Racial Disparities in End-of-Life Communication and Preferences among Chronic Kidney Disease Patients

Exploring the acceptability of a community-enhanced intervention to improve decision support partnership between patients with chronic kidney disease and their family caregivers

Patients face numerous health-related decisions once advanced chronic kidney disease (CKD) is diagnosed. Yet, when patients are underprepared to navigate and discuss health-related decisions, they can make choices inconsistent with their expectations for the future. This pilot study, guided by the multiphase optimization strategy and community-engaged research principles, aimed to explore the acceptability of a developed patient component to a decision-support training intervention called ImPart (Improving Decisional Partnership of CKD Dyads). CKD patients and their family caregivers were recruited from an urban, academic medical center. Eligibility criteria for patients included a diagnosis of stage 3 or higher CKD (on chart review), and caregivers participated in interview sessions only. Patients without a caregiver were not eligible. The intervention was lay coach, telephone-delivered, and designed to be administered in 1-2 week intervals for 4 sessions. An interview guide, developed in collaboration with an advisory group, was designed to ascertain participants' experiences with the intervention. Caregiver interviews focused on changes in the patient's decision ability or engagement. Thirteen patients and eleven caregivers were interviewed. The program was viewed as "good" or "beneficial." Three themes capture the intervention's impact- 1) Frequent and deliberate disease-focused communication, 2) Future planning activation, and 3) Coaching relationship. The piloted intervention was successfully delivered, acceptable to use, and found to promote enhanced disease and future planning communication. By undergoing this work, we ensure that the patient component is feasible to use and meets the needs of participants before implementation in a larger factorial trial.

Equity in Using Artificial Intelligence Mortality Predictions to Target Goals of Care Documentation

BACKGROUND

Artificial intelligence (AI) algorithms are increasingly used to target patients with elevated mortality risk scores for goals-of-care (GOC) conversations.

OBJECTIVE

To evaluate the association between the presence or absence of AI-generated mortality risk scores with GOC documentation.

DESIGN

Retrospective cross-sectional study at one large academic medical center between July 2021 and December 2022.

PARTICIPANTS

Hospitalized adult patients with AI-defined Serious Illness Risk Indicator (SIRI) scores indicating > 30% 90-day mortality risk (defined as "elevated" SIRI) or no SIRI scores due to insufficient data.

INTERVENTION

A targeted intervention to increase GOC documentation for patients with AI-generated scores predicting elevated risk of mortality.

MAIN MEASURES

Odds ratios comparing GOC documentation for patients with elevated or no SIRI scores with similar severity of illness using propensity score matching and risk-adjusted mixed-effects logistic regression.

KEY RESULTS

Among 13,710 patients with elevated (n = 3643, 27%) or no (n = 10,067, 73%) SIRI scores, the median age was 64 years (SD 18). Twenty-five percent were non-White, 18% had Medicaid, 43% were admitted to an intensive care unit, and 11% died during admission. Patients lacking SIRI scores were more likely to be younger (median 60 vs. 72 years, p < 0.0001), be non-White (29% vs. 13%, p < 0.0001), and have Medicaid (22% vs. 9%, p < 0.0001). Patients with elevated versus no SIRI scores were more likely to have GOC documentation in the unmatched (aOR 2.5, p < 0.0001) and propensity-matched cohorts (aOR 2.1, p < 0.0001).

CONCLUSIONS

Using AI predictions of mortality to target GOC documentation may create differences in documentation prevalence between patients with and without AI mortality prediction scores with similar severity of illness. These finding suggest using AI to target GOC documentation may have the unintended consequence of disadvantaging severely ill patients lacking AI-generated scores from receiving targeted GOC documentation, including patients who are more likely to be non-White and have Medicaid insurance.

Advance Care Planning and Palliative Care Consultation in Kidney Transplantation

RATIONALE & OBJECTIVE

Because of the high risk of waitlist mortality and posttransplant complications, kidney transplant (KT) patients may benefit from advance care planning (ACP) and palliative care consultation (PCC). We quantified the prevalence and racial disparities in ACP and PCC among KT candidates and recipients.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

2,575 adult KT candidates and 1,233 adult recipients (2008-2020).

EXPOSURE

Race and ethnicity.

OUTCOMES

All reports of ACP and PCC were abstracted from chart review. ACP was defined as patient self-report of an advance directive, presence of an advance directive in the medical record, or a documented goals-of-care conversation with a provider. PCC was defined as an ordered referral or a documented palliative care note in the medical record.

ANALYTICAL APPROACH

Racial/ethnic disparities in ACP/PCC were estimated using adjusted logistic regression.

