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Shen MJ, Cho S, De Los Santos C, Yarborough S, Maciejewski PK, Prigerson HG. Planning for Your Advance Care Needs (PLAN): A Communication Intervention to Improve Advance Care Planning among Latino Patients with Advanced Cancer. Cancers (Basel) 2023; 15:3623. [PMID: 37509284 PMCID: PMC10377387 DOI: 10.3390/cancers15143623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/02/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The goal of this study was to develop and optimize an intervention designed to address barriers to engagement in advance care planning (ACP) among Latino patients with advanced cancer. The resulting intervention, titled Planning Your Advance Care Needs (PLAN), is grounded in theoretical models of communication competence and sociocultural theory. MATERIALS AND METHODS An initial version of the PLAN manual was developed based on a prior intervention, Ca-HELP, that was designed to improve communication around pain among cancer patients. PLAN uses this framework to coach patients on how to plan for and communicate their end-of-life care needs through ACP. In the present study, feedback was obtained from key stakeholders (n = 11 patients, n = 11 caregivers, n = 10 experts) on this preliminary version of the PLAN manual. Participants provided ratings of acceptability and feedback around the intervention content, format, design, modality, and delivery through quantitative survey questions and semi-structured qualitative interviews. RESULTS Results indicated that the PLAN manual was perceived to be helpful and easy to understand. All stakeholder groups liked the inclusion of explicit communication scripts and guidance for having conversations about ACP with loved ones and doctors. Specific feedback was given to modify PLAN to ensure it was optimized and tailored for Latino patients. Some patients noted reviewing the manual motivated engagement in ACP. CONCLUSIONS Feedback from stakeholders resulted in an optimized, user-centered version of PLAN tailored to Latino patients. Future research will examine the acceptability, feasibility, and potential efficacy of this intervention to improve engagement in ACP.
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Affiliation(s)
- Megan J. Shen
- Division of Clinical Research, Fred Hutchinson Cancer Center, 1100 Fairview Ave. N., Mail Stop D5-290, Seattle, WA 98109, USA; (C.D.L.S.); (S.Y.)
| | - Susie Cho
- School of Nursing, University of Washington, Seattle, WA 98195, USA;
| | - Claudia De Los Santos
- Division of Clinical Research, Fred Hutchinson Cancer Center, 1100 Fairview Ave. N., Mail Stop D5-290, Seattle, WA 98109, USA; (C.D.L.S.); (S.Y.)
| | - Sarah Yarborough
- Division of Clinical Research, Fred Hutchinson Cancer Center, 1100 Fairview Ave. N., Mail Stop D5-290, Seattle, WA 98109, USA; (C.D.L.S.); (S.Y.)
| | - Paul K. Maciejewski
- Department of Radiology, Weill Cornell Medical College, New York, NY 10065, USA;
| | - Holly G. Prigerson
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA;
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Torres-Blasco N, Castro-Figueroa EM, Zamore C, Claros M, Peña-Vargas C, Rosario L, Sanabria G, Breitbart W, Costas-Muñiz R. Family functioning and psychosocial symptoms among Latinx patients coping with advanced cancer. Palliat Support Care 2023; 21:461-464. [PMID: 36098498 PMCID: PMC10008749 DOI: 10.1017/s1478951522001201] [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: 01/05/2023]
Abstract
OBJECTIVES This brief report aims to describe and determine the association of family functioning (e.g., cohesion and expressiveness) with psychosocial needs among Spanish Latinx patients coping with advanced cancers. METHODS Descriptive and correlation analyses were performed on data from 103 patients coping with advanced cancer (Stages III and IV). The measures used were the Family Relationships Index, the Hospital Anxiety and Depression Scale, and the Functional Assessment of Cancer Therapy: General. RESULTS Results indicated that most of the participants had low family function (65%). Participants with higher family functioning (35%) had high levels of quality of life [r(103) .318, p < .002]. A higher level of quality of life was also strongly associated with lower levels of anxiety [r(95) -.653, p < .000], lower levels of depression [r(95) -.733, p < .000], and lower levels of hopelessness [r(95) -.585, p = .000]. A total of 22.3% of Latinx advanced cancer patients reported poor cohesiveness; those with low cohesiveness also had higher levels of depression [r(103) -.28, p = .004] and anxiety [r(103) -.27, p = .005]. Correlations between expressiveness and hopelessness were significant; namely, those with higher expressiveness had lower hopelessness [r(103) -.274, p = .005]. SIGNIFICANCE OF RESULTS Findings present a high correlation between family functioning and psychosocial symptoms.
