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Oshow F, Shah J, Ali SK. Religious, Cultural, and Sex Influences on Advance Care Directives in Patients Admitted to a Tertiary Care Center in Kenya. J Pain Symptom Manage 2024; 67:12-19.e1. [PMID: 37709176 DOI: 10.1016/j.jpainsymman.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023]
Abstract
INTRODUCTION Advance care directives (AD) are instructions from patients regarding the care they would prefer if they could not make medical decisions in the future. It is widely recognized that racial and ethnic as well as sex differences, particularly in the West, can influence AD. However, to the best of our knowledge, there is limited understanding of how these factors impact AD in sub-Saharan Africa. METHODS This prospective cross-sectional study was conducted at the Aga Khan University Hospital, Nairobi. We enrolled patients above the age of 18 years who were admitted to the general medical wards. The data were collected using a structured questionnaire that consisted of questions based on demographics and AD. Descriptive statistics were used to summarize the data, including frequencies and percentages, as well as medians and interquartile ranges. RESULTS The study involved 286 participants, with a median age of 44.0 years (IQR: 37.0 - 52.0). Roughly half of the participants were male (51.7%), and the majority identified themselves as Christians (77.3%) and of African ethnicity (78.3%). Upon further analysis, it was discovered that only 35.3% had an awareness of AD. Notably, individuals from the Hindu religion and Asian ethnicity demonstrated significantly higher knowledge of AD. Furthermore, more males reported having a living will and believed that AD are crucial for patients who could not make independent medical decisions compared to females. CONCLUSION This study indicated a lower awareness and knowledge of AD among the participants. Hindus and Asians exhibited higher levels of awareness regarding AD. Considering the diverse religious and cultural backgrounds in our setting, there is a pressing need for strategies to increase awareness surrounding AD.
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Affiliation(s)
- Fariah Oshow
- Department of Internal Medicine (FO, JS), Aga Khan University, Nairobi, Kenya
| | - Jasmit Shah
- Department of Internal Medicine (FO, JS), Aga Khan University, Nairobi, Kenya; Brain and Mind Institute (JS), Aga Khan University, Nairobi, Kenya
| | - Sayed K Ali
- Department of Internal Medicine (FO, JS), Aga Khan University, Nairobi, Kenya.
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2
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Haines KL, Nguyen BP, Antonescu I, Freeman J, Cox C, Krishnamoorthy V, Kawano B, Agarwal S. Insurance Status and Ethnicity Impact Health Disparities in Rates of Advance Directives in Trauma. Am Surg 2023; 89:88-97. [PMID: 33877932 DOI: 10.1177/00031348211011115] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Advanced directives (ADs) provide a framework from which families may understand patient's wishes. However, end-of-life planning may not be prioritized by everyone. This analysis aimed to determine what populations have ADs and how they affected trauma outcomes. METHODS Adult trauma patients recorded in the American College of Surgeons Trauma Quality Improvement Program (TQIP) from 2013-2015 were included. The primary outcome was presence of an AD. Secondary outcomes included mortality, length of stay (LOS), mechanical ventilation, ICU admission/LOS, withdrawal of life-sustaining measures, and discharge disposition. Multivariable logistic regression models were developed for outcomes. RESULTS 44 705 patients were included in the analyses. Advanced directives were present in 1.79% of patients. The average age for patients with ADs was 77.8 ± 10.7. African American (odds ratio (OR) .53, confidence intervals [CI] .36-.79) and Asian (OR .22, CI .05-.91) patients were less likely to have ADs. Conversely, Medicaid (OR 1.70, CI 1.06-2.73) and Medicare (OR 1.65, CI 1.25-2.17) patients were more likely to have ADs as compared to those with private insurance. The presence of ADs was associated with increased hospital mortality (OR 2.84, CI 2.19-3.70), increased transition to comfort measures (OR 2.87, CI 2.08-3.95), and shorter LOS (CO -.74, CI -1.26-.22). Patients with ADs had an increased odds of hospice care (OR 4.24, CI 3.18-5.64). CONCLUSION Advanced directives at admission are uncommon, particularly among African Americans and Asians. The presence of ADs was associated with increased mortality, use of mechanical ventilation, admission to the ICU, withdrawal of life-sustaining measures, and hospice. Future research should target expansion of ADs among minority populations to alleviate disparities in end-of-life treatment.
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Affiliation(s)
- Krista L Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA.,The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Benjamin P Nguyen
- Department of Surgery, 20868Kaweah Delta Health Care District, Medical Center, Visalia, CA, USA
| | - Ioana Antonescu
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Jennifer Freeman
- Department of Surgery, 3402TCU and UNTHSC School of Medicine, Fort Worth, TX, USA
| | - Christopher Cox
- Division of Pulmonary Critical Care, Department of Medicine, 22957Duke University Medical Center, Durham, NC, USA
| | - Vijay Krishnamoorthy
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Brad Kawano
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Suresh Agarwal
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
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Huayanay I, Pantoja C, Chang C. End of Life Decision-Making Challenges in a Latino Patient with COVID-19: Facing Barriers. Gerontol Geriatr Med 2021; 7:23337214211021726. [PMID: 34104688 PMCID: PMC8170277 DOI: 10.1177/23337214211021726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/13/2021] [Indexed: 11/16/2022] Open
Abstract
COVID-19 pandemic brought difficult scenarios that patients and families are
facing about end- of-life decisions. This exposed some weak areas in the
healthcare system where we can continue improve in reducing disparities and
emphasizing advance care planning from a primary level of care. We present a
case of challenges in end-of-life decision-making in a Latino patient.
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Affiliation(s)
- Irma Huayanay
- School of Medicine, The University of Texas Rio Grande Valley, Edinburg, Texas, USA.,Internal Medicine Residency Program, The University of Texas Rio Grande Valley, Edinburg, Texas, USA.,Doctors Hospital at Renaissance, Edinburg, Texas, USA
| | - Celia Pantoja
- Doctors Hospital at Renaissance, Edinburg, Texas, USA
| | - Chelsea Chang
- School of Medicine, The University of Texas Rio Grande Valley, Edinburg, Texas, USA.,Internal Medicine Residency Program, The University of Texas Rio Grande Valley, Edinburg, Texas, USA.,Doctors Hospital at Renaissance, Edinburg, Texas, USA
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4
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Jia Z, Leiter RE, Yeh IM, Tulsky JA, Sanders JJ. Toward Culturally Tailored Advance Care Planning for the Chinese Diaspora: An Integrative Systematic Review. J Palliat Med 2020; 23:1662-1677. [PMID: 32991239 DOI: 10.1089/jpm.2020.0330] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: The Chinese diaspora experiences disparate end-of-life (EOL) care outcomes. Advance care planning (ACP) may be an effective intervention to improve EOL care, but its reception and uptake in the Chinese diaspora are unknown. Objective: Review and synthesize current literature to develop a culturally tailored ACP framework for the Chinese diaspora. Design: A systematic integrative review framed by Whittemore and Knafl's method was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Data Sources: PubMed, Embase, CINAHL, Web of Science, Cochrane Library, and University of York Center for Reviews and Dissemination were systematically searched for articles published before February 2020. All English, peer-reviewed quantitative, qualitative, and mixed-method literature studying ACP in Chinese adults living outside China and Taiwan were included. A mixed-method appraisal tool was utilized for quality assessment. Results: The search yielded 836 unique articles, from which we included 30. Integrative synthesis resulted in a novel framework to guide culturally tailored ACP among the Chinese diaspora. The framework highlights the importance of an authority-initiated, indirect approach to ACP that maximizes individual and collective harmony. Furthermore, due to evolving sociodemographic and acculturation factors, the perception of harmony may differ between individuals and generations. Conclusion: The Chinese diaspora population is willing to engage in ACP. An individualized, culturally sensitive approach that captures and maximizes harmony will be central to the success of ACP in this population. Further work is required to understand the influence of serious illness, spirituality, and family on ACP.
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Affiliation(s)
- Zhimeng Jia
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Richard E Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Irene M Yeh
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Justin J Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Ariadne Labs, Boston, Massachusetts, USA
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5
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Barnett MD, Marsden AD. The death panel myth among older adults: Political ideology, advance directives, and perceived discrimination on the basis of age. DEATH STUDIES 2019; 45:827-837. [PMID: 31847718 DOI: 10.1080/07481187.2019.1699200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The "death panel" myth holds that the Affordable Care Act sought to determine which Americans are worthy of medical care. Two interview surveys among older adults (Study 1, N = 210, Study 2, N = 196) investigated differences between those who do and do not believe the death panel myth. Those who believed in the death panel myth had more conservative political ideology, lower perceived need for living wills, and higher perceived discrimination on the basis of age. The death panel myth may stem from partisanship and a belief that society places less value on the lives of older adults.