RESULTS

21.4% of KT candidates and 34.9% of recipients engaged in ACP. There were racial/ethnic disparities in ACP among KT candidates (White, 24.4%; Black, 19.1%; Hispanic, 15%; other race and ethnicity, 21.1%; P=0.008) and recipients (White, 39.5%; Black, 31.2%; Hispanic, 26.3%; other race and ethnicity, 26.6%; P=0.007). After adjustment, Black KT recipients had a 29% lower likelihood of engaging in ACP (OR, 0.71; 95% CI, 0.55-0.91) than White KT recipients. Among older (aged≥65 years) recipients, those who were Black had a lower likelihood of engaging in ACP, but there was no racial disparity among younger recipients (P=0.020 for interaction). 4.2% of KT candidates and 5.1% of KT recipients engaged in PCC; there were no racial disparities in PCC among KT candidates (White, 5.3%; Black, 3.6%; Hispanic, 2.5%; other race and ethnicity, 2.1%; P=0.13) or recipients (White, 5.5%; Black, 5.6%; Hispanic, 0.0%; other race and ethnicity, 1.3%; P = 0.21).

LIMITATIONS

Generalizability may be limited to academic transplant centers.

CONCLUSIONS

ACP is not common among KT patients, and minoritized transplant patients are least likely to engage in ACP; PCC is less common. Future efforts should aim to integrate ACP and PCC into the KT process.

PLAIN-LANGUAGE SUMMARY

Kidney transplant (KT) candidates and recipients are at elevated risk of morbidity and mortality. They may benefit from completing a document or conversation with their palliative care provider that outlines their future health care wishes, known as advance care planning (ACP), which is a component of palliative care consultation (PCC). We wanted to determine how many KT candidates and recipients have engaged in ACP or PCC and identify potential racial disparities. We found that 21.4% of candidates and 34.9% of recipients engaged in ACP. After adjustment, Black recipients had a 29% lower likelihood of engaging in ACP. We found that 4.2% of KT candidates and 5.1% of KT recipients engaged in PCC, with no racial disparities found in PCC.

Sociodemographic Disparities in Adults with Kidney Failure: A Meta-Analysis

This meta-analysis aims to assess current evidence regarding sociodemographic disparities among adults with kidney failure. Medline, Scopus, Web of Science, CENTRAL, and Google Scholar were systematically searched from inception to 20 February 2022. Overall, 165 cohort studies were included. Compared to White patients, dialysis survival was significantly better among Black (hazard ratio-HR: 0.68; 95% CI: 0.61-0.75), Asian (HR: 0.67; 95% CI: 0.61-0.72) and Hispanic patients (HR: 0.80; 95% CI: 0.73-0.88). Black individuals were associated with lower rates of successful arteriovenous fistula use, peritoneal dialysis and kidney transplantation, as well as with worse graft survival. Overall survival was significantly better in females after kidney transplantation compared to males (HR: 0.87; 95% CI: 0.84-0.90). Female sex was linked to higher rates of central venous catheter use and a lower probability of kidney transplantation. Indices of low SES were associated with higher mortality risk (HR: 1.22, 95% CI: 1.14-1.31), reduced rates of dialysis with an arteriovenous fistula, peritoneal dialysis and kidney transplantation, as well as higher graft failure risk. In conclusion, Black, Asian and Hispanic patients present better survival in dialysis, while Black, female and socially deprived patients demonstrate lower rates of successful arteriovenous fistula use and limited access to kidney transplantation. PROSPERO registration: CRD42022300839.

Effect of ethnicity and socioeconomic deprivation on uptake of renal supportive care and dialysis decision-making in older adults

Background

Renal supportive care has become an increasingly relevant treatment option as the renal patient population ages. Despite the prevalence of kidney disease amongst ethnic minority and socioeconomically deprived patients, evidence focused on supportive care and dialysis decision-making in these groups is limited.

Methods

This retrospective study selected older patients referred to a low clearance or supportive care service between 1 January 2015 and 31 December 2019. A descriptive analysis of clinical and socioeconomic characteristics according to treatment choice was produced and multivariate logistic regression models used to identify predictive factors for choosing supportive care. Surrogate markers for the success of decision-making processes were evaluated, including time taken to reach a supportive care decision and risk of death without making a treatment decision or within 3 months of starting kidney replacement therapy (KRT). Finally, the association between ethnicity and socioeconomic status and hospital admission rates was compared between treatment groups.

Results

Amongst 1768 patients, 515 chose supportive care and 309 chose KRT. Predictive factors for choosing supportive care included age, frailty and a diagnosis of cognitive impairment. However, there was no association with ethnicity or deprivation. Similarly, these factors were not associated with time taken to make a supportive care decision or the mortality outcome. Amongst those on KRT, more socially advantaged patients had decreased rates of hospital admissions compared with those less advantaged (incident rate ratio 0.96, 95% confidence interval 0.92-0.99).