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Affiliation(s)
- Normarie Torres-Blasco
- School of Behavioral and Brain Sciences, Ponce Research Institute, Ponce Health Sciences University, Ponce, PR, USA
| | - Eida M Castro-Figueroa
- Department of Psychiatry and Human Behavior, School of Behavioral and Brain Sciences, Ponce Research Institute, Ponce Health Sciences University, New York, NY, USA
| | - Carolina Zamore
- Immigrant Health and Cancer Disparities, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Maria Claros
- Immigrant Health and Cancer Disparities, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Cristina Peña-Vargas
- Department of Psychiatry and Human Behavior, Ponce Research Institute, Ponce Health Sciences University, Ponce, PR, USA
| | - Lianel Rosario
- School of Behavioral and Brain Sciences, Ponce Health Sciences University, Ponce, PR, USA
| | - Gabriella Sanabria
- Community and Family Health, College of Public Health, University of South Florida
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Rosario Costas-Muñiz
- Department of Psychiatry and Behavioral Sciences, Immigrant Health and Cancer Disparities, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Torres-Blasco N, Costas-Muñiz R, Zamore C, Porter L, Claros M, Bernal G, Shen MJ, Breitbart W, Rosario L, Peña-Vargas C, Castro-Figueroa EM. Family as a Bridge to Improve Meaning in Latinx Individuals Coping with Cancer. Palliat Med Rep 2022; 3:186-193. [PMID: 36203712 PMCID: PMC9531875 DOI: 10.1089/pmr.2022.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Family and meaning-making resources are culturally congruent and help support Latinx coping with cancer. Objectives: To explore Latinx advanced cancer patients' perspectives on the role of family and meaning/purpose in adjustment to advanced cancer. Methods: A qualitative study was conducted. In-depth interviews were performed and transcripts were analyzed using the method from applied thematic analysis. Setting/Subject: Participants were patients with any advanced cancer diagnosis, recruited from Memorial Sloan Kettering Cancer Center (MSKCC), New York; Lincoln Medical Center (LMC), New York; and Ponce Health Science University (PHSU), Puerto Rico. Measurements: Sociodemographic and semistructured interview. Results: N = 24 in-depth interviews were completed by Latinx advanced cancer patients (Stage III and IV). When evaluating patients' perspectives on the role of family and meaning/purpose in adjustment to advanced cancer, the team generated three categories: (1) family support, (2) family communication, and (3) include support for the family. Many patients reported the importance of family as a source of meaning and social support in the process of cancer diagnosis and treatment. They also reported communication as central to process information and planning. Also, participants describe their desire to incorporate family members into therapy and for encouraging them to seek counseling. Conclusions: Results highlight the need to include syntonic cultural values such as family and meaning for Latinx individuals coping with advanced cancer in psychological interventions.
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Affiliation(s)
- Normarie Torres-Blasco
- Department of Psychiatry and Human Behavior, School of Behavioral and Brain Science, Ponce Research Institute, Ponce Health Sciences University, Ponce, Puerto Rico
| | - Rosario Costas-Muñiz
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, Immigrant Health & Cancer Disparities, New York, New York, USA
| | - Carolina Zamore
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, Immigrant Health & Cancer Disparities, New York, New York, USA
| | - Laura Porter
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Maria Claros
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, Immigrant Health & Cancer Disparities, New York, New York, USA
| | - Guillermo Bernal
- Caribbean Alliance of National Psychological Associations, San Juan, Puerto Rico
| | - Megan J. Shen
- Division of Geriatrics and Palliative Medicine, Department of Medicine, New York, New York, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, Immigrant Health & Cancer Disparities, New York, New York, USA
| | - Lianel Rosario
- Department of Psychiatry and Human Behavior, School of Behavioral and Brain Science, Ponce Research Institute, Ponce Health Sciences University, Ponce, Puerto Rico
| | - Cristina Peña-Vargas
- Department of Psychiatry and Human Behavior, School of Behavioral and Brain Science, Ponce Research Institute, Ponce Health Sciences University, Ponce, Puerto Rico
| | - Eida M. Castro-Figueroa
- Department of Psychiatry and Human Behavior, School of Behavioral and Brain Science, Ponce Research Institute, Ponce Health Sciences University, Ponce, Puerto Rico
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4
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Torres Blasco N, Costas Muñiz R, Zamore C, Porter L, Claros M, Bernal G, Shen MJ, Breitbart W, Castro EM. Cultural adaptation of meaning-centered psychotherapy for latino families: a protocol. BMJ Open 2022; 12:e045487. [PMID: 35379609 PMCID: PMC8981324 DOI: 10.1136/bmjopen-2020-045487] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Literature suggests couple-based interventions that target quality of life and communication can lead to positive outcomes for patients with cancer and their partners. Nevertheless, to date, an intervention to address the needs of Latino families coping with advanced cancer has not been developed. Meta-analytic evidence suggests that culturally adapted evidenced-based intervention targeting a specific cultural group is four times more effective. Our goal is to culturally adapt a novel psychosocial intervention protocol entitled 'Caregivers-Patients Support to Latinx coping advanced-cancer' (CASA). We hypothesised that combine two evidence-based interventions and adapting them, we will sustain a sense of meaning and improving communication as patients approach the end of life among the patient-caregiver dyad. METHODS AND ANALYSIS To culturally adapt CASA, we will follow an innovative hybrid research framework that combines elements of an efficacy model and best practices from the ecological validity model, adaptation process model and intervention mapping. As a first step, we adapt a novel psychosocial intervention protocol entitled protocol entitled 'Caregivers-Patients Support to Latinx coping advanced-cancer' (CASA). The initial CASA protocol integrates two empirically based interventions, meaning-centred psychotherapy and couple communication skills training. This is an exploratory and prepilot study, and it is not necessary for a size calculation. However, based on recommendations for exploratory studies of this nature, a priori size of 114 is selected. We will receive CASA protocol feedback (phase 1b: refine) by conducting 114 questionnaires and 15 semistructured interviews with patients with advanced cancer and their caregivers. The primary outcomes of this study will be identifying the foundational information needed to further the develop the CASA (phase IIa: proof-of-concept and phase IIb: pilot study). ETHICS AND DISSEMINATION The Institutional Review Board of Ponce Research Institute approved the study protocol #1907017527A002. Results will be disseminated through peer-reviewed publications.
