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Jia Z, Kurahashi A, Sharma RK, Mahtani R, Zagorski BM, Sanders JJ, Yarnell C, Detsky M, Lindvall C, Teno JM, Bell CM, Quinn KL. A Comparison of Palliative Care Delivery between Ethnically Chinese and Non-Chinese Canadians in the Last Year of Life. J Gen Intern Med 2024:10.1007/s11606-024-08859-8. [PMID: 38926319 DOI: 10.1007/s11606-024-08859-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Ethnically Chinese adults in Canada and the United States face multiple barriers in accessing equitable, culturally respectful care at the end-of-life. Palliative care (PC) is committed to supporting patients and families in achieving goal-concordant, high-quality serious illness care. Yet, current PC delivery may be culturally misaligned. Therefore, understanding ethnically Chinese patients' use of palliative care may uncover modifiable factors to sustained inequities at the end-of-life. OBJECTIVE To compare the use and delivery of PC in the last year of life between ethnically Chinese and non-Chinese adults. DESIGN Population-based cohort study. PARTICIPANTS All Ontario adults who died between January 1st, 2012, and October 31st, 2022, in Ontario, Canada. EXPOSURES Chinese ethnicity. MAIN MEASURES Elements of physician-delivered PC, including model of care (generalist; specialist; mixed), timing and location of initiation, and type of palliative care physician at initial consultation. KEY RESULTS The final study cohort included 527,700 non-Chinese (50.8% female, 77.9 ± 13.0 mean age, 13.0% rural residence) and 13,587 ethnically Chinese (50.8% female, 79.2 ± 13.6 mean age, 0.6% rural residence) adults. Chinese ethnicity was associated with higher likelihoods of using specialist (adjusted odds ratio [aOR] 1.53, 95%CI 1.46-1.60) and mixed (aOR 1.32, 95%CI 1.26-1.38) over generalist models of PC, compared to non-Chinese patients. Chinese ethnicity was also associated with a higher likelihood of PC initiation in the last 30 days of life (aOR 1.07, 95%CI 1.03-1.11), in the hospital setting (aOR 1.24, 95%CI 1.18-1.30), and by specialist PC physicians (aOR 1.33, 95%CI 1.28-1.38). CONCLUSIONS Chinese ethnicity was associated with a higher likelihood of mixed and specialist models of PC delivery in the last year of life compared to adults who were non-Chinese. These observed differences may be due to later initiation of PC in hospital settings, and potential differences in unmeasured needs that suggest opportunities to initiate early, community-based PC to support ethnically Chinese patients with serious illness.
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Affiliation(s)
- Zhimeng Jia
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada.
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
- Program in Global Palliative Care, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
| | - Allison Kurahashi
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada
| | - Rashmi K Sharma
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ramona Mahtani
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Justin J Sanders
- Department of Family Medicine, McGill University, Montreal, QC, Canada
- Ariadne Labs, Boston, MA, USA
| | - Christopher Yarnell
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine and Research Institute, Scarborough Health Network, Toronto, Canada
| | - Michael Detsky
- Interdepartmental Division of Critical Care Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Charlotta Lindvall
- Harvard Medical School, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Joan M Teno
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Chaim M Bell
- ICES, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto and Sinai Health, Toronto, Ontario, Canada
| | - Kieran L Quinn
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto and Sinai Health, Toronto, Ontario, Canada
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Algu K, Wales J, Anderson M, Omilabu M, Briggs T, Kurahashi AM. Naming racism as a root cause of inequities in palliative care research: a scoping review. BMC Palliat Care 2024; 23:143. [PMID: 38858646 PMCID: PMC11163751 DOI: 10.1186/s12904-024-01465-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 05/22/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Racial and ethnic inequities in palliative care are well-established. The way researchers design and interpret studies investigating race- and ethnicity-based disparities has future implications on the interventions aimed to reduce these inequities. If racism is not discussed when contextualizing findings, it is less likely to be addressed and inequities will persist. OBJECTIVE To summarize the characteristics of 12 years of academic literature that investigates race- or ethnicity-based disparities in palliative care access, outcomes and experiences, and determine the extent to which racism is discussed when interpreting findings. METHODS Following Arksey & O'Malley's methodology for scoping reviews, we searched bibliographic databases for primary, peer reviewed studies globally, in all languages, that collected race or ethnicity variables in a palliative care context (January 1, 2011 to October 17, 2023). We recorded study characteristics and categorized citations based on their research focus-whether race or ethnicity were examined as a major focus (analyzed as a primary independent variable or population of interest) or minor focus (analyzed as a secondary variable) of the research purpose, and the interpretation of findings-whether authors directly or indirectly discussed racism when contextualizing the study results. RESULTS We identified 3000 citations and included 181 in our review. Of these, most were from the United States (88.95%) and examined race or ethnicity as a major focus (71.27%). When interpreting findings, authors directly named racism in 7.18% of publications. They were more likely to use words closely associated with racism (20.44%) or describe systemic or individual factors (41.44%). Racism was directly named in 33.33% of articles published since 2021 versus 3.92% in the 10 years prior, suggesting it is becoming more common. CONCLUSION While the focus on race and ethnicity in palliative care research is increasing, there is room for improvement when acknowledging systemic factors - including racism - during data analysis. Researchers must be purposeful when investigating race and ethnicity, and identify how racism shapes palliative care access, outcomes and experiences of racially and ethnically minoritized patients.