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Affiliation(s)
- Michael D Barnett
- Department of Psychology and Counseling, The University of Texas at Tyler, Tyler, Texas, USA
| | - Arthur D Marsden
- Department of Psychology, University of North Texas, Denton, Texas, USA
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6
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Rodriguez F, Hastings KG, Boothroyd DB, Echeverria S, Lopez L, Cullen M, Harrington RA, Palaniappan LP. Disaggregation of Cause-Specific Cardiovascular Disease Mortality Among Hispanic Subgroups. JAMA Cardiol 2019; 2:240-247. [PMID: 28114655 DOI: 10.1001/jamacardio.2016.4653] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Hispanics are the largest minority group in the United States and face a disproportionate burden of risk factors for cardiovascular disease (CVD) and low socioeconomic position. However, Hispanics paradoxically experience lower all-cause mortality rates compared with their non-Hispanic white (NHW) counterparts. This phenomenon has been largely observed in Mexicans, and whether this holds true for other Hispanic subgroups or whether these favorable trends persist over time remains unknown. Objective To disaggregate a decade of national CVD mortality data for the 3 largest US Hispanic subgroups. Design, Setting, and Participants Deaths from CVD for the 3 largest US Hispanic subgroups-Mexicans, Puerto Ricans, and Cubans-compared with NHWs were extracted from the US National Center for Health Statistics mortality records using the underlying cause of death based on coding from the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (I00-II69). Mortality data were evaluated from January 1, 2003, to December 31, 2012. Population estimates were calculated using linear interpolation from the 2000 and 2010 US Census reports. Data were analyzed from November 2015 to July 2016. Main Outcomes and Measures Mortality due to CVD. Results Participants included 688 074 Mexican, 163 335 Puerto Rican, 130 397 Cuban, and 19 357 160 NHW individuals (49.0% men and 51.0% women; mean [SD] age, 75 [15] years). At the time of CVD death, Mexicans (age, 67 [18] years) and Puerto Ricans (age, 68 [17] years) were younger compared with NHWs (age, 76 [15] years). Mortality rates due to CVD decreased from a mean of 414.2 per 100 000 in 2003 to 303.3 per 100 000 in 2012. Estimated decreases in mortality rate for CVD from 2003 to 2012 ranged from 85 per 100 000 for all Hispanic women to 144 per 100 000 for Cuban men, but rate differences between groups vary substantially, with Puerto Ricans exhibiting similar mortality patterns to NHWs, and Mexicans experiencing lower mortality. Puerto Ricans experienced higher mortality rates for ischemic and hypertensive heart disease compared with other subgroups, whereas Mexicans experienced higher rates of cerebrovascular disease deaths. Conclusions and Relevance Significant differences in CVD mortality rates and changes over time were found among the 3 largest Hispanic subgroups in the United States. Findings suggest that the current aggregate classification of Hispanics masks heterogeneity in CVD mortality reporting, leading to an incomplete understanding of health risks and outcomes in this population.
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Affiliation(s)
- Fatima Rodriguez
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Katherine G Hastings
- Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, California
| | - Derek B Boothroyd
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Sandra Echeverria
- Department of Community Health and Social Sciences, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
| | - Lenny Lopez
- Department of Medicine, University of California, San Francisco, School of Medicine
| | - Mark Cullen
- Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, California
| | - Robert A Harrington
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Latha P Palaniappan
- Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, California
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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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8
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Payne S, Chapman A, Holloway M, Seymour JE, Chau R. Chinese Community Views: Promoting Cultural Competence in Palliative Care. J Palliat Care 2019. [DOI: 10.1177/082585970502100207] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sheila Payne
- Palliative and End-of-Life Care Research Group, University of Sheffield
| | - Alice Chapman
- Palliative and End-of-Life Care Research Group, University of Sheffield
| | | | - Jane E. Seymour
- Palliative and End-of-Life Care Research Group, University of Sheffield
| | - Ruby Chau
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
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9
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Do-Not-Resuscitate and Do-Not-Hospitalize Orders in Nursing Homes: Who Gets Them and Do They Make a Difference? J Am Med Dir Assoc 2019; 20:1169-1174.e1. [PMID: 30975587 DOI: 10.1016/j.jamda.2019.02.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/15/2019] [Accepted: 02/16/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To describe the rate of do-not-resuscitate (DNR) and do-not-hospitalize (DNH) orders among residents newly admitted into long-term care homes. We also assessed the association between DNR and DNH orders with hospital admissions, deaths in hospital, and survival. DESIGN A retrospective cohort study. SETTING AND PARTICIPANTS Admissions in all 640 publicly funded long-term care homes in Ontario, Canada, between January 1, 2010 and March 1, 2012 (n = 49,390). MEASURES We examined if a DNR and/or DNH was recorded on resident's admission assessment. All residents were followed until death, discharge, or end of study to ascertain rates of several outcomes, including death and hospitalization, controlling for resident characteristics. RESULTS Upon admission, 60.7% of residents were recorded to have a DNR and 14.8% a DNH order. Those who were older, female, widowed, lived in rural facilities, lived in higher income neighborhoods prior to entry, had higher health instability or cognitive impairment, and spoke English or French were more likely to receive a DNR or DNH. Survival time was only slightly shorter for those with a DNR and DNH with a mean of 145 and 133 days, respectively, vs 160 and 153 days for those without a DNR and DNH. After controlling for age, sex, rurality, neighborhood income, marital status, health instability, cognitive performance score, and multimorbidity, DNR and DNH were associated with an odds ratio of 0.57 [95% confidence interval (CI) 0.53-0.62] and 0.41 (95% CI 0.37-0.46) for dying in hospital, respectively. Those with a DNR and DNH, after adjustment, had an incidence rate ratio of 0.87 (95% CI 0.83-0.90) and 0.70 (95% CI 0.67-0.73), respectively, days spent in hospital. CONCLUSIONS AND IMPLICATIONS This study outlines identifiable factors influencing whether residents have a DNR and/or DNH order upon admission. Both orders led to lower rates, but not absolute avoidance, of hospitalizations near and at death.
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10
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Choi S, McDonough IM, Kim M, Kim G. The association between the number of chronic health conditions and advance care planning varies by race/ethnicity. Aging Ment Health 2018; 24:453-463. [PMID: 30593253 PMCID: PMC6599541 DOI: 10.1080/13607863.2018.1533521] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objectives: Although a national consensus exists on the need to increase the rates of advance care planning (ACP) for all adults, racial/ethnic differences in ACP have been consistently observed. This study investigated the intersection of racial/ethnic differences and the number of chronic health conditions on ACP among middle-aged and older adults in the United States.Method: Responses from 8,926 adults from the 2014 wave of the Health and Retirement Study were entered into multilevel hierarchical logistic regression analyses with generalized linear mixed models to predict ACP focused on assigning a durable power of attorney for healthcare (DPOAHC) and having a written living will after adjusting for covariates.Results: We found a significant positive relationship between the number of chronic health conditions and ACP. Non-Hispanic Blacks/African Americans and Hispanics were less likely to engage in ACP than non-Hispanic Whites/Caucasians. Racial/ethnic disparities were even starker for completing a living will. The number of chronic health conditions had a greater effect for Hispanics than non-Hispanic Whites/Caucasians on ACP through assigning a DPOAHC and having a living will. The initial disparity in ACP among Hispanics with no chronic health conditions decreased as the number of chronic health conditions increased.Conclusion: Our findings suggest that more chronic health conditions increase the likelihood that Hispanics will complete ACP documents. These ACP differences should be highlighted to researchers, policymakers, and healthcare professionals to reduce stark racial/ethnic disparities in ACP. A comprehensive and culturally caring decision-making approach should be considered when individuals and families engage in ACP.
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Affiliation(s)
- Shinae Choi
- Department of Consumer Sciences, The University of Alabama,
304 Adams Hall, Box 870158, Tuscaloosa, AL 35487, USA, Phone: 205-348-9173,
,Associate, Alabama Research Institute on Aging, The
University of Alabama, Tuscaloosa, AL 35487,Correspondence concerning this article should be
addressed to Shinae Choi
| | - Ian M. McDonough
- Associate, Alabama Research Institute on Aging, The
University of Alabama, Tuscaloosa, AL 35487,Department of Psychology, The University of Alabama, 410A
Gordon Palmer Hall, Box 870348, Tuscaloosa, AL 35487, USA, Phone: 205-737-3442,
| | - Minjung Kim
- Department of Educational Studies, The Ohio State
University, Ramseyer Hall, 29 W Woodruff Ave, Columbus, OH 43210, USA, Phone:
614-247-1858,
| | - Giyeon Kim
- Department of Psychology, Chung-Ang University, 84
Heukseok-Ro, Dongjak-Gu, Seoul 06974, South Korea, Phone: 82-2-820-5165,
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11
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Gutierrez C, Hsu W, Ouyang Q, Yao H, Pollack S, Pan CX. Palliative Care Intervention in the Intensive Care Unit: Comparing Outcomes among Seriously Ill Asian Patients and those of Other Ethnicities. J Palliat Care 2018. [DOI: 10.1177/082585971403000304] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The literature describing the attitude of Asians toward palliative care in the intensive care unit (ICU) is scarce. Aim: The purpose of this study was to compare outcomes of Asians and people of other ethnicities after palliative care intervention in the ICU. Methods: A retrospective chart review was conducted of all ICU patients evaluated by palliative care; the outcomes measured were incidence of life-sustaining treatments, institution of advance care directives, and preferences for end-of-life care. Results: The palliative care team evaluated 119 patients (46.2 percent Caucasian, 27.2 percent Asian, and 26.1 percent other ethnicities). There were no differences in demographics or clinical variables. Thirty-six percent of the Asians, 49 percent of the Caucasians, and 28.6 percent of the patients of other ethnicities (p=0.19) had healthcare proxies. The palliative care team increased advance care directives by more than 40 percent in all groups (p<0.001). There were no differences in the use of life-sustaining treatments or preferences for comfort measures among ethnic groups. Conclusion: Asians are as likely as people of other ethnicities to decide on advance care directives, life-sustaining treatments, and comfort measures after palliative care evaluation in the ICU. Contexte: Il existe très peu de publications décrivant l'attitude des asiatiques envers l'intervention des spécialistes en soins palliatifs dans le service de soins intensifs. But: Cette étude avait pour but de comparer les résultats obtenus chez les asiatiques et d'autres groupes ethniques après l'intervention de ces spécialistes auprès des patients et de leur famille dans le service de soins intensifs. Méthode: On a fait l'analyse rétrospective des dossiers de tous les patients ayant été rencontrés par l'équipe de soins palliatifs; les résultats de l'analyse portaient sur la fréquence des traitements de prolongation de vie, les directives de fin de vie, et les préférences des patients en ce qui avait trait aux soins de fin de vie. Résultats: L'équipe de soins palliatifs a évalué les dossiers de 119 patients (46,2 pourcent d'origine caucasienne, 27,2 pourcent d'origine asiatique, et 26,1 pourcent de diverses origines). Trente-six pourcent des asiatiques, 49 pourcent des caucasiens, et 28,6 pourcent des autres ethniques (p=19) avaient déjà choisi leur mandataire légal. L'équipe de soins palliatifs a augmenté le recours aux directives de fin de vie par plus de 40 pourcent dans tous les groupes (p=<0,001). Il n'y avait aucune différence entre ces groupes quant au recours aux traitements de fin de vie et aux mesures de confort du patient. Conclusion: Suite à une rencontre avec l'équipe de soins palliatifs, les asiatiques, tout comme les autres groupes ethniques, sont tout autant susceptibles de décider de leurs traitements de fin de vie et de recourir aux mesures de confort et aux directives préalables.