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Affiliation(s)
| | - Rosario Costas Muñiz
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Carolina Zamore
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Laura Porter
- Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina, USA
| | - Maria Claros
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Guillermo Bernal
- Professor of Psychology (Retired), Universidad de Puerto Rico, San Juan, Puerto Rico
| | | | - William Breitbart
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - E M Castro
- SBBS, Ponce Health Sciences University, Ponce, Puerto Rico
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5
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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: 6] [Impact Index Per Article: 2.0] [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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Anderson GT. Let's Talk About ACP Pilot Study: A Culturally-Responsive Approach to Advance Care Planning Education in African-American Communities. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2021; 17:267-277. [PMID: 34605361 DOI: 10.1080/15524256.2021.1976354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The COVID-19 Pandemic has emphasized the importance of attending to racial inequity in end-of-life care, as the world has witnessed the disproportionate negative impact on Black and Brown people and communities. Advance care planning (ACP) is of particular concern for this population. This article introduces an ACP toolkit developed as a culturally responsive educational approach to assist African-American faith leaders to inform and educate congregants on end-of-life care options and the process to complete advance care documents. The purpose of this article is to describe the development of The Let's Talk about ACP toolkit and to discuss the results of the pilot study workshop. The procedures of the pilot study included a critical evaluation of an innovative curriculum and workshop process for engaging African Americans around advocacy for the healthcare experience they prefer. Factors such as cultural, generational, and spiritual beliefs and values influenced decision-making. Distrust was one of the most prominent factors raised by participants. Providing resources and tools that encompass culturally responsive approaches to educate and encourage use can help bridge the gap. The next steps for this innovative practice approach is to refine the practice approach and replicate the finding among larger community settings.
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Affiliation(s)
- Gloria T Anderson
- School of Social Work, North Carolina State University, Raleigh, North Carolina, USA
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7
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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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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: 63] [Impact Index Per Article: 21.0] [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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Barker PC, Holland NP, Shore O, Cook RL, Zhang Y, Warring CD, Hagen MG. The Effect of Health Literacy on a Brief Intervention to Improve Advance Directive Completion: A Randomized Controlled Study. J Prim Care Community Health 2021; 12:21501327211000221. [PMID: 33719708 PMCID: PMC7968018 DOI: 10.1177/21501327211000221] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Completion of an advance directive (AD) document is one component of advanced care planning. We evaluated a brief intervention to enhance AD completion and assess whether the intervention effect varied according to health literacy. METHODS A randomized controlled study was conducted in 2 internal medicine clinics. Participants were over 50, without documented AD, no diagnosis of dementia, and spoke English. Participants were screened for health literacy utilizing REALM-SF. Participants were randomized in a 1:1 ratio to the intervention, a 15-minute scripted introduction (grade 7 reading level) to our institution's AD forms (grade 11 reading level) or to the control, in which subjects were handed blank AD forms without explanation. Both groups received reminder calls at 1, 3, and 5 months. The primary outcome was AD completion at 6 months. RESULTS Five hundred twenty-nine subjects were enrolled; half were of limited and half were of adequate health literacy. The AD completion rate was 21.7% and was similar in the intervention vs. the control group (22.4% vs 22.2%, P = .94).More participants with adequate health literacy completed an AD than those with limited health literacy (28.4% vs 16.2%, P = .0008), although the effect of the intervention was no different within adequate or limited literacy groups. CONCLUSION A brief intervention had no impact on AD completion for subjects of adequate or limited health literacy. PRACTICE IMPLICATIONS Our intervention was designed for easy implementation and to be accessible to patients of adequate or limited health literacy. This intervention was not more likely than the control (handing patients an AD form) to improve AD completion for patients of either limited or adequate health literacy. Future efforts and research to improve AD completion rates should focus on interventions that include: multiple inperson contacts with patients, contact with a trusted physician, documents at 5th grade reading level, and graphic/video decision aids. TRIAL REGISTRATION NUMBER NCT02702284, Protocol ID IRB201500776.
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Affiliation(s)
| | | | | | | | - Yang Zhang
- University of Florida, Gainesville, FL, USA
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10
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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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Barwise A, Balls-Berry J, Soleimani J, Karki B, Barrett B, Castillo K, Kreps S, Kunkel H, Vega B, Erwin P, Espinoza Suarez N, Wilson ME. Interventions for End of Life Decision Making for Patients with Limited English Proficiency. J Immigr Minor Health 2020; 22:860-872. [PMID: 31749066 PMCID: PMC7706216 DOI: 10.1007/s10903-019-00947-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Patients with limited English proficiency (LEP) experience disparities in end-of-life decision making and advance care planning. Our objective was to conduct a systematic review to assess the literature about interventions addressing these issues. Our search strategy was built around end-of-life (EOL), LEP, ACP, and goals of care. The databases included Ovid MEDLINE(R), and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily from 1946 to November 9, 2018, Ovid EMBASE. Eight studies from the US and Australia were included (seven studies in Spanish and one study in Greek and Italian). Interventions used trained personnel, video images, web-based programs, and written materials. Interventions were associated with increased advance directive completion and decreased preferences for some life-prolonging treatments. Interventions were deemed to be feasible and acceptable. Few interventions exist to improve end-of-life care for patients with LEP. Data are limited regarding intervention effectiveness.