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Affiliation(s)
- Kavita Algu
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada.
| | - Joshua Wales
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
| | - Michael Anderson
- Waakebiness-Bryce Institute for Indigenous Health, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, ON, M5T 3M7, Canada
| | - Mariam Omilabu
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
| | - Thandi Briggs
- Home and Community Care Support Services Toronto Central, 250 Dundas St. W, Toronto, ON, M5T 2Z5, Canada
| | - Allison M Kurahashi
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
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Iupati S, Stanley J, Egan R, MacLeod R, Davies C, Spence H, Iupati D, Middlemiss T, Gwynne-Robson I. Systematic Review of Models of Effective Community Specialist Palliative Care Services for Evidence of Improved Patient-Related Outcomes, Equity, Integration, and Health Service Utilization. J Palliat Med 2023; 26:1562-1577. [PMID: 37366688 DOI: 10.1089/jpm.2022.0461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
Background: The benefits of palliative care programs are well documented. However, the effectiveness of specialist palliative care services is not well established. The previous lack of consensus on criteria for defining and characterizing models of care has restrained direct comparison between these models and limited the evidence base to inform policy makers. A rapid review for studies published up to 2012 was unable to find an effective model. Aim: To identify effective models of community specialist palliative care services. Design: A mixed-method synthesis design reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Prospero: CRD42020151840. Data sources: Medline, PubMed, EMBASE, CINAHL and the Cochrane Database of Systematic Reviews were searched in September 2019 for primary research and review articles from 2012 to 2019. Supplementary search was conducted on Google in 2020 for policy documents to identify additional relevant studies. Results: The search yielded 2255 articles; 36 articles satisfied the eligibility criteria and 6 additional articles were identified from other sources. Eight systematic reviews and 34 primary studies were identified: observational studies (n = 24), randomized controlled trials (n = 5), and qualitative studies (n = 5). Community specialist palliative care was found to improve symptom burden/quality of life and to reduce secondary service utilization across cancer and noncancer diagnoses. Much of this evidence relates to face-to-face care in home-based settings with both round-the-clock and episodic care. There were few studies addressing pediatric populations or minority groups. Findings from qualitative studies revealed that care coordination, provision of practical help, after-hours support, and medical crisis management were some of the factors contributing to patients' and caregivers' positive experience. Conclusion: Strong evidence exists for community specialist palliative care to improve quality of life and reducing secondary service utilization. Future research should focus on equity outcomes and the interface between generalist and specialist care.