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Affiliation(s)
- Cristina Gutierrez
- Critical Care Medicine Service, Department of Medicine, New York Hospital Queens, 56–45 Main Street, Room WA-100, Flushing, New York 11355, USA
| | - William Hsu
- Internal Medicine, Department of Medicine, New York Hospital Queens, Flushing, New York, USA
| | - Qin Ouyang
- Internal Medicine, Department of Medicine, New York Hospital Queens, Flushing, New York, USA
| | - Haijun Yao
- Department of Pathology and Laboratory, Lutheran Medical Center, Brooklyn, New York, USA
| | - Simcha Pollack
- Computer Information Systems and Decision Sciences, Tobin College of Business, St. John's University, Jamaica, New York, USA
| | - Cynthia X. Pan
- Geriatrics and Palliative Care Medicine, Department of Medicine, New York Hospital Queens, Flushing, New York, USA
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12
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Cappell K, Sundaram V, Park A, Shiraz P, Gupta R, Jenkins P, Periyakoil VSJ, Muffly L. Advance Directive Utilization Is Associated with Less Aggressive End-of-Life Care in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2018; 24:1035-1040. [PMID: 29371107 DOI: 10.1016/j.bbmt.2018.01.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/15/2018] [Indexed: 11/30/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is associated with significant morbidity and mortality, making advance care planning (ACP) and management especially important in this patient population. A paucity of data exists on the utilization of ACP among allogeneic HCT recipients and the relationship between ACP and intensity of healthcare utilization in these patients. We performed a retrospective review of patients receiving allogeneic HCT at our institution from 2008 to 2015 who had subsequently died after HCT. Documentation and timing of advance directive (AD) completion were abstracted from the electronic medical record. Outcomes of interest included use of intensive care unit (ICU) level of care at any time point after HCT, within 30 days of death, and within 14 days of death; use of mechanical ventilation at any time after HCT; and location of death. Univariate logistic regression was performed to explore associations between AD completion and each outcome. Of the 1031 patients who received allogeneic HCT during the study period, 422 decedents (41%) were included in the analysis. Forty-four percent had AD documentation prior to death. Most patients (69%) indicated that if terminally ill, they did not wish to be subjected to life-prolonging treatment attempts. Race/ethnicity was significantly associated with AD documentation, with non-Hispanic white patients documenting ADs more frequently (51%) compared with Hispanic (22%) or Asian patients (35%; P = .0007). Patients with ADs were less likely to use the ICU during the transplant course (41% for patients with ADs versus 52% of patients without ADs; P = .03) and also were less likely to receive mechanical ventilation at any point after transplantation (21% versus 37%, P < .001). AD documentation was also associated with decreased ICU use at the end of life; relative to patients without ADs, patients with ADs were more likely to die at home or in hospital as opposed to in the ICU (odds ratio, .44; 95% confidence interval, .27 to .72). ACP remains underused in allogeneic HCT. Adoption of a systematic practice to standardize AD documentation as part of allogeneic HCT planning has the potential to significantly reduce ICU use and mechanical ventilation while improving quality of care at end of life in HCT recipients.
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Affiliation(s)
- Kathryn Cappell
- Department of Medicine, Blood and Marrow Transplantation, Stanford University, Stanford, California
| | - Vandana Sundaram
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, California
| | - Annie Park
- Department of Hematology/Oncology, Kaiser Permanente, Santa Clara, California
| | - Parveen Shiraz
- Department of Hematology/Oncology, Kaiser Permanente, Santa Clara, California
| | - Ridhi Gupta
- Department of Medicine, Blood and Marrow Transplantation, Stanford University, Stanford, California
| | - Patricia Jenkins
- Department of Medicine, Blood and Marrow Transplantation, Stanford University, Stanford, California
| | | | - Lori Muffly
- Department of Medicine, Blood and Marrow Transplantation, Stanford University, Stanford, California.
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Pfirstinger J, Bleyer B, Blum C, Rechenmacher M, Wiese CH, Gruber H. Determinants of completion of advance directives: a cross-sectional comparison of 649 outpatients from private practices versus 2158 outpatients from a university clinic. BMJ Open 2017; 7:e015708. [PMID: 29273648 PMCID: PMC5778305 DOI: 10.1136/bmjopen-2016-015708] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To compare outpatients from private practices and outpatients from a university clinic regarding the determinants of completion of advance directives (AD) in order to generalise results of studies from one setting to the other. Five determinants of completion of AD were studied: familiarity with AD, source of information about AD, prior experiences with own life-threatening diseases or family members in need of care and motives in favour and against completion of AD. DESIGN Observational cross-sectional study. SETTING Private practices and a university clinic in Germany in 2012. PARTICIPANTS 649 outpatients from private practices and 2158 outpatients from 10 departments of a university clinic. OUTCOME MEASURES Completion of AD, familiarity with AD, sources of information about AD (consultation), prior experiences (with own life-threatening disease and family members in need of care), motives in favour of or against completion of AD, sociodemographic data. RESULTS Determinants of completion of AD did not differ between outpatients from private practices versus university clinic outpatients. Prior experience with severe disease led to a significantly higher rate of completion of AD (33%/36% with vs 24%/24% without prior experience). Participants with completion of AD had more often received legal than medical consultation before completion, but participants without completion of AD are rather aiming for medical consultation. The motives in favour of or against completion of AD indicated inconsistent patterns. CONCLUSIONS Determinants of completion of AD are comparable in outpatients from private practices and outpatients from a university clinic. Generalisations from university clinic samples towards a broader context thus seem to be legitimate. Only one-third of patients with prior experience with own life-threatening diseases or family members in need of care had completed an AD as expression of their autonomous volition. The participants' motives for or against completion of AD indicate that ADs are considered a kind of 'negative autonomy' as instruments to prevent particular forms of therapy. Interactive, repeated and situation-based AD discussions might reach a higher percentage of patients and concurrently enable personal volitions and thereby strengthen individual 'positive autonomy'.
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Affiliation(s)
- Jochen Pfirstinger
- Department of Internal Medicine II, St. Marien Hospital Amberg, Amberg, Germany
- Department of Hematology, Regensburg University Hospital, Regensburg, Germany
| | - Bernhard Bleyer
- Institute of Sustainability, Ostbayerische Technische Hochschule Amberg-Weiden, Amberg, Germany
- Faculty of Catholic Theology, University of Regensburg, Regensburg, Germany
| | - Christian Blum
- Department of Educational Science, University of Regensburg, Regensburg, Germany
| | | | - Christoph H Wiese
- Department of Anaesthesiology, Regensburg University Hospital, Regensburg, Germany
- Department of Anaesthesiology, Herzogin Elisabeth Hospital, Braunschweig, Germany
| | - Hans Gruber
- Department of Educational Science, University of Regensburg, Regensburg, Germany
- Faculty of Education, University of Turku, Turku, Finland
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Sun A, Bui Q, Tsoh JY, Gildengorin G, Chan J, Cheng J, Lai K, McPhee S, Nguyen T. Efficacy of a Church-Based, Culturally Tailored Program to Promote Completion of Advance Directives Among Asian Americans. J Immigr Minor Health 2017; 19:381-391. [PMID: 27103618 PMCID: PMC5074907 DOI: 10.1007/s10903-016-0365-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Having an Advance Directive (AD) can help to guide medical decision-making. Asian Americans (AA) are less likely than White Americans to complete an AD. This pilot study investigated the feasibility and efficacy of a church-based intervention to increase knowledge and behavior change related to AD among Chinese and Vietnamese Americans. This study utilized a single group pre- and post-intervention design with 174 participants from 4 churches. Domain assessed: demographics; AD-related knowledge, beliefs, attitudes, and intentions; AD completion; and conversations with a healthcare proxy. Data were analyzed using Chi square and multiple logistic regression techniques. We observed significant increases in participants' AD-related knowledge, intentions, and a gain in supportive beliefs and attitudes about AD, resulting in 71.8 % AD completion, and 25.0 % having had a proxy conversation. Providing culturally-tailored intervention and step-by-step guidance can help to achieve significant changes in AD related knowledge and behavior in AA church goers.
