Attitudes on end-of-life care and advance care planning in the lesbian and gay community

Project Respect: experiences of seriously ill LGBTQ+ patients and partners with their health care providers

Discrimination against lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons in health care creates barriers to serious illness care, including patients avoiding or delaying necessary care, providers disrespecting wishes of surrogates, and adverse outcomes for patients and families. A cross-sectional mixed-methods study using an online survey was used to determine the extent to which LGBTQ+ patients and spouses, partners, and widows experienced disrespectful or inadequate care due to sexual orientation or gender identity. A total of 290 LGBTQ+ patients and partners reported high levels of disrespectful and inadequate care, including 35.2% stating their provider was insensitive to them because of their identity; 30% reporting their provider was unaware of LGBTQ+ health needs; 23.1% feeling judged; 20.7% experiencing rudeness; 20.3% stating providers did not use their correct pronouns; and 19.7% reporting their treatment decisions were disregarded. Black and Hispanic patients were 2-4 times more likely than non-Hispanic White patients to report discrimination. This study demonstrated high levels of disrespectful and inadequate care towards patients and partners due to being LGBTQ+, which was especially problematic for Black and Hispanic patients and those living in politically conservative regions. Recommendations include federal and state civil rights laws to prohibit LGBTQ+ discrimination and institutional practices to address discrimination, including cultural sensitivity training for staff.

Geriatric Palliative Care: Providing Excellent Care to Lesbian, Gay, Bisexual, Transgender, Queer Older Adults

LGBTQ+ patients encounter discrimination and bias in health care settings. They experience worse health outcomes than their cisgender and heterosexual counterparts. There are numerous ways to provide equitable and comprehensive palliative care to seriously ill LGBTQ+ individuals. These strategies include communication techniques, encouragement to complete advance directives, implicit bias training, and interdisciplinary collaboration.

Advance Care Planning among Older Gay Men Living with HIV in Montreal, Canada: Challenges to Thinking and Talking about Future Care

This qualitative study employed a cross sectional focus group design to explore how older gay men living with HIV, experience, perceive, and engage with advance care planning (ACP). Seven gay men 50+, residing in Montreal, Canada, participated in a focus group that was audio-recorded, transcribed, and thematically analyzed. Findings suggested that social isolation, preoccupations with day-to-day living, and managing disclosures related to sexual orientation and HIV status created barriers to these men's capacities to think about let alone talk about future care. These findings challenge current conceptualizations of ACP, which position reflection as an individual process that precedes allocating a decision-maker and communicating care preferences. Analyses further revealed that relational connections helped create a space where ACP could occur for participants. Hence, improving the uptake of ACP amongst older gay men with HIV may require interventions that embed such discussions into broader programs aimed at building support and community.

The role of sexual orientation, age, living arrangements and self-rated health in planning for end-of-life care for lesbian, gay and bisexual (LGB) older people in the UK

This article reports on findings from the quantitative phase of a two-year research project designed to explore end-of-life care experiences and needs of lesbian, gay, bisexual and transgender people. We draw on a subset of the sample (N = 180/237) to analyse the relationship between advance care planning, sexual orientation, living arrangements and self-rated health. The results contribute to a growing body of evidence on how sexual minorities approach and make decisions on advance care planning. A greater understanding of such patterns could help inform the way healthcare professionals engage in conversations about end-of-life care planning with older LGB people.

Palliative care needs, concerns, and affirmative strategies for the LGBTQ population

The Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning population, also known as sexual and gender minorities, are an incredibly marginalized and vulnerable population that have been disproportionately affected by the provision, delivery, and optimal access to high-quality medical care including palliative, hospice, and end-of-life care. The long-standing and unique experiences shaped by positive and negative historical events have led to a better understanding of significant barriers and gaps in equitable healthcare for this population. The intersection of both internal and external stressors as well as minority identities in the context of discriminatory political and societal infrastructures have resulted in variable health outcomes that continues to be plagued by economic barriers, oppressive legislative policies, and undesirable societal practices. It could not be more urgent and timely to call upon the government and healthcare systems at large to execute reforms in policies and regulations, engage in cultural competency training, and promote cultural shifts in beliefs, attitudes, and practices that will ultimately recognize, prioritize, and address the needs of this population. After all, health care access is a universal right regardless of personal, social, political, and economic determinants of comprehensive medical care.

