA; George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Debra Benator
- George Washington University School of Medicine and Health Sciences, Washington, DC; Washington DC Veterans Affairs Medical Center, Washington, DC
| | - Rachel K Scott
- MedStar: Health Research Institute and Washington Hospital Center; George Washington University Milken School of Public Health, Washington, DC, USA
| | - Isabella H Greenberg
- Division of Adolescent and Young Adult Medicine, Children's National, Center for Translational Science/Children's Research Institute, Washington, DC, USA
| | - Patricia Tanjutco
- MedStar: Health Research Institute and Washington Hospital Center; George Washington University Milken School of Public Health, Washington, DC, USA
| | | | - Tara E Weixel
- Office of the Clinical Director, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Yao I Cheng
- Division of Adolescent and Young Adult Medicine, Children's National, Center for Translational Science/Children's Research Institute, Washington, DC, USA
| | - Jichuan Wang
- Division of Adolescent and Young Adult Medicine, Children's National, Center for Translational Science/Children's Research Institute, Washington, DC, USA; George Washington University School of Medicine and Health Sciences, Washington, DC
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