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Affiliation(s)
- Angela Sun
- Chinese Community Health Resource Center, 728 Pacific Avenue Suite 115, San Francisco, CA, 94133, USA.
| | - Quynh Bui
- Department of Family and Community Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Janice Y Tsoh
- Department of Psychiatry, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Ginny Gildengorin
- Division of General Internal Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Joanne Chan
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Joyce Cheng
- Chinese Community Health Resource Center, 728 Pacific Avenue Suite 115, San Francisco, CA, 94133, USA
| | - Ky Lai
- Division of General Internal Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Stephen McPhee
- Division of General Internal Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Tung Nguyen
- Division of General Internal Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
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Holmes SM, Karlin J, Stonington SD, Gottheil DL. The first nationwide survey of MD-PhDs in the social sciences and humanities: training patterns and career choices. BMC MEDICAL EDUCATION 2017; 17:60. [PMID: 28327141 PMCID: PMC5361808 DOI: 10.1186/s12909-017-0896-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 03/09/2017] [Indexed: 05/30/2023]
Abstract
BACKGROUND While several articles on MD-PhD trainees in the basic sciences have been published in the past several years, very little research exists on physician-investigators in the social sciences and humanities. However, the numbers of MD-PhDs training in these fields and the number of programs offering training in these fields are increasing, particularly within the US. In addition, accountability for the public funding for MD-PhD programs requires knowledge about this growing population of trainees and their career trajectories. The aim of this paper is to describe the first cohorts of MD-PhDs in the social sciences and humanities, to characterize their training and career paths, and to better understand their experiences of training and subsequent research and practice. METHODS This paper utilizes a multi-pronged recruitment method and novel survey instrument to examine an understudied population of MD-PhD trainees in the social sciences and humanities, many of whom completed both degrees without formal programmatic support. The survey instrument was designed to collect demographic, training and career trajectory data, as well as experiences of and perspectives on training and career. It describes their routes to professional development, characterizes obstacles to and predictors of success, and explores career trends. RESULTS The average length of time to complete both degrees was 9 years. The vast majority (90%) completed a clinical residency, almost all (98%) were engaged in research, the vast majority (88%) were employed in academic institutions, and several others (9%) held leadership positions in national and international health organizations. Very few (4%) went into private practice. The survey responses supply recommendations for supporting current trainees as well as areas for future research. CONCLUSIONS In general, MD-PhDs in the social sciences and humanities have careers that fit the goals of agencies providing public funding for training physician-investigators: they are involved in mutually-informative medical research, clinical practice, and teaching - working to improve our responses to the social, cultural, and political determinants of health and health care. These findings provide strong evidence for continued and improved funding and programmatic support for MD-PhD trainees in the social sciences and humanities.
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Affiliation(s)
- Seth M. Holmes
- Public Health and Medical Anthropology, University of California Berkeley, 50 University Hall, MC 7360, Berkeley, CA 94720 USA
- Anthropology, History and Social Medicine, School of Medicine, University of California San Francisco, 50 University Hall, MC 7360, Berkeley, CA 94720 USA
- Department of Medicine, Alameda County Medical Center, 50 University Hall, MC 7360, Berkeley, CA 94720 USA
| | - Jennifer Karlin
- Family and Community Medicine, School of Medicine, University of California San Francisco, San Francisco, USA
| | - Scott D. Stonington
- Department of Anthropology and Department of Medicine, School of Medicine, University of Michigan, Michigan, USA
| | - Diane L. Gottheil
- Medical Scholars Program, University of Illinois College of Medicine at Urbana-Champaign, Illinois, USA
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Weerasinghe S, Maddalena V. Negotiation, Mediation and Communication between Cultures: End-of-Life Care for South Asian Immigrants in Canada from the Perspective of Family Caregivers. SOCIAL WORK IN PUBLIC HEALTH 2016; 31:665-677. [PMID: 27362293 DOI: 10.1080/19371918.2015.1137521] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
In the present study, we explored family caregivers' experiences in providing end-of-life care for terminally ill South Asian immigrants. We employed qualitative methods and. in-depth interviews were conducted with seven family caregivers living in Nova Scotia, Canada. Interview data were validated, coded and organized for themes. Three major themes identified in the data illustrated (a) how South Asian caregivers experienced clashes between biomedical and ethno-cultural realms of care that led to cultural insensitivity, (b) how family members acted as mediators, and (c) how communication issues that challenged cultural sensitivity were handled. Findings provide directions for culturally sensitive end-of-life care planning.
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Affiliation(s)
- Swarna Weerasinghe
- a Community Health and Epidemiology, Dalhousie University, Centre for Clinical Research , Halifax , Nova Scotia , Canada
| | - Victor Maddalena
- b Faculty of Medicine, Division of Community Health and Humanities , Memorial University of Newfoundland , St. John's , Newfoundland and Labrador, Canada
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Abstract
This study examines the process of advance care planning in managed care programs serving the frail elderly and assesses the contributions of individual versus program characteristics on choices made. Data about 3,548 participants in nine programs were obtained. Logistic regressions examine associations between independent variables and end-of-life treatment choices. Interviews with the programs’ medical directors augment quantitative analysis. When all of the known participant characteristics are accounted for, substantial amount of variation attributable to the program-indicator variable remains. Program effect explains 36% of the variation in do-not-resuscitate choice, 66% in the choice of artificial feeding, and 50% relating to the presence of health care proxy. The variation in treatment choices attributable to the program of enrollment and the interviews with the medical directors suggest that provider practice styles are important in determining patients’ choices at the end of life. Interventions to enhance advance care planning should target providers of care.
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Lynn T, Curtis A, Lagerwey MD. Association Between Attitude Toward Death and Completion of Advance Directives. OMEGA-JOURNAL OF DEATH AND DYING 2016. [DOI: 10.1177/0030222815598418] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Advance directives provide health-care instruction for incapacitated individuals and authorize who may make health-care decisions for that individual. Identified factors do not explain all variance related to advance directive completion. This study was an analysis of an association between advance directive completion and death attitudes. Surveys that included the Death Attitude Profile—Revised were completed anonymously. Comparisons of means, chi-square, and logistic regression tests were conducted. Among individuals who did not consider themselves religious, the mean death avoidance attitude scores differed significantly among those with advance directives (mean = 1.93) and those without (mean = 4.05) as did the mean approach acceptance attitude scores of those with advance directives (mean = 5.73) and those without (mean = 3.71). Among individuals who do consider themselves religious, the mean escape acceptance attitude scores differed significantly among those with advance directives (mean = 5.11) and those without (mean = 4.15). The complicated relationships among religiosity, advance directives, and death attitudes warrant further study.
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Affiliation(s)
- Theresa Lynn
- Wings of Hope Hospice, Western Michigan University, Pullman, MI, USA
| | - Amy Curtis
- Western Michigan University, Kalamazoo, MI, USA
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Barrett RK. Dialogues in Diversity: An Invited Series of Papers, Advance Directives, DNRs, and End-of-Life Care for African Americans. OMEGA-JOURNAL OF DEATH AND DYING 2016. [DOI: 10.2190/8c1y-cpwa-132n-uwxy] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The article utilizes a meta-analysis of the existing empirical research and theory on health care directives to provide some insights into the documented pattern of African Americans to use advance directives less than Whites. A number of relevant factors are highlighted and examined. In addition the article attempts to provide some insights into African American family life and traditional values regarding the care of the elderly and end-of-life care. The African American tradition of employing a family-centered decision making process during family crisis, as well as a significant cultural mistrust of institutionalized care is also explored. The article also attempts to offer some practical suggestions for clinical care givers working with African Americans to enhance culturally sensitive care giving and the utilization of advanced directives among African Americans at the end-of-life.
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McDonald DD, Deloge JA, Joslin N, Petow WA, Severson JS, Votino R, Shea MD, Drenga JML, Brennan MT, Moran AB, Del Signore E. Communicating End-of-Life Preferences. West J Nurs Res 2016; 25:652-66; discussion 667-75. [PMID: 14528616 DOI: 10.1177/0193945903254062] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this survey was to explore how adults communicate their end-of-life preferences. Face-to-face interviews were conducted with 119 community-dwelling adults who had previously engaged in conversations about their end-of-life preferences. Factors that made it easier to initiate the discussion included having personal experience with illness or death (24.4%), being straightforward (24.4%), or having someone else facilitate the discussion (11.8%). Most described vague end-of-life preferences such as not wanting any machines (41.2%) or heroics (34.5%). Although 22.7% reported using a living will to make their preferences clear, only 5.9% mentioned repeating or reinforcing their preferences. In all, 21% had discussed their end-of-life preferences with their physicians. These findings show discussions about end-of-life preferences frequently lack the clarity and detail needed by significant others and health care providers to honor the preferences. Routine dialogue with health care providers and significant others about end-of-life preferences might provide greater clarity and comfort.
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21
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Witte TH, Menon AS, Ruskin PE, Wiley C, Hebel JR. Advance Directives among Elderly Veterans. J Appl Gerontol 2016. [DOI: 10.1177/0733464803022002002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The goal of this study was to identify various sociodemographic and clinical variables related to the completion of advance directives among 281 elderly male veterans recruited from the acute medical inpatient unit of a Veterans Affairs Medical Center. Results found the rates of advance directives to be higher among elderly male veterans compared to other populations (44% had either a durable power of attorney or a living will, 34.2% had a living will, and 35.2% had a durable power of attorney). In addition, individuals who completed an advance directive were significantly more likely to be Caucasian than non-Caucasian. Other than race, there were other important factors including religiosity, desire for life-saving treatment, social support, and depressive symptoms that were related to the completion of advance directives among elderly veterans. Such factors seem consistent with the research literature on nonveteran populations.