"It Made Me Feel Like I Didn't Know My Own Body": Patient-Provider Relationships, LGBTQ+ Identity, and End-of-Life Discussions

PURPOSE

LGBTQ+ individuals experience multiple challenges receiving quality care at the end of life, such as lack of confidence in the healthcare system to address their needs and lack of knowledge about advance care planning. Important gaps remain about the needs of LGBTQ+ individuals in the provider-patient relationship and how critical discussions about the end of life occur or do not occur in that relationship. The purpose of this study is to explore patients' narratives of their relationship with their provider and their experiences discussing end-of-life care with their providers, among patients who do and do not identify as LGBTQ+.

METHODS

Twenty-nine attendants of an event devoted to LGBTQ+ health, 15 of which identified as LGBTQ+, completed an altered version of the CAHPS® Patient Narrative Elicitation Protocol. We used inductive content analysis to qualitatively analyze the data.

RESULTS

Respondents described wanting to be heard, finding safety and trust, and valuing competency in their relationship with their provider. Respondents who identified as LGBTQ+ additionally 1) valued providers who avoided making assumptions, 2) looked for cues of safety to indicate they would be accepted by the provider, and 3) sought providers competent in LGBTQ+ care needs. Few respondents had discussed end-of-life care with their provider, although some assumed that their provider may or may not be able to meet their needs based on aspects of their provider-patient relationship.

CONCLUSIONS

Strengthening patient-provider relationships may help improve the care of LGBTQ+ populations, particularly for the end of life.

A Systematic Review of the Discrimination Against Sexual and Gender Minority in Health Care Settings

The present systematic review aimed to determine discrimination experiences of sexual and gender minority (SGM) individuals and attitudes toward SGM among health care staff in health care settings. Following PRISMA guidelines, the review was conducted in 3 databases (PubMed, Cochrane Library, Science Direct) using keywords of sexual and gender minority, including “gay,” “lesbian,” “bisexual,” “transgender,” “LGB,” “LGBT,” “health care discrimination,” “stigma,” “homophobia,” “transphobia,” and “attitudes of healthcare professionals” from May to September 2016. Predetermined inclusion criteria were selected. Thirty quantitative studies were eligible for inclusion in this review. Discriminative behaviors experienced by SGM individuals were stigma, denial or refusal of health care, and verbal or physical abuse. Knowledge and educational levels, beliefs, and religion of health care providers affected their attitudes toward SGM patients and their homophobia level. These findings revealed that health care providers needed more education about SGM issues, and SGM-friendly policies should be created for improving health care for SGM individuals.

Motivations for advance care and end-of-life planning among lesbian, gay, and bisexual older adults

Lesbian, gay, and bisexual (LGB) older adults are more likely than their heterosexual peers to experience health disparities, discrimination from healthcare providers based on sexual orientation, and rejection from their family of origin, all of which can complicate medical care and decision making, as well as end-of-life arrangements. Yet, relatively few studies of LGB seniors have looked at motivations for advance care and end-of-life planning, which are strategies that can help ensure that healthcare treatment and end-of-life wishes are enacted as desired. The present qualitative study investigated this topic with a purposive sample of nine LGB and same-gender-loving adults in a metropolitan region of the Southeastern United States. The study involved in-depth face-to-face interviews, followed by a brief pen-and-paper survey. Participants' ages ranged from 65 to 77; the sample included five men and four women. Six individuals were white/Caucasian, while three were African American/Black. We identified three themes related to motivations for advance care and end-of-life planning: wanting a sense of agency, learning from others, and reducing conflict and confusion for loved ones. We discuss the importance of these findings for social work practice with LGB older adults and for social work education, as well as implications for future research.