Conclusion

Predictive factors for choosing supportive care were clinical, rather than socioeconomic. Lower socioeconomic status was associated with increased rates of hospitalization in the KRT group. This is a possible signal that these groups experienced greater morbidity on KRT versus supportive care, an association not demonstrated amongst higher socioeconomic groups.

Kidney Organoid Derived from Human Pluripotent and Adult Stem Cells for Disease Modeling

Kidney disease affects a significant portion of the global population, yet effective therapies are lacking despite advancements in identifying genetic causes. This limitation can be attributed to the absence of adequate in vitro models that accurately mimic human kidney disease, hindering targeted therapeutic development. However, the emergence of human induced pluripotent stem cells (PSCs) and the development of organoids using them have opened up a way to model kidney development and disease in humans, as well as validate the effects of new drugs. To fully leverage their capabilities in these fields, it is crucial for kidney organoids to closely resemble the structure and functionality of adult human kidneys. In this review, we aim to discuss the potential of using human PSCs or adult kidney stem cell-derived kidney organoids to model genetic kidney disease and renal cancer.

How does ethnicity affect presence of advance care planning in care records for individuals with advanced disease? A mixed-methods systematic review

BACKGROUND

Advance care planning (ACP) is the process supporting individuals with life-limiting illness to make informed decisions about their future healthcare. Ethnic disparities in ACP have been widely highlighted, but interpretation is challenging due to methodological heterogeneity. This review aims to examine differences in the presence of documented ACP in individuals' care records for people with advanced disease by ethnic group, and identify patient and clinician related factors contributing to this.

METHODS

Mixed-methods systematic review. Keyword searches on six electronic databases were conducted (01/2000-04/2022). The primary outcome measure was statistically significant differences in the presence of ACP in patients' care records by ethnicity: quantitative data was summarised and tabulated. The secondary outcome measures were patient and clinician-based factors affecting ACP. Data was analysed qualitatively through thematic analysis; themes were developed and presented in a narrative synthesis. Feedback on themes was gained from Patient and Public Involvement (PPI) representatives. Study quality was assessed through Joanna Briggs Institute Critical Appraisal tools and Gough's Weight of Evidence.

RESULTS

N=35 papers were included in total; all had Medium/High Weight of Evidence. Fifteen papers (comparing two or more ethnic groups) addressed the primary outcome measure. Twelve of the fifteen papers reported White patients had statistically higher rates of formally documented ACP in their care records than patients from other ethnic groups. There were no significant differences in the presence of informal ACP between ethnic groups. Nineteen papers addressed the secondary outcome measure; thirteen discussed patient-based factors impacting ACP presence with four key themes: poor awareness and understanding of ACP; financial constraints; faith and religion; and family involvement. Eight papers discussed clinician-based factors with three key themes: poor clinician confidence around cultural values and ideals; exacerbation of institutional constraints; and pre-conceived ideas of patients' wishes.

CONCLUSIONS

This review found differences in the presence of legal ACP across ethnic groups despite similar presence of informal end of life conversations. Factors including low clinician confidence to deliver culturally sensitive, individualised conversations around ACP, and patients reasons for not wishing to engage in ACP (including, faith, religion or family preferences) may begin to explain some documented differences.

TRIAL REGISTRATION

PROSPERO-CRD42022315252.

Kidney Failure Patients' Perceptions and Definitions of Health: A Qualitative Study

Rationale & Objective

Patients with kidney failure who have used multiple treatment modalities are a unique source of information for how different options may best fit their values. We aimed to understand how people interpret their health and kidney failure treatment experience to inform providers who facilitate shared decision-making conversations.

Study Design

This qualitative, interpretive phenomenological study explores how patients with kidney failure interpret health throughout their treatment trajectory.

Setting & Participants

We recruited a purposive sample of patients who had used 3 or more kidney failure treatment options, including transplant and dialysis from transplant clinics and online support groups, for semi-structured interviews. Eligible participants were over 18 and spoke English for a total of 7 current transplant, 10 current home dialysis, and 1 current in-center patient.

Analytical Approach

A 6-step iterative process of data analysis occurred concurrently with data collection.

Results

Half of the 18 participants were Black; 67% were women. Three interrelated themes emerged from interviews: ability to engage in meaningful activities; working for balance; and living in context. Participants evaluated health according to their ability to engage in meaningful activities while balancing their emotional and physical needs with their life goals. When their social and treatment environments supported their autonomy, participants also considered themselves healthy.

Limitations

The inclusion of only English-speaking patients limits the transferability of findings. A longitudinal design, repeated interviews, observation, and dyadic interviews would increase the health care providers' understanding and interpretation of health.