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Affiliation(s)
| | | | - Paul E. Ruskin
- Department of Veterans Affairs, Maryland Health Care System
| | - Cynthia Wiley
- Department of Veterans Affairs, Maryland Health Care System
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Rhodes RL, Elwood B, Lee SC, Tiro JA, Halm EA, Skinner CS. The Desires of Their Hearts: The Multidisciplinary Perspectives of African Americans on End-of-Life Care in the African American Community. Am J Hosp Palliat Care 2016; 34:510-517. [PMID: 26878868 DOI: 10.1177/1049909116631776] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Studies have identified racial differences in advance care planning and use of hospice for care at the end of life. Multiple reasons for underuse among African American patients and their families have been proposed and deserve further exploration. OBJECTIVE The goal of this study was to examine perceptions of advance care planning, palliative care, and hospice among a diverse sample of African Americans with varying degrees of personal and professional experience with end-of-life care and use these responses to inform a culturally sensitive intervention to promote awareness of these options. METHODS Semistructured interviews and focus groups were conducted with African Americans who had varying degrees of experience and exposure to end-of-life care both personally and professionally. We conducted in-depth qualitative analyses of these interviews and focus group transcripts and determined that thematic saturation had been achieved. RESULTS Several themes emerged. Participants felt that advance care planning, palliative care, and hospice can be beneficial to African American patients and their families but identified specific barriers to completion of advance directives and hospice enrollment, including lack of knowledge, fear that these measures may hasten death or cause providers to deliver inadequate care, and perceived conflict with patients' faith and religious beliefs. Providers described approaches they use to address these barriers in their practices. CONCLUSION Findings, which are consistent with and further elucidate those identified from previous research, will inform design of a culturally sensitive intervention to increase awareness and understanding of advance care planning, palliative care, and hospice among members of the African American community.
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Affiliation(s)
- Ramona L Rhodes
- 1 Division of Geriatric Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.,2 Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA
| | - Bryan Elwood
- 3 Division of Outcomes and Health Services Research, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA
| | - Simon C Lee
- 2 Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA.,4 Division of Behavioral and Communication Sciences, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA
| | - Jasmin A Tiro
- 2 Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA.,4 Division of Behavioral and Communication Sciences, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ethan A Halm
- 2 Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA.,3 Division of Outcomes and Health Services Research, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.,5 Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Celette S Skinner
- 2 Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA.,4 Division of Behavioral and Communication Sciences, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA
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Knowledge of advance directive and perceptions of end-of-life care in Chinese-American elders: The role of acculturation. Palliat Support Care 2015; 13:1677-84. [PMID: 26062573 DOI: 10.1017/s147895151500067x] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE This study aimed to describe knowledge of an advance directive (AD) and preferences regarding end-of-life (EoL) care communication, decision making, and designation of surrogates in Chinese-American elders and to examine the role of acculturation variables in AD awareness. METHOD Survey data were collected through face-to-face interviews on a sample of 385 Chinese-American elders aged 55 or above living in the Phoenix metropolitan area. The choice of language (Mandarin, Cantonese, or English) and place of interview (senior apartments, Chinese senior centers, or homes) was at the respondent's preference. Hierarchical logistic regression analysis was employed to examine the influence of acculturation variables on AD awareness. RESULTS Some 21% of participants had heard about ADs, and only 10% had completed one. Elders with higher acculturation levels (OR = 1.04, p < 0.10) and those residing more than 20 years in the United States (OR = 6.87, p < 0.01) were more likely to be aware of ADs after controlling for the effects of demographics, health, and experiences of EoL care. The majority preferred physicians to initiate AD discussions (84.9%) and identified burdens on families as the most important factor in making EoL decisions (89.3%). About 55.1 % considered daughters as the preferred healthcare surrogate. SIGNIFICANCE OF RESULTS Acculturation levels influence awareness of an AD, and family values are crucial in EoL care decision making. Cultural factors should be considered in designing and delivering appropriate programs to promote knowledge of EoL care among Chinese-American elders and their families.
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Williamson JD. Improving Care Management and Health Outcomes for Frail Older People: Implications of the PACE Model. J Am Geriatr Soc 2015. [DOI: 10.1111/jgs.2000.48.11.1529] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Care planning in dementia is made more complicated by the increasing prevalence of multiple chronic comorbidities, also termed 'frailty'. Consideration of the reciprocal impact of dementia and other health issues is critical to appropriate care planning. This may be best achieved through an ordered process whereby the clinician first considers medical evidence and its limitations to the medical, physical and social determinants of the patient's health trajectory and quality of life. The next step is to provide information and recommendations to the patient and a second decision maker (who will become increasingly involved as dementia progresses). The end point of care planning is an informed and empowered decision maker who is able to dynamically apply skills to measure any treatment option that may be proposed, while having access to the decisional support of a health professional familiar with the patient's health status.
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Affiliation(s)
- Paige Moorhouse
- Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, NS, Canada.
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Zhang W. Older Adults Making End of Life Decisions: An Application of Roy's Adaptation Model. J Aging Res 2013; 2013:470812. [PMID: 24455259 PMCID: PMC3888737 DOI: 10.1155/2013/470812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 10/15/2013] [Indexed: 11/24/2022] Open
Abstract
Purpose. The purpose of this study was to identify variables that influenced completion of advanced directives in the context of adaptation from national data in older adults. Knowledge gained from this study would help us identify factors that might influence end of life discussions and shed light on strategies on effective communication on advance care planning. Design and Method. A model-testing design and path analysis were used to examine secondary data from 938 participants. Items were extracted from the data set to correspond to variables for this study. Scales were constructed and reliabilities were tested. Results. The final path model showed that physical impairment, self-rated health, continuing to work, and family structure had direct and indirect effects on completion of advanced directives. Five percent of the variance was accounted for by the path analysis. Conclusion. The variance accounted for by the model was small. This could have been due to the use of secondary data and limitations imposed for measurement. However, health care providers and families should explore patient's perception of self-health as well as their family and work situation in order to strategize a motivational discussion on advance directive or end of life care planning.
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Affiliation(s)
- Weihua Zhang
- Nell Hodgson Woodruff School of Nursing Emory University, 1520 Clifton Road, Atlanta, GA 30322-4207, USA
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Loggers ET, Maciejewski PK, Jimenez R, Nilsson M, Paulk E, Stieglitz H, Prigerson HG. Predictors of intensive end-of-life and hospice care in Latino and white advanced cancer patients. J Palliat Med 2013; 16:1249-54. [PMID: 24053593 DOI: 10.1089/jpm.2013.0164] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The role of end-of-life (EOL) care preferences and conversations in receipt of care near death for Latinos is unclear. OBJECTIVE This study examines rates and predictors of intensive EOL and hospice care among Latino and white advanced cancer patients. DESIGN Two-hundred-and-ninety-two self-reported Latino (n=58) and white (n=234) Stage IV cancer patients participated in a U.S. multisite, prospective, cohort study from September 2002 to August 2008. The Latino and white, non-Hispanic participants were interviewed and followed until death, a median of 118.5 days from baseline. MEASUREMENTS Patient-reported, baseline predictors of EOL care included EOL care preference; terminal illness acknowledgement; EOL discussion; completion of a DNR order; and religious coping. Caregiver postmortem interviews provided information regarding EOL care received. Intensive EOL care was defined as resuscitation and/or ventilation followed by death in an intensive care unit. Hospice was either in- or outpatient. RESULTS Latino and white patients received intensive EOL and hospice care at similar rates (5.2% and 3.4% for intensive care, p=0.88; 70.7% versus 73.4% for hospice, p=0.33). No white or Latino patient who reported a DNR order or EOL discussion at baseline received intensive EOL care. Religious coping and a preference for life-extending care predicted intensive EOL care for white patients (adjusted odds ratio [aOR] 6.69 [p=0.02] and aOR 6.63 [p=0.01], respectively), but not for Latinos. No predictors were associated with Latino hospice care. CONCLUSIONS EOL discussions and DNR orders may prevent intensive EOL care among Latino cancer patients. Efforts should continue to engage Latino patients and caregivers in these activities.
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Affiliation(s)
- Elizabeth T Loggers
- 1 Group Health Research Institute , Group Health Co-operative, Seattle, Washington
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Raijmakers NJH, Rietjens JA, Kouwenhoven PS, Vezzoni C, van Thiel GJ, van Delden JJ, van der Heide A. Involvement of the Dutch General Population in Advance Care Planning: A Cross-Sectional Survey. J Palliat Med 2013; 16:1055-61. [DOI: 10.1089/jpm.2012.0555] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Natasja J. H. Raijmakers
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, the Netherlands
- Department of Medical Oncology, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Judith A.C. Rietjens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | | | - Cristiano Vezzoni
- Department of Sociology and Social Research, University of Trento, Italy
- Department of Health Sciences, Metamedica, University Medical Center Groningen, University of Groningen, The Netherlands
| | | | | | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, the Netherlands
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Laguna J, Enguídanos S, Siciliano M, Coulourides-Kogan A. Racial/ethnic minority access to end-of-life care: a conceptual framework. Home Health Care Serv Q 2012; 31:60-83. [PMID: 22424307 DOI: 10.1080/01621424.2011.641922] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Minority underutilization of hospice care has been well-documented; however, explanations addressing disparities have failed to examine the scope of factors in operation. Drawing from previous health care access models, a framework is proposed in which access to end-of-life care results from an interaction between patient-level, system-level, and societal-level barriers with provider-level mediators. The proposed framework introduces an innovative mediating factor missing in previous models, provider personal characteristics, to better explain care access disparities. This article offers a synthesis of previous research and proposes a framework that is useful to researchers and clinicians working with minorities at end of life.
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Affiliation(s)
- Jeff Laguna
- University of Southern California, Davis School of Gerontology, Los Angeles, California 90089-0191, USA.