Caregiving preferences and advance care planning among older adults living with HIV

With the increase in the US of the number of older adults living with HIV, more research is needed to understand the caregiving and advance care planning needs of this population. This descriptive study examined the relationship between social support and caregiving preferences and advance care planning. Older adults living with HIV were recruited from clinics in Los Angeles, CA and New Orleans, LA to complete cross-sectional surveys (n = 154). Logistic regression analyses were modeled to determine the characteristics associated with 1) preference for formal short-term term care, 2) preference for formal long-term care, 3) having at least one contact for emergency care, 4) having an advance directive or living will, and 5) having a healthcare proxy or agent. The mean age was 56.8 years. The majority of participants indicated a preference for informal support for both short-term (73.4%) and long-term care (66.2%), 13.2% had no one they could call for emergency care, 26.0% had an advance directive/living will, and 30.5% had a healthcare proxy/agent. In adjusted models, greater social support was associated with preference for informal short-term care and with having at least one emergency contact. Findings suggest that older adults living with HIV prefer informal sources of support for their caregiving needs despite having small social networks and individuals with limited social networks are particularly vulnerable due to lack of access to caregivers in sudden or unexpected health situations.

Australian doctors' knowledge of and compliance with the law relating to end-of-life decisions: implications for LGBTI patients

In most developed countries, competent patients have the legal right to refuse any medical treatment; Advance Care Planning mechanisms extend this right to non-competent patients. However, some groups, including lesbian, gay, bisexual, transgender and intersex (LGBTI) people, risk their wishes not being respected if they lose capacity, more than others. Little is known about medical practitioners' knowledge of, or attitudes to, the law in this area, especially in relation to LGBTI people, or how the law influences their decision-making. An Australian postal survey explored knowledge and attitudes of medical specialists to legal issues relating to withdrawing/ withholding life-sustaining treatment from adults without capacity. One scenario (the focus of this paper) asked which of four plausible substitute decision-makers, including a same-sex partner, had the legal authority to make such decisions. The overall response rate was 32% (867/2702). Less than one-third of respondents correctly identified the same-sex partner as the legally authorised decision-maker. LGBTI people face multiple obstacles to having their end-of-life wishes respected. Where healthcare providers are also ignorant of the partner's legal right to make such decisions, the problem is compounded. Improved legal education for clinicians and promotion of educational resources for members of the LGBTI community is needed.

Barriers to End-of-Life Care for LGBT Persons in the Absence of Legal Marriage or Adequate Legal Documentation

End-of-life care has attracted increased attention in recent years due to increases in both the number and mean age of the world's population; however, the experiences of LGBT persons during end-of-life care remain understudied. Given the health disparities and barriers to care experienced throughout the life course of LGBT persons, the frequent involvement of legal spouses in end-of-life care, and the recency of marriage equality, it can be surmised that LGBT persons might experience significantly different barriers to their desired end-of-life care compared to their heterosexual and cisgender counterparts. This article aims to synthesize what is known about these barriers, particularly in the absence of legal marriage or protective legal documentation. Of two hundred and twelve articles reviewed, twenty-three were included for analysis. Common barriers that emerged were discriminatory laws (e.g., prohibitions against same-sex marriage) and policies, lack of decision-making capacity, lack of knowledge regarding patient wishes, lack of visitation rights, challenges from biological next of kin, and discrimination and psychological distress. Recommendations for future research are provided based on gaps that were identified. These include increased research on transgender persons and bisexual persons, and on providers of end-of-life care. In addition, the recommendations take into account that important legislative and policy changes occurred after the period in which the studies reviewed here were published. The impact of those changes cannot be reported in this study and should be determined by future studies. This synthesis provides the contextual understanding necessary for research and improvement in this vastly understudied area.

Palliative and End-of-Life Care for Lesbian, Gay, Bisexual, and Transgender (LGBT) Cancer Patients and Their Caregivers

OBJECTIVE

To identify the unique needs of lesbian, gay, bisexual, and transgender (LGBT) cancer patients and caregivers, and review recommendations supporting more effective and inclusive palliative and end-of-life care.