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Affiliation(s)
- Amelia Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Joyce Balls-Berry
- Office for Community Engagement in Research, Center for Clinical and Translational Science, Division of Epidemiology, Mayo Clinic, Rochester, MN, USA
| | - Jalal Soleimani
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Bibek Karki
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | | | - Samantha Kreps
- Health Sciences, University of Minnesota, Rochester, MN, USA
| | - Hilary Kunkel
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Beatriz Vega
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Patricia Erwin
- Department of Education Administration, Rochester, MN, USA
| | | | - Michael E Wilson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Knowledge Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
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12
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Nouri SS, Barnes DE, Volow AM, McMahan RD, Kushel M, Jin C, Boscardin J, Sudore RL. Health Literacy Matters More Than Experience for Advance Care Planning Knowledge Among Older Adults. J Am Geriatr Soc 2019; 67:2151-2156. [PMID: 31424575 DOI: 10.1111/jgs.16129] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/02/2019] [Accepted: 07/13/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Advance care planning (ACP) engagement is low among vulnerable populations, including those with limited health literacy (LHL). Limited knowledge about ACP may be a modifiable mediator of the relationship between LHL and ACP. Our goal was to determine whether health literacy is associated with ACP knowledge. DESIGN Cross-sectional design. SETTING A public health delivery system and Veterans Affairs Medical Center in San Francisco, CA. PARTICIPANTS English- and Spanish-speaking patients (N = 1400). MEASUREMENTS ACP knowledge was assessed with seven validated multiple-choice questions. Health literacy was measured using a validated scale. Sociodemographic measures included age, sex, language, education, race, health status, and social support. Prior ACP experience was defined as having documented legal forms and/or goals-of-care discussions in the medical record. We used Kruskal-Wallis tests and linear regression to examine associations of ACP knowledge with LHL, prior ACP experience, and sociodemographic factors. RESULTS Mean age of participants was 65 (±10) years, 48% were women, 34% had LHL, 32% were Spanish speaking, 47% had high school education or less, and 70% were nonwhite. Mean 7-point knowledge scores were lower for those with limited vs adequate health literacy (3.8 [SD = 1.9 vs 5.5 (SD = 1.7); P < .001). In multivariable analysis, ACP knowledge scores were 1.0 point lower among those with LHL; 0.6 points lower among Spanish speakers and those with high school education or less; and 0.5 points lower among individuals of nonwhite race (P < .001 for all). Knowledge scores were 0.02 points lower per year of older age (P = .007) and 0.01 points higher per point of greater social support (P = .005). Prior ACP experience was not associated with knowledge after adjustment (P = .7). CONCLUSIONS Health literacy and sociodemographics are stronger predictors than prior ACP experience of ACP knowledge. This study suggests that providing easy-to-understand ACP materials is paramount and should be offered even if patients have previous experience with the ACP process. J Am Geriatr Soc 67:2151-2156, 2019.
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Affiliation(s)
- Sarah S Nouri
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Deborah E Barnes
- Department of Psychiatry, University of California, San Francisco, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Division of Geriatrics, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California.,Innovation and Implementation Center in Aging and Palliative Care Research), University of California, San Francisco, San Francisco, California
| | - Aiesha M Volow
- Division of Geriatrics, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California.,Innovation and Implementation Center in Aging and Palliative Care Research), University of California, San Francisco, San Francisco, California.,Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Ryan D McMahan
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Margot Kushel
- Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California.,Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California
| | - Chengshi Jin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - John Boscardin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Innovation and Implementation Center in Aging and Palliative Care Research), University of California, San Francisco, San Francisco, California
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California.,Innovation and Implementation Center in Aging and Palliative Care Research), University of California, San Francisco, San Francisco, California.,Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California
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13
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Attitudes and completion of advance care planning: Assessing the contribution of health beliefs about Alzheimer's disease among Israeli laypersons. Palliat Support Care 2019; 17:655-661. [DOI: 10.1017/s1478951519000336] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectivesThe purpose of this study was to assess laypersons’ attitudes and completion of advance care planning (ACP) and to examine associations with sociodemographic characteristics and health beliefs on Alzheimer's disease.MethodsA cross-sectional telephone survey was conducted during April and May 2017, with a sample of 514 Israeli adults, aged 18 years and above. A structured, pretested questionnaire assessing participants’ awareness, attitudes, and completion of ACP, as well as health beliefs on Alzheimer's disease (subjective knowledge, susceptibility, and worry), and sociodemographic factors, was used.ResultsTwo-fifths of the participants had heard of at least one of the terms: advance directives or durable power of attorney. Overall, participants expressed positive attitudes toward ACP. Results of regression models showed that gender, religiosity, and subjective knowledge of Alzheimer's disease were statistically significant correlates of attitudes toward ACP. Adding health beliefs on Alzheimer's disease doubled the amount of the variance explained, from 3% to 6%.Significance of resultsOur results support the use of cognitive models of health behavior by assessing intra-personal beliefs and knowledge to understand ACP attitudes and completion. Specifically, we demonstrated the importance of knowledge of Alzheimer's disease for ACP attitudes, suggesting the importance of including a module on the topic to ACP interventions.
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14
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Maldonado LY, Goodson RB, Mulroy MC, Johnson EM, Reilly JM, Homeier DC. Wellness in Sickness and Health (The W.I.S.H. Project): Advance Care Planning Preferences and Experiences Among Elderly Latino Patients. Clin Gerontol 2019; 42:259-266. [PMID: 29206578 DOI: 10.1080/07317115.2017.1389793] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To assess advance care planning (ACP) preferences, experiences, and comfort in discussing end-of-life (EOL) care among elderly Latinos. METHODS Patients aged 60 and older from the Los Angeles County and University of Southern California (LAC+USC) Medical Center Geriatrics Clinic (n = 41) participated in this intervention. Trained staff conducted ACP counseling with participants in their preferred language, which included: (a) pre-counseling survey about demographics and EOL care attitudes, (b) discussion of ACP and optional completion of an advance directive (AD), and (c) post-session survey. RESULTS Patients were primarily Spanish speaking with an average of 2.7 chronic medical conditions. Most had not previously documented (95%) or discussed (76%) EOL wishes. Most were unaware they had control over their EOL treatment (61%), but valued learning about EOL options (83%). Post-counseling, 85% reported comfort discussing EOL goals compared to 66% pre-session, and 88% elected to complete an AD. Nearly half of patients reported a desire to discuss EOL wishes sooner. CONCLUSIONS Elderly Latino patients are interested in ACP, given individualized, culturally competent counseling in their preferred language. CLINICAL IMPLICATIONS Patients should be offered the opportunity to discuss and document EOL wishes at all primary care appointments, regardless of health status. Counseling should be completed in the patient's preferred language, using culturally competent materials, and with family members present if this is the patient's preference. Cultural-competency training for providers could enhance the impact of EOL discussions and improve ACP completion rates for Latino patients.