Conclusions

The themes demonstrated patients evaluated health based on ability to engage in meaningful activities while maintaining balance. The treatment context, particularly how health care providers responded to patients' physiological experience, autonomy, and power, influenced interpretation of patient treatment experiences. Integrating patient interpretations of health with quantitative measures of treatment effectiveness can help health care providers better partner with patients to provide effective care for kidney failure.

Racial Disparities in Health Beliefs and Advance Care Planning Among Patients Receiving Maintenance Dialysis

CONTEXT

Among people receiving maintenance dialysis, little is known about racial disparities in the occurrence of prognostic discussions, beliefs about future health, and completion of advance care planning (ACP) documents.

OBJECTIVES

We examined whether Black patients receiving maintenance dialysis differ from White patients in prognostic discussions, beliefs about future health, and completion of ACP-related documents.

METHODS

We surveyed adult patients receiving maintenance dialysis from seven dialysis units in Cleveland, Ohio, and hospitalized patients at a tertiary care hospital in Cleveland. Of the 450 patients who were asked to participate in the study, 423 (94%) agreed. We restricted the current secondary analyses to include only Black (n=285) and White (n=114) patients. The survey assessed patients' knowledge of their kidney disease, attitudes toward chronic kidney disease (CKD) treatment, preferences for end-of-life (EoL) care, the patient-reported occurrence of prognostic discussions, experiences with kidney therapy decision making, sentiments of dialysis regret, beliefs about health over the next 12 months, and advance care planning. We used stepwise logistic regression to determine if race was associated with the occurrence of prognostic discussions, beliefs about future health, and completion of an ACP-related document, while controlling for potential confounders.

RESULTS

We found no significant difference in the frequency of prognostic discussions between Black (11.9%) versus White patients (7%) (P=0.15). However, Black patients (19%) had lower odds of believing that their health would worsen over the next 12 months (OR 0.22, CI 0.12, 0.44) and reporting completion of any ACP-related document (OR 0.5, CI 0.32, 0.81) compared to White patients CONCLUSION: Racial differences exist in beliefs about future health and completion of ACP-related documents. Systemic efforts to investigate differences in health beliefs and address racial disparities in the completion of ACP-related documents are needed.

Ethical Challenges When Caring for African American Older Adults Requesting to Withdraw From Dialysis

The number of African American adults 65 years and older with end-stage kidney disease receiving maintenance hemodialysis is increasing. The high symptom burden (ie, pain, fatigue, depression) can make it challenging for many to continue dialysis, which can lead to request to withdraw from dialysis. This can present ethical challenges when someone has diminished decision-making capacity and no advance directives or family to assist with this complex decision. This article will provide a brief overview of ethical issues to consider when responding to an older adult's request to withdraw from a life-sustaining treatment such as dialysis. Suggestions for research to address the gaps in knowledge will be presented.

Toward a basic science of communication in serious illness

High-quality communication can mitigate suffering during serious illness. Innovations in theory and technology present the opportunity to advance serious illness communication research, moving beyond inquiry that links broad communication constructs to health outcomes toward operationalizing and understanding the impact of discrete communication functions on human experience. Given the high stakes of communication during serious illness, we see a critical need to develop a basic science approach to serious illness communication research. Such an approach seeks to link "what actually happens during a conversation" - the lexical and non-lexical communication content elements, as well as contextual factors - with the emotional and cognitive experiences of patients, caregivers, and clinicians. This paper defines and justifies a basic science approach to serious illness communication research and outlines investigative and methodological opportunities in this area. A systematic understanding of the building blocks of serious illness communication can help identify evidence-informed communication strategies that promote positive patient outcomes, shape more targeted communication skills training for clinicians, and lead to more tailored and meaningful serious illness care.

A Decade of Studying Drivers of Disparities in End-of-Life Care for Black Americans: Using the NIMHD Framework for Health Disparities Research to Map the Path Ahead

OBJECTIVE

The purpose of this paper is to provide a review of the existing literature on racial disparities in quality of palliative and end-of-life care and to demonstrate gaps in the exploration of underlying mechanisms that produce these disparities.

BACKGROUND

Countless studies over several decades have revealed that our healthcare system in the United States consistently produces poorer quality end-of-life care for Black compared with White patients. Effective interventions to reduce these disparities are sparse and hindered by a limited understanding of the root causes of these disparities.

METHODS

We searched PubMed, CINAHL and PsychInfo for research manuscripts that tested hypotheses about causal mechanisms for disparities in end-of-life care for Black patients. These studies were categorized by domains outlined in the National Institute of Minority Health and Health Disparities (NIMHD) framework, which are biological, behavioral, physical/built environment, sociocultural and health care systems domains. Within these domains, studies were further categorized as focusing on the individual, interpersonal, community or societal level of influence.