DATA SOURCES

Published research and clinical guidelines.

CONCLUSION

Transitions in care raise particular challenges for LGBT patients, including provider communication, perceptions of safety and acceptance, and assessing and respecting patients' definitions of family and spirituality.

IMPLICATIONS FOR NURSING PRACTICE

LGBT patients and their caregivers need competent nurses to support them, especially during transitions. Implementing LGBT-inclusive education, training, and practice will improve outcomes for LGBT cancer patients and their caregivers - and potentially all patients.

Lesbian, gay, bisexual and transgender people's attitudes to end-of-life decision-making and advance care planning

AIM

To examine lesbian, gay, bisexual and transgender (LGBT) people's attitudes to advance care planning (ACP) options and alternative decision-making at the end of life.

METHOD

Three hundred and five LGBT people completed an online or paper-based questionnaire, comprising fixed-choice questions and open-ended questions.

RESULTS

Most respondents, particularly those identifying as female or transgender, preferred a partner to be their alternative decision-maker at the end of life should the need arise. Fifty-two per cent of respondents had spoken to this person about their wishes. Regarding legal options enabling end-of-life decision-making, 29% had an enduring power of attorney, 18% an enduring guardian and 12% an advance care directive.

CONCLUSION

Despite the significance of ACP for promoting the rights of LGBT people at the end of life, the take-up of these options was nearly as low as for the general population. The potential for targeted strategies to increase the take-up of ACP is identified.

The diverse impact of advance care planning: a long-term follow-up study on patients' and relatives' experiences

BACKGROUND

Advance care planning (ACP) is a process of discussing and recording patients' preferences for future care, aiming to guide healthcare decisions at the end of life (EOL).

AIM

To explore nuances in the long-term impact of ACP by studying patient and relative experiences.

DESIGN

A qualitative follow-up interview study. Interviews were recorded, transcribed and analysed using thematic synthesis.

SETTING/PARTICIPANTS

3 patients with a life-limiting disease (lung or heart disease), affiliated with a major Danish hospital, and 7 relatives were interviewed 1 year after participating in an ACP discussion.

RESULTS

The experiences were diverse. Some patients and relatives felt 'relieved', 'more secure' and more in control due to ACP. To some, ACP had led to open communication rather than 'beating around the bush', and to spending more quality time together. However, others perceived ACP as irrelevant. Some stated that the patient's wishes had not been met regardless of ACP. Others felt that EOL questions cannot be realistically considered until 'you're in the middle of it', because many factors are involved. In one case, participating in ACP led to a patient-relative conflict, resulting in EOL issues being 'tucked away'.

CONCLUSIONS

The study reveals great diversity in patient and relative experiences of ACP. The study challenges previous research which mainly emphasises ACP as a valuable tool to optimise EOL care. This study stresses the importance of awareness of the highly individual nature of preferences and needs of patients and relatives regarding information, involvement and communication about EOL care.

Social Work Practice with LGBT Elders at End of Life: Developing Practice Evaluation and Clinical Skills Through a Cultural Perspective

This article focuses on culturally sensitive clinical issues related to best practices with lesbian, gay, bisexual, transgender (LGBT) elder patients at end-of-life (EOL) at key points in the therapeutic relationship. Vital concepts, including practice evaluation and clinical skills, are presented through a cultural and oncology lens. There is a paucity of LGBT research and literature as well as a shortfall of MSW graduate school education specific to social work palliative and end-of-life care (PELC) practice with LGBT elders. The content of this article is designed to be adapted and used as an educational tool for institutions, agencies, graduate programs, medical professions, social work, and students. Learning the unique elements of LGBT cultural history and their implications on EOL care can improve social work practice. This article provides an examination from assessment and engagement basics to advance care planning incorporating specific LGBT EOL issues.