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Abstract
Objectives: The author investigated (a) whether Whites, Blacks, Latinos, and Asians differ in their rates of advance care planning (ACP; that is, living will, health care proxies, discussions), (b) sources of within-racial group heterogeneity, and (c) racial differences in the explanations offered for not doing ACP. Methods: The author estimated logistic regression models with data from a national sample of married and cohabiting adults ages 18 to 64 in the Knowledge Networks study ( N = 2,111). Results: Latinos are less likely than Whites to discuss preferences and to have a living will, although the latter gap is fully accounted for by education. Asians are less likely than Whites to have discussions, but more likely to have living wills. Black-White differences emerge only among low SES (socioeconomic status) subgroups. Each group noted distinctive obstacles to planning. Discussion: Public policies should target increasing rates of ACP for all adults prior to onset of major health concerns.
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Erlandson KM, Allshouse AA, Duong S, MaWhinney S, Kohrt WM, Campbell TB. HIV, aging, and advance care planning: are we successfully planning for the future? J Palliat Med 2012; 15:1124-9. [PMID: 22694717 DOI: 10.1089/jpm.2011.0510] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Studies of advance care planning (ACP) completion rates in HIV-infected persons pre-date the "graying" of the HIV epidemic. We sought to examine current ACP completion rates and factors influencing completion among HIV-infected persons. METHODS HIV-1-seropositive persons aged 45-65 years on effective antiretroviral therapy for a minimum of 6 months were enrolled in a cross-sectional survey. Likelihood of ACP was assessed by demographic and clinical characteristics, tested with odds ratios (OR) and 95% Wald confidence intervals (CI), and adjusted for gender. RESULTS Of 238 participants, 112 (47%) completed ACP. Persons ≥55 years of age (OR 2.8; CI 1.6,5.0; p<0.001), males (OR 4.1; CI 1.8,9.3; p=0.004), and persons with higher education (OR 2.2; CI 1.3,4.0; p=0.007) were more likely to have completed ACP. Persons with a cardiac event were more likely to have completed ACP (OR 5.5; CI 1.6,25; p=0.03), although this effect was diminished after adjusting for gender (OR 4.5; CI 0.95,21.4; p=0.06). HIV infection diagnosed for greater than 5 years was not associated with ACP completion (OR 1.3; CI 0.7,2.7; p=0.4). Current CD4(+) cell counts were similar between those completing and not completing documentation (588 cells/μL and 604 cells/μL, respectively; p=0.7). The likelihood of ACP did not significantly differ with other comorbidities. DISCUSSION Less than 50% of middle-aged patients in HIV care had documented ACP. In particular, women and those with lower education were at greatest risk of non-completion and may need interventions to improve ACP.
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Affiliation(s)
- Kristine M Erlandson
- Department of Medicine, Division of Infectious Disease, University of Colorado-Anschutz Medical Campus, Aurora, Colorado 80045, USA.
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Mwaria CB. Pain Management for the Terminally Ill: The Role of Race and Religion. JOURNAL OF THE ISLAMIC MEDICAL ASSOCIATION OF NORTH AMERICA 2012; 43:208-14. [PMID: 23610512 PMCID: PMC3516116 DOI: 10.5915/43-3-9039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Martin MY, Pisu M, Oster RA, Urmie JM, Schrag D, Huskamp HA, Lee J, Kiefe CI, Fouad MN. Racial variation in willingness to trade financial resources for life-prolonging cancer treatment. Cancer 2011; 117:3476-84. [PMID: 21523759 DOI: 10.1002/cncr.25839] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 11/11/2010] [Accepted: 11/16/2010] [Indexed: 11/09/2022]
Abstract
BACKGROUND Minority patients receive more aggressive care at the end of life, but it is unclear whether this trend is consistent with their preferences. We compared the willingness to use personal financial resources to extend life among white, black, Hispanic, and Asian cancer patients. METHODS Patients with newly diagnosed lung or colorectal cancer participating in the Cancer Care Outcomes Research and Surveillance observational study were interviewed about myriad aspects of their care, including their willingness to expend personal financial resources to prolong life. We evaluated the association of race/ethnicity with preference for life-extending treatment controlling for clinical, sociodemographic, and psychosocial factors using logistic regression. RESULTS Among patients (N = 4214), 80% of blacks reported a willingness to spend all resources to extend life, versus 54% of whites, 69% of Hispanics, and 72% of Asians (P<.001). In multivariate analyses, blacks were more likely to opt for expending all financial resources to extend life than whites (odds ratio, 2.41; 95% confidence interval, 1.84-3.17; P < .001). CONCLUSIONS Black cancer patients are more willing to exhaust personal financial resources to extend life. Delivering quality cancer care requires an understanding of how these preferences impact cancer care and outcomes.
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Affiliation(s)
- Michelle Y Martin
- Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294-4410, USA.
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Hirschman KB, Abbott KM, Hanlon AL, Prvu Bettger J, Naylor MD. What factors are associated with having an advance directive among older adults who are new to long term care services? J Am Med Dir Assoc 2011; 13:82.e7-11. [PMID: 21450235 DOI: 10.1016/j.jamda.2010.12.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Revised: 12/09/2010] [Accepted: 12/13/2010] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To explore differences in having an advance directive among older adults newly transitioned to long term services and support (LTSS) settings (ie, nursing homes [NHs]; assisted living facilities [ALFs]; home and community-based services). DESIGN Cross sectional survey. SETTING LTSS in New York and Pennsylvania. PARTICIPANTS Participants were 470 older adults who recently started receiving LTSS. Included in this analyses, N = 442 (ALF: n = 153; NH: n = 145; home and community-based services: n = 144). MEASUREMENTS Interviews consisted of questions about advance directives (living will and health care power of attorney), significant health changes in the 6 months before the start of long term care support services, Mini-Mental State Examination, and basic demographics. RESULTS Sixty-one percent (270/442) of older adults receiving LTSS reported having either a living will and/or an health care power of attorney. ALF residents reported having an advance directive more frequently than NH residents and older adults receiving LTSS in their own home (living will: χ(2)[2]= 120.9; P < .001; health care power of attorney: χ(2)[2]= 69.1; P < .001). In multivariate logistic regression models, receiving LTSS at an ALF (OR = 5.01; P < .001), being white (OR = 2.87; P < .001), having more than 12 years of education (OR = 2.50; P < .001), and experiencing a significant health change in past 6 months (OR = 1.97; P = .007) were predictive of having a living will. Receiving LTSS at an ALF (OR = 4.16; P < .001), having more than 12 years of education (OR = 1.74, P = .022), and having had a significant change in health in the last 6 months (OR = 1.61; P = .037) were predictive in having an health care power of attorney in this population of LTSS recipients. CONCLUSIONS These data provide insight into advance directives and older adults new to LTSS. Future research is needed to better understand the barriers to completing advance directives before and during enrollment in LTSS as well as to assess advance directive completion changes over time for this population of older adults.
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Affiliation(s)
- Karen B Hirschman
- School of Nursing, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Muni S, Engelberg RA, Treece PD, Dotolo D, Curtis JR. The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU. Chest 2011; 139:1025-1033. [PMID: 21292758 DOI: 10.1378/chest.10-3011] [Citation(s) in RCA: 150] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND There is conflicting evidence about the influence of race/ethnicity on the use of intensive care at the end of life, and little is known about the influence of socioeconomic status. METHODS We examined patients who died in the ICU in 15 hospitals. Race/ethnicity was assessed as white and nonwhite. Socioeconomic status included patient education, health insurance, and income by zip code. To explore differences in end-of-life care, we examined the use of (1) advance directives, (2) life-sustaining therapies, (3) symptom management, (4) communication, and (5) support services. RESULTS Medical charts were abstracted for 3,138/3,400 patients of whom 2,479 (79%) were white and 659 (21%) were nonwhite (or Hispanic). In logistic regressions adjusted for patient demographics, socioeconomic factors, and site, nonwhite patients were less likely to have living wills (OR, 0.41; 95% CI, 0.32-0.54) and more likely to die with full support (OR, 1.59; 95% CI, 1.30-1.94). In documentation of family conferences, nonwhite patients were more likely to have documentation that prognosis was discussed (OR, 1.47; 95% CI, 1.21-1.77) and that physicians recommended withdrawal of life support (OR, 1.57; 95% CI, 1.11-2.21). Nonwhite patients also were more likely to have discord documented among family members or with clinicians (OR, 1.49; 95% CI, 1.04-2.15). Socioeconomic status did not modify these associations and was not a consistent predictor of end-of-life care. CONCLUSIONS We found numerous racial/ethnic differences in end-of-life care in the ICU that were not influenced by socioeconomic status. These differences could be due to treatment preferences, disparities, or both. Improving ICU end-of-life care for all patients and families will require a better understanding of these issues. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00685893; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Sarah Muni
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, CA
| | - Ruth A Engelberg
- Harborview Medical Center and the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Patsy D Treece
- Harborview Medical Center and the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Danae Dotolo
- Harborview Medical Center and the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - J Randall Curtis
- Harborview Medical Center and the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA.
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Cohen MJ, McCannon JB, Edgman-Levitan S, Kormos WA. Exploring attitudes toward advance care directives in two diverse settings. J Palliat Med 2010; 13:1427-32. [PMID: 21091225 DOI: 10.1089/jpm.2010.0200] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Advance care directives (ACD) are not used equally by different ethnic groups in the United States. Theories regarding this difference include lack of access to health care, mistrust of the health care system, absence of surrogate decision makers, and universal lack of knowledge on this topic. Few studies have investigated attitudes toward advance care planning for future end-of-life decision-making in the Latino and Cambodian communities. METHODS Six focus groups were conducted, including a total of 20 Latino and 19 Cambodian patients of two community health centers. Focus groups were audiotaped, transcribed, and qualitatively analyzed to identify major themes regarding attitudes toward advance directives and engaging in discussion about advance care planning. RESULTS Most patients did not have a health care proxy nor had discussed this topic with their doctor. Two broad themes were identified: integration of belief systems (including religion, suffering/destiny, and importance of quality of life) as well as process/preferences regarding decision-making (including family roles, provider roles, confusion/uncertainty regarding ACD, and openness to learning about ACD). CONCLUSIONS In focus groups discussing end-of-life decision making among Latino and Cambodian patients, two main themes emerged: integration of belief systems and process/preferences regarding end-of-life care. In particular, efforts to improve completion of advance care directives in diverse populations should consider patients' emphasis on quality of life and destiny in end-of-life planning as well as the role of family consensus in decision-making.