RESULTS

The majority of the studies focused on the Healthcare System and Sociocultural domains. Within the Health Care System domain, studies were evenly distributed among the individual, interpersonal, and community level of influence, but less attention was paid to the societal level of influence. In the Sociocultural domain, most studies focused on the individual level of influence. Those focusing on the individual level of influence tended to be of poorer quality.

CONCLUSIONS

The sociocultural environment, physical/built environment, behavioral and biological domains remain understudied areas of potential causal mechanisms for racial disparities in end-of-life care. In the Healthcare System domain, social influences including healthcare policy and law are understudied. In the sociocultural domain, the majority of the studies still focused on the individual level of influence, missing key areas of research in interpersonal discrimination and local and societal structural discrimination. Studies that focus on individual factors should be better screened to ensure that they are of high quality and avoid stigmatizing Black communities.

Engaging African American family Caregivers in Developing a Culturally-responsive Interview Guide: A Multiphase Process and Approach

Qualitatively eliciting historically marginalized populations' beliefs, values, and preferences is critical to capturing information that authentically characterizes their experiences and can be used to develop culturally-responsive interventions. Eliciting these rich perspectives requires researchers to have highly effective qualitative interviewing guides, which can be optimized through community engagement. However, researchers have had little methodological guidance on how community member engagement can aid development of interview guides. The purpose of this article is to provide a series of steps, each supported by a case example from our work with African American family caregivers, for developing an interview guide through community engagement. We conclude by highlighting how involving historically marginalized community members in these early stages of research study development can build trust, research partnerships, and acknowledge their contribution to the development of new knowledge.

Dialysis symptom index burden and symptom clusters in a prospective cohort of dialysis patients

Background

Dialysis patients experience a high symptom burden, which may adversely impact their quality of life. Whereas other specialties emphasize routine symptom assessment, symptom burden is not well-characterized in dialysis patients. We sought to examine the prevalence and severity of unpleasant symptoms in a prospective hemodialysis cohort.

Methods

Among 122 hemodialysis patients from the prospective Malnutrition, Diet, and Racial Disparities in Chronic Kidney Disease (CKD) study, CKD-associated symptoms were ascertained by the Dialysis Symptom Index, a validated survey assessing symptom burden/severity (with higher scores indicating greater symptom severity), over 6/2020–10/2020. We examined the presence of (1) individual symptoms and symptom severity scores, and (2) symptom clusters (defined as ≥ 2 related concurrent symptoms), as well as correlations with clinical characteristics.

Results

Symptom severity scores were higher among non-Hispanic White and Hispanic patients, whereas scores were lower in Black and Asian/Pacific Islander patients. In the overall cohort, the most common individual symptoms included feeling tired/lack of energy (71.3%), dry skin (61.5%), trouble falling asleep (44.3%), muscle cramps (42.6%), and itching (42.6%), with similar patterns observed across racial/ethnic groups. The most prevalent symptom clusters included feeling tired/lack of energy + trouble falling asleep (37.7%); trouble falling asleep + trouble staying asleep (34.4%); and feeling tired/lack of energy + trouble staying asleep (32.0%). Lower hemoglobin, iron stores, and dialysis adequacy correlated with higher individual and overall symptom severity scores.

Conclusion

We observed a high prevalence of unpleasant symptoms and symptom clusters in a diverse hemodialysis cohort. Further studies are needed to identify targeted therapies that ameliorate symptom burden in CKD.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40620-022-01313-0.

Predictors of do-not-resuscitate order utilization in decompensated cirrhosis hospitalized patients: A nationwide inpatient cohort study

INTRODUCTION AND OBJECTIVES

Decompensated cirrhosis carries high inpatient morbidity and mortality. Consequently, advance care planning is an integral aspect of medical care in this patient population. Our study aims to identify do-not-resuscitate (DNR) order utilization and demographic disparities in decompensated cirrhosis patients.

PATIENTS OR MATERIALS AND METHODS

Nationwide Inpatient Sample was used to extract the cohort of patients from January 1st, 2016 to December 31st, 2017, based on the most comprehensive and recent data. The first cohort included hospitalized patients with decompensated cirrhosis. The second cohort included patients with decompensated cirrhosis with at least one contraindication for liver transplantation.

RESULTS

A cohort of 585,859 decompensated cirrhosis patients was utilized. DNR orders were present in 14.2% of hospitalized patients. DNR utilization rate among patients with relative contraindication for liver transplantation was 15.0%. After adjusting for co-morbid conditions, disease severity, and inpatient mortality, African-American and Hispanic patient populations had significantly lower DNR utilization rates. There were regional, and hospital-level differences noted. Moreover, advanced age, advanced stage of decompensated cirrhosis, inpatient mortality, and relative contraindications for liver transplantation (metastatic neoplasms, dementia, alcohol misuse, severe cardiopulmonary disease, medical non-adherence) were independently associated with increased DNR utilization rates.