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Affiliation(s)
- Salina Iupati
- Department of Preventive and Social Medicine, University of Otago Dunedin School of Medicine, Dunedin, New Zealand
- Te Omanga Hospice, Lower Hutt, New Zealand
| | - James Stanley
- Biostatistics Group, University of Otago, Wellington, New Zealand
| | - Richard Egan
- Department of Preventive and Social Medicine, University of Otago Dunedin School of Medicine, Dunedin, New Zealand
| | - Roderick MacLeod
- Department of General Practice and Primary Care, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Cheryl Davies
- Tu Kotahi Māori Asthma and Research Trust, Lower Hutt, New Zealand
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Nouri S, Li L, Huang C, Chung A, Stokes SC, Pan S, Wong EC, Newman J, Woo JW, Cheng J, Tan CH, Wertz M, Wood-Hughes E, Quinn M, Pantilat SZ, Lyles CR, Ritchie CS, Sudore RL. "At the End I Have a Say": Engaging the Chinese Community in Advance Care Planning. J Pain Symptom Manage 2023; 66:551-560.e1. [PMID: 37536524 PMCID: PMC10593504 DOI: 10.1016/j.jpainsymman.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 05/22/2023] [Accepted: 07/24/2023] [Indexed: 08/05/2023]
Abstract
CONTEXT Despite the association of advance care planning (ACP) with improved patient and caregiver outcomes, Chinese American elders have low rates of ACP. OBJECTIVES Assess ACP facilitators/barriers in the San Francisco (SF) Chinese community and codesign, implement, and test community-based ACP-promoting pilot events. METHODS A Chinese Community Committee (N = 19 community-based organization leaders, health system representatives, community members) conducted focus groups in Cantonese and English with Chinese older adults (age ≥55), caregivers, and community leaders. The Committee designed and implemented pilot events in-person and online. We analyzed focus group data using thematic analysis; assessed pre-to-post-event readiness to engage in ACP (validated survey; 14 scale, 4 = most ready); and assessed event acceptability. RESULTS A total of 34 people participated in six focus groups. Themes described Chinese community-specific importance of ACP (e.g., reduces family burden), barriers (e.g., younger generations lack tools to discuss ACP with elders and vice versa), and facilitators (e.g., intergenerational events, culturally/linguistically appropriate materials). Based on focus groups findings, the Committee developed a novel ACP tool and designed intergenerational events. A total of 195 participants attended 10 events; 95% were Chinese, 90% spoke Chinese languages, 80% were women. ACP readiness increased significantly (1.66 [SD 0.84] vs. 2.03 [SD 0.85]; P < 0.001); 94% of participants were comfortable attending and 96% would recommend events. CONCLUSION Community-developed intergenerational events that highlight the value of ACP and address barriers are acceptable and increase ACP engagement in the Chinese community.
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Affiliation(s)
- Sarah Nouri
- Division of Palliative Medicine, Department of Medicine (S.N., M.Q., S.Z.P.), University of California San Francisco, San Francisco, California, USA.
| | - Lingsheng Li
- Division of Geriatrics, Department of Medicine (L.L.), University of California San Francisco, San Francisco, California, USA
| | - Carrie Huang
- Thriving in Place (C.H.), San Francisco, California, USA
| | - Anni Chung
- Self-Help for the Elderly (A.C.), San Francisco, California, USA
| | - Sandy Chen Stokes
- Chinese American Coalition for Compassionate Care (S.C.S., S.P.), Cupertino, California, USA
| | - Shirley Pan
- Chinese American Coalition for Compassionate Care (S.C.S., S.P.), Cupertino, California, USA
| | - Elizabeth C Wong
- Independent community advocate (E.C.W.), San Francisco, California, USA
| | - Jeffrey Newman
- Institute for Health & Aging, University of California San Francisco (J.N.), San Francisco, California, USA
| | - Joseph W Woo
- Chinese Community Healthcare Association (J.W.W.), San Francisco, California, USA
| | - Joyce Cheng
- Chinese Community Health Resource Center (J.C.), San Francisco, California, USA
| | - Charissa H Tan
- John A. Burns School of Medicine, University of Hawai'i at Mānoa (C.H.T.), Honolulu, Hawaii, USA
| | - Molly Wertz
- Molly Wertz Consulting (M.W.), San Francisco, California, USA
| | - Elyse Wood-Hughes
- Richmond Senior Center, Golden Gate Senior Services (E.W.H.), San Francisco, California, USA
| | - Mara Quinn
- Division of Palliative Medicine, Department of Medicine (S.N., M.Q., S.Z.P.), University of California San Francisco, San Francisco, California, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine, Department of Medicine (S.N., M.Q., S.Z.P.), University of California San Francisco, San Francisco, California, USA
| | - Courtney R Lyles
- Division of General Internal Medicine, Department of Medicine (C.R.L.), Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Christine S Ritchie
- Division of Palliative Care and Geriatric Medicine, Department of Medicine (C.S.R.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine (R.L.S.), University of California San Francisco, San Francisco, California, USA
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Nakao-Hayashizaka KC. End-of-Life Preparedness Among Japanese Americans: A Community Survey. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2022; 18:216-234. [PMID: 35815782 DOI: 10.1080/15524256.2022.2093312] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The purpose of this study was to investigate the level of preparedness among Japanese American older adults for life's end by examining their knowledge, preferences, and arrangements for end-of-life issues. A total of 248 community dwelling Japanese Americans aged 50 and older participated in the study. The cross-sectional survey results indicated that participants believed they were well-informed about end-of-life issues and well-prepared for their lives' end. While most participants were in favor of making end-of-life arrangements, particularly with regard to making a will/living trust, creating an advance health care directive, appointing a health care agent, and funeral planning, relatively few favored life-prolonging treatment or planning for organ donation. They placed a high value on natural death and family-centered decision-making processes. These findings highlight the importance of awareness and cultural humility for social workers when providing culturally informed services at life's end to diverse Americans, including Japanese American older adults and their families.
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