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Affiliation(s)
- Marya J Cohen
- Division of General Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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Abstract
AbstractObjective:The purpose of this study was to determine the factors which influence advance directive (AD) completion among older adults.Method:Direct interviews of hospitalized and community-dwelling cognitively intact patients >65 years of age were conducted in three tertiary teaching settings in New York. Analysis of AD completion focused on its correlation with demographics, personal beliefs, knowledge, attitudes, and exposure to educational media initiatives. We identified five variables with loadings of at least 0.30 in absolute value, along with five demographic variables (significant in the univariate analyses) for multiple logistic regression. The backward elimination method was used to select the final set of jointly significant predictor variables.Results:Of the 200 subjects consenting to an interview, 125 subjects (63%) had completed ADs. In comparing groups with and without ADs, gender (p < 0.0002), age (p < 0.0161), race (p < 0.0001), education (p < 0.0039), and religion (p < 0.0104) were significantly associated with having an AD. Factors predicting AD completion are: thinking an AD will help in the relief of suffering at the end of life, (OR 76.3,p < 0.0001), being asked to complete ADs/ or receiving explanation about ADs (OR 55.2,p < 0.0001), having undergone major surgery (OR 6.3,p < 0.0017), female gender (OR 11.1,p < 0.0001) and increasing age (76–85vs.59–75: OR 3.4,p < 0.0543; <85vs. 59–75: OR 6.3,p < 0.0263).Significance of results:This study suggests that among older adults, the probability of completing ADs is related to personal requests by health care providers, educational level, and exposure to advance care planning media campaigns.
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Ouslander JG, Lamb G, Perloe M, Givens JH, Kluge L, Rutland T, Atherly A, Saliba D. Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes, and Costs. J Am Geriatr Soc 2010; 58:627-35. [PMID: 20398146 DOI: 10.1111/j.1532-5415.2010.02768.x] [Citation(s) in RCA: 345] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Joseph G Ouslander
- Charles E. Schmidt College of Biomedical Sciences and Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida, USA.
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Pruchno R, Cartwright FP, Wilson-Genderson M. The effects of race on patient preferences and spouse substituted judgments. Int J Aging Hum Dev 2009; 69:31-54. [PMID: 19803339 DOI: 10.2190/ag.69.1.c] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Knowledge about the ways in which race affects decision-making at the end of life is minimal, yet this information is critical for providing culturally sensitive care at the end of life. Data matching socio-demographic characteristics of 34 black and 34 white patients with end-stage renal disease and their spouses reveal that there are no significant differences in the preferences to continue dialysis on the part of black and white patients. However, the substituted judgments of black and white spouses differ from one another, with black spouses being more likely to indicate that they believe that the patient would be more inclined to continue dialysis under a host of hypothetical conditions than white spouses. Structural equation modeling analyses revealed that differences in spouse substituted judgments between black and white spouses are explained as a direct function of race differences in perception of patient's health, and caregiver burden, and that indirect effects are associated with spouse's fear of death and participation in religious services. We conclude that these variables rather than race per se explain differences in end of life decision making.
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Affiliation(s)
- Rachel Pruchno
- New Jersey Institue for Successful Aging, University of Medicine & Dentistry of New Jersey-School of Osteopathic Medicine, Stratford, NJ 08084, USA.
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Cesta MA, Cardenas-Turanzas M, Wakefield C, Price KJ, Nates JL. Life-Supportive Therapy Withdrawal and Length of Stay in a Large Oncologic Intensive Care Unit at the End of Life. J Palliat Med 2009; 12:713-8. [DOI: 10.1089/jpm.2009.0045] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mark A. Cesta
- Emergency Health Centre at Willowbrook, Houston, Texas
| | - Marylou Cardenas-Turanzas
- Department of Critical Care Medicine, Division of Anesthesiology and Critical Care, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Chris Wakefield
- Department of Critical Care Medicine, Division of Anesthesiology and Critical Care, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Kristen J. Price
- Department of Critical Care Medicine, Division of Anesthesiology and Critical Care, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Joseph L. Nates
- Department of Critical Care Medicine, Division of Anesthesiology and Critical Care, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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Lawrence JF. The advance directive prevalence in long-term care: a comparison of relationships between a nurse practitioner healthcare model and a traditional healthcare model. ACTA ACUST UNITED AC 2009; 21:179-85. [PMID: 19302695 DOI: 10.1111/j.1745-7599.2008.00381.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study was to examine rates of completion of advance directives (ADs) among institutionalized older adults in three geographically diverse areas of the country--Arizona, Georgia, and Massachusetts. Comparisons among four variables--gender, race, education, and type of healthcare model (Evercare vs. non-Evercare), related to AD completion rates were examined. DATA SOURCES This study was a secondary data analysis using deidentified data from 11,775 older adults enrolled in the Evercare healthcare model to 91,443 non-Evercare older adults (Minimum Data Set) during the last quarter of 2004. Chi-square analysis was used to examine any differences in gender, race, education, and healthcare model associated with the completion rates of ADs. CONCLUSIONS The Evercare healthcare model that used nurse practitioners (NPs) consistently had significantly higher (p < .001) completion rates of ADs compared to the non-Evercare healthcare model that did not use NPs. Black people and white people in the Evercare healthcare model had similar rates of AD completion (p > .001), which is contrary to previous findings where black people had a lower completion rate. Males and females in the Evercare healthcare model had similar rates of AD completion (p > .001), which is also contrary to previous findings where females had a higher completion rate. Finally, older adults with a high school education or less and older adults with greater than a high school education in the Evercare healthcare model had similar rates of AD completion (p > .001), which is contrary to previous findings where individuals with increased education had a higher completion rate. IMPLICATIONS FOR PRACTICE With the increasing number of older adults in the general and the long-term care population, older adults should be encouraged to complete their ADs when discussing their medical decisions with their healthcare providers. Through the use of the Evercare healthcare model, NPs are well prepared to assist their clients and families in identifying these decisions. As a result, a significantly greater proportion of ADs have been completed by individuals enrolled in the Evercare healthcare model when compared to non-Evercare individuals living in long-term care settings. By using this model, Evercare NPs ensure that the specific medical choices of their patients are carried out.
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Affiliation(s)
- James F Lawrence
- B.F. Lewis School of Nursing, Georgia State University, Atlanta, Georgia 30319, USA.
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Daaleman TP, Emmett, CP, Dobbs, D, Williams, SW. An Exploratory Study of Advance Care Planning in Seriously Ill African-American Elders. J Natl Med Assoc 2008; 100:1457-62. [DOI: 10.1016/s0027-9684(15)31547-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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McCarthy EP, Pencina MJ, Kelly-Hayes M, Evans JC, Oberacker EJ, D'Agostino RB, Burns RB, Murabito JM. Advance care planning and health care preferences of community-dwelling elders: the Framingham Heart Study. J Gerontol A Biol Sci Med Sci 2008; 63:951-9. [PMID: 18840800 DOI: 10.1093/gerona/63.9.951] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The study objective was to describe self-reported advance care planning, health care preferences, use of advance directives, and health perceptions in a very elderly community-dwelling sample. METHODS We interviewed surviving participants of the original cohort of the Framingham Heart Study who were cognitively intact and attended a routine research examination between February 2004 and October 2005. Participants were queried about discussions about end-of-life care, preferences for care, documentation of advance directives, and health perceptions. RESULTS Among 220 community-dwelling respondents, 67% were women with a mean age of 88 years (range 84-100 years). Overall, 69% discussed their wishes for medical care at the end of life with someone, but only 17% discussed their wishes with a physician or health care provider. Two thirds had a health care proxy, 55% had a living will, and 41% had both. Most (80%) respondents preferred comfort care over life-extending care, and 71% preferred to die at home; however, substantially fewer respondents said they would rather die than receive specific life-prolonging interventions (chronic ventilator [63%] or feeding tube [64%]). Many were willing to endure distressing health states, with fewer than half indicating that they would rather die than live out their life in a great deal of pain (46%) or be confused and/or forgetful (45%) all of the time. CONCLUSIONS Although the vast majority of very elderly community-dwellers in this sample appear to prefer comfort measures at the end of life, many said they were willing to endure specific life-prolonging interventions and distressing health states to avoid death. Our results highlight the need for physicians to better understand patients' preferences and goals of care to help them make informed decisions at the end of life.
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Affiliation(s)
- Ellen P McCarthy
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Suite 220, Brookline, MA 02446, USA.