CONCLUSIONS

The rate of DNR utilization in patients with relative contraindications for liver transplantation was similar to patients without any relative contraindications. Moreover, there were significant demographic and hospital-level predictors of DNR utilization. This information can guide resource allocation in educating patients and their families regarding prognosis and outcome expectations.

Awareness of Hospice Care Among Rural African-Americans: Findings From Social Determinants of Health Framework

Background: Despite the need for hospice care as our society ages, adults in the U.S.'s southern rural region have limited awareness of hospice care. Objective: This study aims to assess the rate of awareness of hospice care among rural residents living in Alabama's Black Belt region and examine social determinants of health (SDH) associated with the awareness. Methods: A cross-sectional survey was conducted among a convenience sample living in Alabama's Black Belt region (N = 179, age = 18-91). Participants' awareness of hospice care, demographic characteristics (ie, age and gender), and SDH (ie, financial resources strain, food insecurity, education and health literacy, social isolation, and interpersonal safety) were assessed. Lastly, a binary logistic regression was used to examine the association between SDH and hospice awareness among participants while controlling for demographic characteristics. Results: The majority of participants had heard of hospice care (n = 150, 82.1%), and older participants (50 years old or older) were more likely to report having heard of hospice care (OR = 7.35, P < 0.05). Participants reporting worries about stable housing (OR = 0.05, P < 0.05) and higher social isolation were less likely to have heard of hospice care (OR = 0.53, P < 0.05), while participants with higher health literacy had a higher likelihood to have heard of it (OR = 2.60, P < 0.01). Conclusions: Our study is the first study assessing the status of hospice awareness among residents of Alabama's Black Belt region. This study highlighted that factors including age and certain SDH (ie, housing status, health literacy, and social isolation) might be considered in the intervention to improve hospice awareness.

Completion of advance directives among African Americans and Whites adults

OBJECTIVE

The primary purpose of this study was to analyze the completion of advance directives among African American and White adults and examine related factors, including demographics, socio-economic status, health conditions, and experiences with health care providers.

METHODS

This study used data from the Survey of California Adults on Serious Illness and End-of-Life 2019. We compared correlates of completion of advance directives among a sample of 1635 African American and White adults. Multivariate analysis was conducted.

RESULTS

Whites were 50% more likely to complete an advance directive than African Americans. The major differences between African Americans and Whites were mainly explained by the level of mistrust and discrimination experienced by African Americans and partially explained by demographic characteristics. Our study showed that at both bivariate and multivariate levels, participation in religious activities was associated with higher odds of completion of an advance directive for both African Americans and Whites.

CONCLUSION

Interventional studies needed to address the impact of mistrust and perceived discrimination on advance directive completion.

PRACTICAL IMPLICATIONS

Culturally appropriate multifaceted, theoretical- and religious-based interventions are needed that include minority health care providers, church leaders, and legal counselors to educate, modify attitudes, provide skills and resources for communicating with health care providers and family members.

Let's Talk About ACP Pilot Study: A Culturally-Responsive Approach to Advance Care Planning Education in African-American Communities

The COVID-19 Pandemic has emphasized the importance of attending to racial inequity in end-of-life care, as the world has witnessed the disproportionate negative impact on Black and Brown people and communities. Advance care planning (ACP) is of particular concern for this population. This article introduces an ACP toolkit developed as a culturally responsive educational approach to assist African-American faith leaders to inform and educate congregants on end-of-life care options and the process to complete advance care documents. The purpose of this article is to describe the development of The Let's Talk about ACP toolkit and to discuss the results of the pilot study workshop. The procedures of the pilot study included a critical evaluation of an innovative curriculum and workshop process for engaging African Americans around advocacy for the healthcare experience they prefer. Factors such as cultural, generational, and spiritual beliefs and values influenced decision-making. Distrust was one of the most prominent factors raised by participants. Providing resources and tools that encompass culturally responsive approaches to educate and encourage use can help bridge the gap. The next steps for this innovative practice approach is to refine the practice approach and replicate the finding among larger community settings.

Preparedness for Serious Illnesses: Impact of Ethnicity, Mistrust, Perceived Discrimination, and Health Communication

BACKGROUND

Increasing severity of serious illness requires individuals to prepare and make decisions to mitigate adverse consequences of their illness. In a racial and ethnically diverse sample, the current study examined preparedness for serious illness among adults in California.