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Affiliation(s)
- Lauren Y Maldonado
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA
| | - Ruth B Goodson
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA
| | - Matthew C Mulroy
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA
| | - Emily M Johnson
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA.,b Department of Family Medicine, LAC+USC Medical Center , Los Angeles , California , USA
| | - Jo M Reilly
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA.,b Department of Family Medicine, LAC+USC Medical Center , Los Angeles , California , USA
| | - Diana C Homeier
- a Keck School of Medicine of the University of Southern California , Los Angeles , California , USA.,c Department of Family Medicine and Geriatrics Clinic, LAC+USC Medical Center , Los Angeles , California , USA
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15
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Partain DK, Sanders JJ, Leiter RE, Carey EC, Strand JJ. End-of-Life Care for Seriously Ill International Patients at a Global Destination Medical Center. Mayo Clin Proc 2018; 93:1720-1727. [PMID: 30522592 DOI: 10.1016/j.mayocp.2018.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 06/27/2018] [Accepted: 08/14/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To characterize the end-of-life care of all international patients who died at a global destination medical center from January 1, 2005, through December 31, 2015. PATIENTS AND METHODS We performed a retrospective review of all adult international patients who died at a global destination medical center from January 1, 2005, through December 31, 2015. RESULTS Eighty-two international patients from 25 countries and 5 continents died during the study period (median age, 59.5 years; 59% male). Of the study cohort, 11% (n=9) completed an advance directive, 61% (n=50) died in the intensive care unit, 26% (n=21) had a full code order at the time of death, and 73% (n=19 of 26) receiving cardiopulmonary resuscitation did not survive the resuscitation process. CONCLUSION Seriously ill international patients who travel to receive health care in the United States face many barriers to receiving high-quality end-of-life care. Seriously ill international patients are coming to the United States in increasing numbers, and little is known about their end-of-life care. There are many unique needs in the care of this complex patient population, and further research is needed to understand how to provide high-quality end-of-life care to these patients.
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Affiliation(s)
- Daniel K Partain
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA
| | - Justin J Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA
| | - Richard E Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA
| | - Elise C Carey
- Section of Palliative Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, MN; Center for Palliative Medicine, Mayo Clinic, Rochester, MN
| | - Jacob J Strand
- Section of Palliative Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, MN; Center for Palliative Medicine, Mayo Clinic, Rochester, MN.
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16
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An Integrated Review of Research Using Clinical Decision Support to Improve Advance Directive Documentation. J Hosp Palliat Nurs 2017. [DOI: 10.1097/njh.0000000000000351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Portanova J, Ailshire J, Perez C, Rahman A, Enguidanos S. Ethnic Differences in Advance Directive Completion and Care Preferences: What Has Changed in a Decade? J Am Geriatr Soc 2017; 65:1352-1357. [PMID: 28276051 DOI: 10.1111/jgs.14800] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Studies have documented ethnic differences in advance directive (AD) completion, with lower rates in minority groups. Of those with ADs, blacks are more likely than whites to prefer aggressive care, but little is known about how these differences in preferences have changed over time in ethnic groups. This nationally representative study aimed to investigate whether these differences in AD development persisted after adjusting for important confounding variables. Year of death was analyzed to see how AD completion changed over time within ethnic groups, and for those with an AD, the association between these factors and opting for aggressive care was investigated. Data from the 2000 to 2012 Health and Retirement Study (HRS) exit interviews from 7,177 decedents were used. Analyses included logistic regression to determine the relationship between ethnicity and AD completion and preferences for aggressive care and how it changed over time in ethnic groups. Forty-six percent of decedents had completed an AD (whites 51.7%, Hispanics 18.0%, blacks 15.0%). Of blacks completing an AD, 23.8% elected prolonged care, compared with 13.3% of Hispanics and 3.3% of whites. Logistic regression revealed that blacks 75% lower odds of completing an AD and Hispanics had 70% lower odds. Model covariates had a small influence on ethnic differences, although in examining the change in AD completion over time, the odds of having an AD increased with each subsequent death year for blacks and whites but not Hispanics. Additional research is needed to investigate the effect of cultural differences in AD completion rates of ethnic minority groups to ensure that preferences are honored in the clinical setting.
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Affiliation(s)
- Jaclyn Portanova
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California
| | - Jennifer Ailshire
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California
| | - Catherine Perez
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California
| | - Anna Rahman
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California
| | - Susan Enguidanos
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California
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18
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Elmeadawy S, Fitzner C, Elsner F, Dietrich CG. Wissen, Haltung und Meinung von Patienten zum neuen Patientenverfügungsgesetz. Schmerz 2017; 31:54-61. [DOI: 10.1007/s00482-016-0124-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Noh H, Kim J, Sims OT, Ji S, Sawyer P. Racial Differences in Associations of Perceived Health and Social and Physical Activities With Advance Care Planning, End-of-Life Concerns, and Hospice Knowledge. Am J Hosp Palliat Care 2016; 35:34-40. [PMID: 27815498 DOI: 10.1177/1049909116677021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Associations of perceived health and social and physical activities with end-of-life (EOL) issues have been rarely studied, not to mention racial disparities in such associations. To address this gap, this study examined racial differences in the associations of perceived health and levels of social and physical activities with advance care planning, EOL concerns, and knowledge of hospice care among community-dwelling older adults in Alabama. Data from a statewide survey of 1044 community-dwelling older adults on their long-term care needs were analyzed using descriptive statistics and logistic and linear regressions. Results showed that black older adults were less likely to know about or document advance care planning and to have accurate knowledge of hospice care; however, despite their poorer perceived health, black older adults reported fewer EOL concerns. Higher levels of perceived health and social and physical activities were associated with knowledge about advance care planning among white older adults but not among black older adults. Both black and white older adults with poorer perceived health and lower levels of social and physical activities tended to have more EOL concerns and less knowledge of hospice care. These findings suggest that interventions to address suboptimal levels of perceived health and social and physical activities among black older adults may increase knowledge of advance care planning. Also, supportive services to address EOL concerns should be targeted at older adults with poorer perceived health and limited participation in social and physical activities.