LGBT people's knowledge of and preparedness to discuss end-of-life care planning options

Despite the devastating impact of HIV/AIDS, end-of-life care planning among lesbian, gay, bisexual and transgender (LGBT) communities is relatively under-researched, especially in Australia. This paper reports findings of a survey of 305 LGBT people living in New South Wales, which examined their knowledge of and attitudes towards end-of-life care. The focus of this paper is their preparedness to discuss with healthcare providers any end-of-life care plans. The results highlight that while the majority of respondents were aware of three of the four key end-of-life care planning options available in New South Wales--enduring powers of attorney, enduring guardians and person responsible (only a minority had heard of advance healthcare directives)--a much smaller number of people had actually taken up these options. Only a minority of respondents were able to identify correctly who had the legal right to make treatment decisions for a person who is unconscious following a car accident. A small proportion of people had discussed end-of-life care options with general practitioners or another main healthcare provider, and only in very few cases were these issues raised by the practitioners themselves. Those most likely to not feel comfortable discussing these issues with practitioners included younger people, those not fully open about their sexuality to family members, and transgender people and others who do not define their gender as male or female. The paper highlights the importance of education strategies to raise awareness of the end-of-life care planning options among LGBT people, as well as strategies for increasing health providers' preparedness to discuss these issues with LGBT patients.

Older lesbians and bereavement: experiencing the loss of a partner

There is very little research focused on older bereaved lesbians. This study is a response to the lack of knowledge about the issues for older lesbians who lose a partner. We examined bereavement issues for 55 older lesbians. The study asked participants to describe their concerns and experiences after losing a partner. Qualitative analysis identified several themes that ran throughout, including disenfranchised grief, the loneliness of isolation, and the frustration of relentless battles. These findings indicate the need for social workers to educate themselves and others about the particular needs facing this vulnerable group of older women.

Social care networks and older LGBT adults: challenges for the future

Research on service needs among older adults rarely addresses the special circumstances of lesbian, gay, bisexual, and transgender (LGBT) individuals, such as their reliance on friend-centered social networks or the experience of discrimination from service providers. Limited data suggests that older LGBT adults underutilize health and social services that are important in maintaining independence and quality of life. This study explored the social care networks of this population using a mixed-methods approach. Data were obtained from 210 LGBT older adults. The average age was 60 years, and 71% were men, 24% were women, and 5% were transgender or intersex. One-third was Black, and 62% were Caucasian. Quantitative assessments found high levels of morbidity and friend-centered support networks. Need for and use of services was frequently reported. Content analysis revealed unmet needs for basic supports, including housing, economic supports, and help with entitlements. Limited opportunities for socialization were strongly expressed, particularly among older lesbians. Implications for senior programs and policies are discussed.

Religion and Spirituality as Important Components of Men’s Health and Wellness

Men’s health has been receiving increased attention in health care research and practice because of associated negative outcomes and men’s reluctance to seek help. Religion or religiosity, defined as involvement in an organized, structured community focused on moral code, and spirituality, defined as the subjective, mystical, and holistic interpretation of personal beliefs and behaviors, have been associated with positive health outcomes. Specifically, religion and spirituality mediate an increase in positive health outcomes and a decrease in risk factors through social and existential well-being. However, men seem to be less religious and spiritual compared with women, a potential problem as men may be missing an important pathway to health and wellness. This state-of-the-art review examines the intersections of religion, spirituality, and health and focuses on how religion and spirituality relate specifically to men’s health and health behaviors. Subsequently, 4 health problems with religious and spiritual implications are examined that have been identified in the literature as pertinent to men’s health: (a) prostate cancer screening and coping, (b) HIV/AIDS prevention and coping, (c) addictions, and (d) palliative care. Finally, suggestions are offered for clinicians to incorporate an understanding of religion and spirituality into their patient encounters.