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Abbo ED, Sobotka S, Meltzer DO. Patient preferences in instructional advance directives. J Palliat Med 2008; 11:555-62. [PMID: 18454606 DOI: 10.1089/jpm.2007.0255] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Instructional advance directives (ADs) are traditionally written to apply in terminal illness. As such, they do not readily capture patient preferences for care in acute and chronic illness. OBJECTIVE To test whether patients prefer a modified AD that includes preferences to limit life-sustaining therapy (LST) for critical illness and advanced dementia over a traditional AD. METHODS A convenience sample of medically stable, hospitalized general medical patients were presented a traditional AD (the recommended Illinois statutory living will that limits LST in terminal illness) and a modified AD. The modified AD presents four conditional options: (1) to limit LST in terminal illness, (2) to limit LST in critical illness to a reasonable trial, (3) to refuse LST in advanced dementia (described in lay language), and (4) to refuse artificial hydration and nutrition (AHN) in advanced dementia. The primary outcome was the preferred AD to present to patients. Secondary outcomes included the AD choice of those who executed an AD and the options chosen by those executing the modified AD. RESULTS Seventy-two patients completed the survey. Eighty-six percent (95% confidence interval [CI], 76%-93%), preferred that the modified AD be presented to patients over the traditional AD. Twenty-one patients chose to execute an AD. Eighteen (86%; 95% CI, 64%-97%), executed the modified AD. Twelve executed all four options. CONCLUSIONS Traditional instructional ADs fail to capture important patient preferences. Future research should further validate these preferences and explore whether including these specific options in ADs can improve their efficacy.
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Affiliation(s)
- Elmer D Abbo
- Section of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, Illinois 60637, USA.
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Golden AG, Corvea MH, Dang S, Llorente M, Silverman MA. Assessing Advance Directives in the Homebound Elderly. Am J Hosp Palliat Care 2008; 26:13-7. [DOI: 10.1177/1049909108324359] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We studied the prevalence of specific barriers that prevent indigent homebound older adults from obtaining advance directives and tested the effectiveness of clinical reminders for lowering the number of clients without advance directives. Case managers interviewed 1569 clients to determine whether they had an advance directive. All 530 clients without advance directives were contacted 3 months later to determine if advance directives had been obtained. Clients who still did not have advance directives were asked to list 1 or more reasons they did not have advance directives. About 57.8% of the barriers identified may reflect reluctance on the part of clients to address their own mortality. Reminders by the case managers were ineffective at lowering the number of homebound older adults without advance directives. Further studies are needed to identify and design strategies for convincing this population of homebound elderly to establish advance directives.
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Affiliation(s)
| | | | | | | | - Michael A. Silverman
- Miami Miller School of Medicine and Miami Jewish Home and Hospital, Miami, Florida
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Volandes AE, Ariza M, Abbo ED, Paasche-Orlow M. Overcoming educational barriers for advance care planning in Latinos with video images. J Palliat Med 2008; 11:700-6. [PMID: 18588401 DOI: 10.1089/jpm.2007.0172] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Studies of end-of-life care have shown that Latino patients want more aggressive care compared to white patients. While this has been attributed to aspects of ethnicity, national origin, and religion, it is possible that limited education might obscure the true relationship between Latino patients and their end-of-life care preferences. METHODS Spanish-speaking subjects presenting to their primary care doctors were asked their preferences for end-of-life care before watching a video of advanced dementia. Subjects then viewed a 2-minute video of a patient with advanced dementia and were asked again about their preferences. Unadjusted and adjusted logistic regression models were fit using stepwise algorithms to examine factors related to preferences. RESULTS A total of 104 subjects completed the interview. Before seeing the video, 42 (40%) subjects preferred comfort care; 43 (41%) desired life-prolonging care; 11 (11%) chose limited care; and 8 (8%) were unsure of their preferences. Subject preferences changed significantly after the video: 78 (75%) of the subjects chose comfort care; 8 (8%) desired life-prolonging care; 14 (13%) chose limited care; and, 4 (4%) were unsure of their preferences (p < 0.001). Unadjusted and adjusted analyses revealed a statistically significant difference regarding prevideo preferences based on educational level. After the video, differences in preferences based on educational level disappeared. CONCLUSIONS Educational level was an independent predictor of end-of-life preferences after hearing a verbal description of advanced dementia. After viewing a video of a patient with advanced dementia there were no longer any differences in the distribution of preferences according to educational level. These findings suggest that educational level is an important variable to consider in research and in patient care when communicating about end-of-life care preferences. While attention to patients' culture is important, it is also important to avoid ascribing choices to culture that may actually reflect inadequate comprehension. Attention to communication barriers with techniques like the video used in the current study may help ensure optimal end-of-life care for Latino patients irrespective of educational level.
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Affiliation(s)
- Angelo E Volandes
- General Medicine Unit, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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Smith AK, McCarthy EP, Paulk E, Balboni TA, Maciejewski PK, Block SD, Prigerson HG. Racial and ethnic differences in advance care planning among patients with cancer: impact of terminal illness acknowledgment, religiousness, and treatment preferences. J Clin Oncol 2008; 26:4131-7. [PMID: 18757326 DOI: 10.1200/jco.2007.14.8452] [Citation(s) in RCA: 205] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Despite well-documented racial and ethnic differences in advance care planning (ACP), we know little about why these differences exist. This study tested proposed mediators of racial/ethnic differences in ACP. PATIENTS AND METHODS We studied 312 non-Hispanic white, 83 non-Hispanic black, and 73 Hispanic patients with advanced cancer in the Coping with Cancer study, a federally funded multisite prospective cohort study designed to examine racial/ethnic disparities in ACP and end-of-life care. We assessed the impact of terminal illness acknowledgment, religiousness, and treatment preferences on racial/ethnic differences in ACP. RESULTS Compared with white patients, black and Hispanic patients were less likely to have an ACP (white patients, 80%; black patients, 47%; Hispanic patients, 47%) and more likely to want life-prolonging care even if he or she had only a few days left to live (white patients, 14%; black patients, 45%; Hispanic patients, 34%) and to consider religion very important (white patients, 44%; black patients, 88%; Hispanic patients, 73%; all P < .001, comparison of black or Hispanic patients with white patients). Hispanic patients were less likely and black patients marginally less likely to acknowledge their terminally ill status (white patients, 39% v Hispanic patients, 11%; P < .001; white v black patients, 27%; P = .05). Racial/ethnic differences in ACP persisted after adjustment for clinical and demographic factors, terminal illness acknowledgment, religiousness, and treatment preferences (has ACP, black v white patients, adjusted relative risk, 0.64 [95% CI, 0.49 to 0.83]; Hispanic v white patients, 0.65 [95% CI, 0.47 to 0.89]). CONCLUSION Although black and Hispanic patients are less likely to consider themselves terminally ill and more likely to want intensive treatment, these factors did not explain observed disparities in ACP.
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Affiliation(s)
- Alexander K Smith
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 1309 Beacon St, Brookline, MA 02446, USA.
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Sudore RL, Schickedanz AD, Landefeld CS, Williams BA, Lindquist K, Pantilat SZ, Schillinger D. Engagement in multiple steps of the advance care planning process: a descriptive study of diverse older adults. J Am Geriatr Soc 2008; 56:1006-13. [PMID: 18410324 PMCID: PMC5723440 DOI: 10.1111/j.1532-5415.2008.01701.x] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To assess engagement in multiple steps of the advance care planning (ACP) process 6 months after exposure to an advance directive. In this study, ACP is conceptualized similarly to the behavior change model. DESIGN Descriptive study. SETTINGS County general medicine clinic in San Francisco. PARTICIPANTS One hundred seventy-three English or Spanish speakers, aged 50 and older (mean 61) given a standard (12th-grade reading level) and an easy-to-read (5th-grade reading level) advance directive. MEASUREMENTS Six months after exposure to two advance directives, self-reported ACP contemplation; discussions with family, friends discussions with clinicians; and documentation were measured. Associations were examined between ACP steps and between subject characteristics ACP engagement. RESULTS Most participants (73%) were nonwhite and 31% had less than a high school education. Sixty-one percent contemplated ACP, 56% discussed ACP with family or friends, 22% discussed ACP with clinicians, and 13% documented ACP wishes. Subjects who had discussed ACP with their family or friends were more likely to discuss ACP with their clinicians (36% vs 2%, P<.001) and document ACP wishes (18% vs 4%, P=.009) than those who had not. Latinos and subjects with less than a high school education discussed ACP more often with family or friends (P<.06) and clinicians (P<.03) than other ethnic groups and subjects with more education. CONCLUSIONS ACP involves distinct steps including contemplation, discussions, and documentation. The ACP paradigm should be broadened to include contemplation and discussions. Promoting discussions with family and friends may be one of the most important targets for ACP interventions, and literacy- and language-appropriate advance directives may help reverse patterns of sociodemographic disparities in ACP.
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Affiliation(s)
- Rebecca L Sudore
- Division of Geriatrics, University of California at San Franciso, and San Francisco Veterans Affairs Medical Center, San Francisco, California 94121, USA.
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A Literature Review of Preferences for End-of-Life Care in Developed Countries by Individuals With Different Cultural Affiliations and Ethnicity. J Hosp Palliat Nurs 2008. [DOI: 10.1097/01.njh.0000306740.10636.64] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Shanawani H, Wenrich MD, Tonelli MR, Curtis JR. Meeting physicians' responsibilities in providing end-of-life care. Chest 2008; 133:775-86. [PMID: 18321905 DOI: 10.1378/chest.07-2177] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Despite many clinical examples of exemplary end-of-life care, a number of studies highlight significant shortcomings in the quality of end-of-life care that the majority of patients receive. In part, this stems from inconsistencies in training and supporting clinicians in delivering end-of-life care. This review describes the responsibilities of pulmonary and critical care physicians in providing end-of-life care to patients and their families. While many responsibilities are common to all physicians who care for patients with life-limiting illness, some issues are particularly relevant to pulmonary and critical care physicians. These issues include prognostication and decision making about goals of care, challenges and approaches to communicating with patients and their family, the role of interdisciplinary collaboration, principles and practice of withholding and withdrawing life-sustaining measures, and cultural competency in end-of-life care.
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Affiliation(s)
- Hasan Shanawani
- Division of Pulmonary and Critical Care Medicine, Wayne State University School of Medicine, Detroit, MI, USA
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