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Affiliation(s)
- Hyunjin Noh
- 1 School of Social Work, University of Alabama, Tuscaloosa, AL, USA
| | - Junghyun Kim
- 2 Korea Institute for Health and Social Affairs, Sejong, South Korea
| | - Omar T Sims
- 3 Department of Social Work, College of Arts and Sciences, University of Alabama at Birmingham, Birmingham, AL, USA.,4 Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.,5 Comprehensvie Center for Healthy Aging, University of Alabama at Birmingham, Birmingham, AL, USA.,6 Center for AIDS Research, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shaonin Ji
- 7 Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Patricia Sawyer
- 8 Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
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21
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Integrating palliative care into primary care for patients with chronic, life-limiting conditions. Nurse Pract 2016; 41:42-8; quiz 49. [PMID: 26886272 DOI: 10.1097/01.npr.0000480588.01667.58] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
As longevity increases, individuals with chronic, life-limiting conditions will live longer with disease burden and functional decline. Nurse practitioners can integrate symptom management, early decision-making, and supportive care into the primary care setting to improve quality of life and decrease economic and emotional impact at the end of life.
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22
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Narang AK, Wright AA, Nicholas LH. Trends in Advance Care Planning in Patients With Cancer: Results From a National Longitudinal Survey. JAMA Oncol 2016; 1:601-8. [PMID: 26181909 DOI: 10.1001/jamaoncol.2015.1976] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
IMPORTANCE Advance care planning (ACP) may prevent end-of-life (EOL) care that is nonbeneficial and discordant with patient wishes. Despite long-standing recognition of the merits of ACP in oncology, it is unclear whether participation in ACP by patients with cancer has increased over time. OBJECTIVES To characterize trends in durable power of attorney (DPOA) assignment, living will creation, and participation in discussions of EOL care preferences and to explore associations between ACP subtypes and EOL treatment intensity as reflected in EOL care decisions and terminal hospitalizations. DESIGN, SETTING, AND PARTICIPANTS We analyzed prospectively collected survey data from 1985 next-of-kin surrogates of Health and Retirement Study (HRS) participants with cancer who died between 2000 and 2012, including data from in-depth "exit" interviews conducted with the surrogates after the participant's death. The HRS is a nationally representative, biennial, longitudinal panel study of US residents older than 50 years. Trends in ACP subtypes were tested, and multivariable logistic regression models examined for associations between ACP subtypes and measures of treatment intensity. MAIN OUTCOMES AND MEASURES Trends in the surrogate-reported frequency of DPOA assignment, living will creation, and participation in discussions of EOL care preferences; associations between ACP subtypes and both surrogate-reported EOL care decisions and terminal hospitalizations. RESULTS From 2000 to 2012, there was an increase in DPOA assignment (52% to 74%, P = .03), without significant change in use of living wills (49% to 40%, P = .63) or EOL discussions (68% to 60%, P = .62). Surrogate reports that patients received "all care possible" at EOL increased during the period (7% to 58%, P = .004), and rates of terminal hospitalizations were unchanged (29% to 27%, P = .70). Limiting or withholding treatment was associated with living wills (adjusted odds ratio [AOR], 2.51; 95% CI, 1.53-4.11; P < .001) and EOL discussions (AOR, 1.93; 95% CI, 1.53-3.14; P = .002) but not with DPOA assignment. CONCLUSIONS AND RELEVANCE Use of DPOA increased significantly between 2000 and 2012 but was not associated with EOL care decisions. Importantly, there was no growth in key ACP domains such as discussions of care preferences. Efforts that bolster communication of EOL care preferences and also incorporate surrogate decision makers are critically needed to ensure receipt of goal-concordant care.
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Affiliation(s)
- Amol K Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alexi A Wright
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts3Harvard Medical School, Boston, Massachusetts
| | - Lauren H Nicholas
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland5Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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23
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Shen MJ, Prigerson HG, Paulk E, Trevino KM, Penedo FJ, Tergas AI, Epstein AS, Neugut AI, Maciejewski PK. Impact of end-of-life discussions on the reduction of Latino/non-Latino disparities in do-not-resuscitate order completion. Cancer 2016; 122:1749-56. [PMID: 26992109 DOI: 10.1002/cncr.29973] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 12/24/2015] [Accepted: 01/07/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Compared with non-Latino, white patients with advanced cancer, Latino patients with advanced cancer are less likely to sign do-not-resuscitate (DNR) orders, which is a form of advance care planning associated with better quality of life at the end of life (EOL). Latinos' completion of DNR orders may be more sensitive to clinical discussions regarding EOL care. The current study examined differences between Latino and white terminally ill patients with cancer with regard to the association between EOL discussions and DNR order completion. METHODS A total of 117 participants with advanced cancer (61 of whom were Latino and 56 of whom were non-Latino white individuals) were recruited between 2002 and 2008 from Parkland Hospital (a public hospital in Dallas, Texas) as part of the Coping with Cancer study, which is a large, multiinstitutional, prospective cohort study of patients with advanced cancer that is designed to examine social and psychological influences on EOL care. In structured interviews, patients reported if they had EOL discussions with their physicians, and if they completed DNR orders. RESULTS The association between EOL discussions and DNR order completion was significantly greater in Latino compared with white patients, adjusting for potential confounds (interaction adjusted odds ratio, 6.64; P = .041). Latino patients who had an EOL discussion were >10 times more likely (adjusted odds ratio, 10.91; P = .001) to complete a DNR order than those who had not, and were found to be equally as likely to complete a DNR order as white patients. CONCLUSIONS Differences in the impact of EOL discussions on DNR order completion may explain Latino/non-Latino ethnic disparities in DNR order completion in EOL care, and point to a means to eliminate those disparities. Cancer 2016;122:1749-56. © 2016 American Cancer Society.