End-of-life care for gay, lesbian, bisexual and transgender people

There is little understanding in Australia of the special issues faced by gay, lesbian, bisexual and transgender people in end-of-life care and advance care planning. This exploratory study aimed to achieve an initial understanding of these issues to inform the development of a larger study involving gay, lesbian, bisexual and transgender service users. Consultations were carried out with 19 service providers and 6 gay, lesbian, bisexual and transgender community members in the Northern Rivers and metropolitan Sydney areas of New South Wales, Australia. Participants reported barriers to health care service access due to discrimination, inappropriate care and lack of knowledge among both consumers and health care workers of legal rights at the end of life. While advance care planning can assist with improving end-of-life care, respondents reported a number of obstacles. These included a lack of knowledge and absence of perceived need and the additional obstacle of social isolation, leading to difficulties identifying alternative decision-makers. The study highlighted the need for education for gay, lesbian, bisexual and transgender people and health and aged care providers on existing legal provisions to prevent discrimination in end-of-life care.

Spiritual dimensions of surgical palliative care

The spiritual dimensions of surgical palliative care encompass recognition of mortality (physician and patient); knowledge of moral and ethical dilemmas of medical decision making; respect for each individual and for all belief systems; responsibility to remain physically and psychologically present for the patient and family; and knowledge of when chaplains, palliative care professionals, or social workers should be consulted. Certain aspects of surgical palliative care distinguish it from palliative care in other medical disciplines such as the 2 definitions (palliative procedure and palliative care), treating a disproportionate share of patients who suffer unforeseen tragic events, and the surgical system.

Artificial nutrition and hydration at the end of life

Considerable controversy surrounds the issue of care at the end of life (EOL) for older adults. Technological advances and the legal, ethical, clinical, religious, cultural, personal, and fiscal considerations in the provision of artificial hydration and nutrition support to older adults near death are presented in this comprehensive review.

Silent Voices and Invisible Walls

The needs and desires of lesbians and gay men with cancer at the end of their lives are not fundamentally different from any other dying individual's needs. There are, however, significant legal restrictions and societal attitudes that can negatively affect the dying experiences of lesbians and gay men. Lesbians and gay men face many challenges at the end of their lives, including issues of disclosure in the healthcare setting, discrimination, misconceptions, legal and financial barriers and the disenfranchised grief of surviving same-sex partners. Oncology social workers can play a prominent role in advocating for these individuals to allow for dignity and support in spite of these barriers and provide effective interventions to help in assisting lesbians and gaymen with healthcare decision-making and end-of-life care planning.

Promoting Effective Social Work Policy in End-of-Life and Palliative Care

Policy developments in the health care arena in general, and in end-of-life and palliative care in particular, strongly influence the practice environment for the delivery of hospice and palliative care services and the diverse roles of social work practitioners. This article analyzes policy developments in two crucial areas-ethics and law and disenfranchisement and health disparities. It focuses on the recent social work literature and other key sources and provides recommendations to promote the roles of social workers in ethics consultation, public policy, and advocacy and to integrate better the perspectives and concerns of diverse communities into palliative care practice, education, and policy.

Social work competencies in palliative and end-of-life care

Social workers from clinical, academic, and research settings met in 2002 for a national Social Work Leadership Summit on Palliative and End-of-Life Care. Participants placed the highest priority on the development and broad dissemination of a summary document of the state-of-the-art practice of social work in palliative and end-of-life care. Nine Summit participants reviewed the literature and constructed this detailed description of the knowledge, skills, and values that are requisite for the unique, essential, and appropriate role of social work. This comprehensive statement delineates individual, family, group, team, community, and organizational interventions that extend across settings, cultures, and populations and encompasses advocacy, education, training, clinical practice, community organization, administration, supervision, policy, and research. This document is intended to guide preparation and credentialing of professional social workers, to assist interdisciplinary colleagues in their collaboration with social workers, and to provide the background for the testing of quality indicators and "best practice" social work interventions.

Sexuality at the end of life

There is very little research literature that addresses sexuality at the end of life. Although end-of-life care has become a priority for nursing education, the issue of end-of-life sexuality is not included in the curriculum. Nurses are frequently in a position to establish relationships with couples that encourage a frank discussion and information sharing. As patient advocates, nurses can address end-of-life sexuality issues by taking a sexual history and implementing a general intervention model, such as the PLISSIT. Couples need to be reassured that if they have enjoyed a close sexual relationship, sexual intimacy may continue to be part of their relationship, even at the end of life.