METHODS

This cross-sectional study used data from the Survey of California Adults on Serious Illness and End-of-Life 2019. Participants included 542 non-Hispanic White (52%), non-Hispanic Black (28%), and Hispanic (20%) adults who reported at least one chronic medical condition that they perceived to be a serious illness. Race/ethnicity, socio-demographic factors, health status, discrimination, mistrust, and communication with provider were measured. To perform data analysis, we used logistic regression models.

RESULTS

Our findings revealed that 19%, 24%, and 34% of non-Hispanic White, non-Hispanic Blacks, and Hispanic believed they were not prepared if their medical condition gets worse, respectively. Over 60% indicated that their healthcare providers never engaged them in discussions of their feelings of fear, stress, or sadness related to their illnesses. Results of bivariate analyses showed that race/ethnicity was associated with serious illness preparedness. However, multivariate analysis uncovered that serious illness preparedness was only lower in the presence of medical mistrust in healthcare providers, perceived discrimination, less communication with providers, and poorer quality of self-rated health.

CONCLUSION

This study draws attention to the need for healthcare systems and primary care providers to engage in effective discussions and education regarding serious illness preparedness with their patients, which can be beneficial for both individuals and family members and increase quality of care.

Place of death in Parkinson's disease: trends in the USA

BACKGROUND

Parkinson's disease (PD) is a significant cause of mortality but little is known about the place of death for patients with PD in the USA, a key metric of end-of-life care.

METHODOLOGY

A trend analysis was conducted for years 2003-2017 using aggregated death certificate data from the Centers for Disease Control and Prevention Wide-ranging OnLine Data for Epidemiologic Research) database, with individual-level mortality data from the Mortality Multiple Cause-of-Death Public Use Record available between 2013 and 2017. All natural deaths for which PD was identified as an underlying cause of death were identified. Place of death was categorised as hospital, decedent home, hospice facility, nursing home/long-term care and other.

RESULTS

Between 2003 and 2017, 346141 deaths were attributed to PD (59% males, 93.7% White). Most deaths occurred in patients aged 75-84 years (43.9%), followed by those aged ≥85 years (40.9 %). Hospital and nursing home deaths decreased from 18% (n=3240) and 52.6% (n=9474) in 2003 to 9.2% (n=2949) and 42% (n=13 429) in 2017, respectively. Home deaths increased from 21.1% (n=3804) to 32.4% (n=10 347) and hospice facility deaths increased from 0.3% (n=47) in 2003 to 8.6% (n=2739) in 2017. Female sex, being married and college education were associated with increased odds of home deaths while Hispanic ethnicity and non-white race were associated with increased odds of hospital deaths.

CONCLUSION

Home and hospice facility deaths are gradually increasing in patients with PD. Particular attention should be provided to vulnerable socioeconomic groups that continue to have higher rates of hospital deaths and decreased usage of hospice facilities.

Advance Care Planning in Older Adults with CKD: Patient, Care Partner, and Clinician Perspectives

BACKGROUND

Older patients with advanced CKD are at high risk for serious complications and death, yet few discuss advance care planning (ACP) with their kidney clinicians. Examining barriers and facilitators to ACP among such patients might help identify patient-centered opportunities for improvement.

METHODS

In semistructured interviews in March through August 2019 with purposively sampled patients (aged ≥70 years, CKD stages 4-5, nondialysis), care partners, and clinicians at clinics in across the United States, participants described discussions, factors contributing to ACP completion or avoidance, and perceived value of ACP. We used thematic analysis to analyze data.

RESULTS

We conducted 68 semistructured interviews with 23 patients, 19 care partners, and 26 clinicians. Only seven of 26 (27%) clinicians routinely discussed ACP. About half of the patients had documented ACP, mostly outside the health care system. We found divergent ACP definitions and perspectives; kidney clinicians largely defined ACP as completion of formal documentation, whereas patients viewed it more holistically, wanting discussions about goals, prognosis, and disease trajectory. Clinicians avoided ACP with patients from minority groups, perceiving cultural or religious barriers. Four themes and subthemes informing variation in decisions to discuss ACP and approaches emerged: (1) role ambiguity and responsibility for ACP, (2) questioning the value of ACP, (3) confronting institutional barriers (time, training, reimbursement, and the electronic medical record, EMR), and (4) consequences of avoiding ACP (disparities in ACP access and overconfidence that patients' wishes are known).

CONCLUSIONS

Patients, care partners, and clinicians hold discordant views about the responsibility for discussing ACP and the scope for it. This presents critical barriers to the process, leaving ACP insufficiently discussed with older adults with advanced CKD.