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Affiliation(s)
- Megan Johnson Shen
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York.,Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Holly G Prigerson
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York.,Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Elizabeth Paulk
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kelly M Trevino
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York.,Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Frank J Penedo
- Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
| | - Ana I Tergas
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Andrew S Epstein
- Gastrointestinal Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alfred I Neugut
- Department of Medicine, Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York.,Department of Epidemiology, Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Paul K Maciejewski
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York.,Department of Radiology, Weill Cornell Medicine, New York, New York
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24
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Silva MD, Genoff M, Zaballa A, Jewell S, Stabler S, Gany FM, Diamond LC. Interpreting at the End of Life: A Systematic Review of the Impact of Interpreters on the Delivery of Palliative Care Services to Cancer Patients With Limited English Proficiency. J Pain Symptom Manage 2016; 51:569-80. [PMID: 26549596 PMCID: PMC4955824 DOI: 10.1016/j.jpainsymman.2015.10.011] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 10/22/2015] [Accepted: 10/23/2015] [Indexed: 11/23/2022]
Abstract
CONTEXT Language barriers can influence the health quality and outcomes of limited English proficiency (LEP) patients at end of life, including symptom assessment and utilization of hospice services. OBJECTIVES To determine how professional medical interpreters influence the delivery of palliative care services to LEP patients. METHODS We conducted a systematic review of the literature in all available languages of six databases from 1960 to 2014. Studies evaluated use of language services for LEP patients who received palliative care services. Data were abstracted from 10 articles and collected on study design, size, comparison groups, outcomes, and interpreter characteristics. RESULTS Six qualitative and four quantitative studies assessed the use of interpreters in palliative care. All studies found that the quality of care provided to LEP patients receiving palliative services is influenced by the type of interpreter used. When professional interpreters were not used, LEP patients and families had inadequate understanding about diagnosis and prognosis during goals of care conversations, and patients had worse symptom management at the end of life, including pain and anxiety. Half of the studies concluded that professional interpreters were not used adequately, and several studies suggested that premeetings between clinicians and interpreters were important to discuss topics and terminology to be used during goals of care discussions. CONCLUSION LEP patients had worse quality of end-of-life care and goals of care discussions when professional interpreters were not used. More intervention studies are needed to improve the quality of care provided to LEP patients and families receiving palliative services.
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Affiliation(s)
- Milagros D Silva
- Department of Geriatrics and Palliative Medicine, Weill Cornell Medical Center, New York, New York, USA.
| | - Margaux Genoff
- Immigrant Health and Cancer Disparities Service, Department of Psychiatry & Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Alexandra Zaballa
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Sarah Jewell
- Medical Library, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Stacy Stabler
- Department of Palliative Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Francesca M Gany
- Department of Healthcare Policy and Research, Weill Cornell Medical Center, New York, New York, USA; Immigrant Health and Cancer Disparities Service, Department of Psychiatry & Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Lisa C Diamond
- Department of Healthcare Policy and Research, Weill Cornell Medical Center, New York, New York, USA; Immigrant Health and Cancer Disparities Service, Department of Psychiatry & Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, New York, USA; Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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25
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McLean E, Habicht L, Foote J. Perceptions of Advance Care Planning Among Latino Adults in the Community Setting. Creat Nurs 2016. [DOI: 10.1891/1078-4535.22.2.106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Rates of advance care planning (ACP) among Latinos are as low as 10% compared to an average of 26% among adults living in the United States. Typical American values of autonomy and self-determination that underlie ACP often conflict with the values of group decision-making, fatalism, and respect for hierarchy that influence decision making in the Latino community. Research suggests that community-based initiatives and culturally competent patient education improves rates of ACP in the Latino community. Findings discuss the use of culturally sensitive and linguistically appropriate ACP video education with Latinos in a metropolitan community setting, as well as recommendations for practice.
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Lee JJ, Long AC, Curtis JR, Engelberg RA. The Influence of Race/Ethnicity and Education on Family Ratings of the Quality of Dying in the ICU. J Pain Symptom Manage 2016; 51:9-16. [PMID: 26384556 PMCID: PMC4701575 DOI: 10.1016/j.jpainsymman.2015.08.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 08/22/2015] [Accepted: 09/03/2015] [Indexed: 11/19/2022]
Abstract
CONTEXT Racial and ethnic differences in end-of-life care may be attributable to both patient preferences and health-care disparities. Identifying factors that differentiate preferences from disparities may enhance end-of-life care for critically ill patients and their families. OBJECTIVES To understand the association of minority race/ethnicity and education with family ratings of the quality of dying and death, taking into consideration possible markers of patient and family preferences for end-of-life care as mediators of this association. METHODS Data were obtained from 15 intensive care units participating in a cluster-randomized trial of a palliative care intervention. Family members of decedents completed self-report surveys evaluating quality of dying. We used regression analyses to identify associations between race/ethnicity, education, and quality of dying ratings. We then used path analyses to investigate whether advance directives and life-sustaining treatment acted as mediators between patient characteristics and ratings of quality of dying. RESULTS Family members returned 1290 surveys for 2850 decedents. Patient and family minority race/ethnicity were both associated with lower ratings of quality of dying. Presence of a living will and dying in the setting of full support mediated the relationship between patient race and family ratings; patient race exerted an indirect, rather than direct, effect on quality of dying. Family minority race had a direct effect on lower ratings of quality of dying. Neither patient nor family education was associated with quality of dying. CONCLUSION Minority race/ethnicity was associated with lower family ratings of quality of dying. This association was mediated by factors that may be markers of patient and family preferences (living will, death in the setting of full support); family member minority race/ethnicity was directly associated with lower ratings of quality of dying. Our findings generate hypothesized pathways that require future evaluation.
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Affiliation(s)
- Janet J Lee
- University of Washington, Seattle, Washington, USA
| | - Ann C Long
- University of Washington, Seattle, Washington, USA
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Lee MC, Hinderer KA, Friedmann E. Engaging Chinese American Adults in Advance Care Planning: A Community-Based, Culturally Sensitive Seminar. J Gerontol Nurs 2015; 41:17-21. [PMID: 25912237 DOI: 10.3928/00989134-20150406-01] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 01/26/2015] [Indexed: 11/20/2022]
Abstract
Ethnic minority groups are less engaged than Caucasian American adults in advance care planning (ACP). Knowledge deficits, language, and culture are barriers to ACP. Limited research exists on ACP and advance directives in the Chinese American adult population. Using a pre-posttest, repeated measures design, the current study explored the effectiveness of a nurseled, culturally sensitive ACP seminar for Chinese American adults on (a) knowledge, completion, and discussion of advance directives; and (b) the relationship between demographic variables, advance directive completion, and ACP discussions. A convenience sample of 72 urban, community-dwelling Chinese American adults (mean age=61 years) was included. Knowledge, advance directive completion, and ACP discussions increased significantly after attending the nurse-led seminar (p<0.01). Increased age correlated with advance directive completion and ACP discussions; female gender correlated with ACP discussions. Nursing education in a community setting increased advance directive knowledge and ACP engagement in Chinese American adults.
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Allen SL, Davis KS, Rousseau PC, Iverson PJ, Mauldin PD, Moran WP. Advanced Care Directives: Overcoming the Obstacles. J Grad Med Educ 2015. [PMID: 26217430 PMCID: PMC4507937 DOI: 10.4300/jgme-d-14-00145.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Advanced care directives (ACDs) and end-of-life discussions are important and typically difficult to initiate because of the sensitive nature of the topic and competing clinical priorities. Resident physicians need to have these conversations but often do not in their continuity clinics. OBJECTIVE We implemented a program to (1) increase physician opportunity to discuss end-of-life wishes with their patients, and (2) improve residents' confidence in leading discussions regarding ACDs. INTERVENTION A total of 95 residents in an academic outpatient internal medicine resident continuity clinic participated in a formalized curriculum (didactic sessions, simulations, and academic detailing). Clinic workflow alterations prompted the staff to question if patients had an ACD or living will, and then cued residents to discuss these issues with the patients if they did not. RESULTS Of the 77% of patients who were asked about ACDs, 74% had no ACD but were interested in discussing this topic. After our intervention, 65% (62 of 95) of our residents reported having at least 1 outpatient discussion with their patients. Residents reported increased confidence directing and discussing advanced care planning with older patients and conducting a family meeting (P < .01). CONCLUSIONS By delivering a formalized curriculum and creating a clinical environment that supports such discussions, resident physicians had more ACD discussions with their patients and reported increased confidence. When provided information and opportunity, patients consistently expressed interest in talking with their physician about their advanced care wishes.
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Long AC, Engelberg RA, Downey L, Kross EK, Reinke LF, Cecere Feemster L, Dotolo D, Ford DW, Back AL, Curtis JR. Race, income, and education: associations with patient and family ratings of end-of-life care and communication provided by physicians-in-training. J Palliat Med 2014; 17:435-47. [PMID: 24592958 DOI: 10.1089/jpm.2013.0214] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Minority race and lower socioeconomic status are associated with poorer patient ratings of health care quality and provider communication. OBJECTIVE To examine the association of race/ethnicity or socioeconomic status with patients' and families' ratings of end-of-life care and communication about end-of-life care provided by physicians-in-training. METHODS As a component of a randomized trial evaluating a program designed to improve clinician communication about end-of-life care, patients and patients' families completed preintervention survey data regarding care and communication provided by internal medicine residents and medical subspecialty fellows. We examined associations between patient and family race or socioeconomic status and ratings they gave trainees on two questionnaires: the Quality of End-of-Life Care (QEOLC) and Quality of Communication (QOC). RESULTS Patients from racial/ethnic minority groups, patients with lower income, and patients with lower educational attainment gave trainees higher ratings on the end-of-life care subscale of the QOC (QOCeol). In path models, patient educational attainment and income had a direct effect on outcomes, while race/ethnicity did not. Lower family educational attainment was also associated with higher trainee ratings on the QOCeol, while family non-white race was associated with lower trainee ratings on the QEOLC and general subscale of the QOC. CONCLUSIONS Patient race is associated with perceptions of the quality of communication about end-of-life care provided by physicians-in-training, but the association was opposite to our hypothesis and appears to be mediated by socioeconomic status. Family member predictors of these perceptions differ from those observed for patients. Further investigation of these associations may guide interventions to improve care delivered to patients and families.
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Affiliation(s)
- Ann C Long
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington , Seattle, Washington
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