Disparities in Palliative and Hospice Care and Completion of Advance Care Planning and Directives Among Non-Hispanic Blacks: A Scoping Review of Recent Literature

OBJECTIVES

Published research in disparities in advance care planning, palliative, and end-of-life care is limited. However, available data points to significant barriers to palliative and end-of-life care among minority adults. The main objective of this scoping review was to summarize the current published research and literature on disparities in palliative and hospice care and completion of advance care planning and directives among non-Hispanc Blacks.

METHODS

The scoping review method was used because currently published research in disparities in palliative and hospice cares as well as advance care planning are limited. Nine electronic databases and websites were searched to identify English-language peer-reviewed publications published within last 20 years. A total of 147 studies that addressed palliative care, hospice care, and advance care planning and included non-Hispanic Blacks were incorporated in this study. The literature review include manuscripts that discuss the intersection of social determinants of health and end-of-life care for non-Hispanic Blacks. We examined the potential role and impact of several factors, including knowledge regarding palliative and hospice care; healthcare literacy; communication with providers and family; perceived or experienced discrimination with healthcare systems; mistrust in healthcare providers; health care coverage, religious-related activities and beliefs on palliative and hospice care utilization and completion of advance directives among non-Hispanic Blacks.

DISCUSSION

Cross-sectional and longitudinal national surveys, as well as local community- and clinic-based data, unequivocally point to major disparities in palliative and hospice care in the United States. Results suggest that national and community-based, multi-faceted, multi-disciplinary, theoretical-based, resourceful, culturally-sensitive interventions are urgently needed. A number of practical investigational interventions are offered. Additionally, we identify several research questions which need to be addressed in future research.

Integrating Conservative kidney management Options and advance care Planning Education (COPE) into routine CKD care: a protocol for a pilot randomised controlled trial

INTRODUCTION

Predialysis education for patients with advanced chronic kidney disease (CKD) typically focuses narrowly on haemodialysis and peritoneal dialysis as future treatment options. However, patients who are older or seriously ill may not want to pursue dialysis and/or may not benefit from this treatment. Conservative kidney management, a reasonable alternative treatment, and advance care planning (ACP) are often left out of patient education and shared decision-making. In this study, we will pilot an educational intervention (Conservative Kidney Management Options and Advance Care Planning Education-COPE) to improve knowledge of conservative kidney management and ACP among patients with advanced CKD who are older and/or have poor functional status.

METHODS AND ANALYSIS

This is a single-centre pilot randomised controlled trial at an academic centre in Philadelphia, PA. Eligible patients will have: age ≥70 years and/or poor functional status (as defined by Karnofsky Performance Index Score <70), advanced CKD (estimated glomerular filtration rate<20 mL/min/1.73 m²), prefer to speak English during clinical encounters and self-report as black or white race. Enrolled patients will be randomised 1:1, with stratification by race, to receive enhanced usual care or usual care and in-person education about conservative kidney management and ACP (COPE). The primary outcome is change in knowledge of CKM and ACP. We will also explore intervention feasibility and acceptability, change in communication of preferences and differences in the intervention's effects on knowledge and communication of preferences by race. We will assess outcomes at baseline, immediately post-education and at 2 and 12 weeks.

ETHICS AND DISSEMINATION

This protocol has been approved by the Institutional Review Board at the University of Pennsylvania. We will obtain written informed consent from all participants. The results from this work will be presented at academic conferences and disseminated through peer-reviewed journals.

TRIAL REGISTRATION NUMBER

This trial is registered at ClinicalTrials.gov under NCT03229811.

Advance care planning among African American patients on haemodialysis and their end-of-life care preferences

BACKGROUND

African Americans in the general population have been shown to be less likely than White ethnic groups to participate in advance care planning; however, advance care planning in the population receiving dialysis has not been well explored.

OBJECTIVE

We examined the prevalence of African American patients receiving haemodialysis' advance care planning discussions, and whether advance care planning impacts end-of-life care preferences.

DESIGN

In-person interviewer-administered surveys of African American patients receiving in-centre haemodialysis.

SETTING/PARTICIPANTS

About 101 participants at three large dialysis organisation units in Chicago.

OUTCOMES

Self-reported advance care planning and preferences for life-extending treatments at end-of-life.

RESULTS

Most patients (69%) report no advance care planning discussions with their healthcare providers. Nearly all patients (92%) without prior advance care planning reported their healthcare providers approached them about advance care planning. While the majority of patients indicated preference for aggressive life-extending care, prior conversations about end-of-life care wishes either with family members or a healthcare provider significantly decreased patients' likelihood of choosing aggressive life-extending care across three scenarios (all p < 0.05). Significantly more patients reported that common end-of-life scenarios related to increased dependence/disability were "not worth living through" compared with those associated with increased burden on family, decreased cognitive function, and severe pain/discomfort.

CONCLUSION

African Americans with end-stage renal disease need more frequent, culturally-sensitive advance care planning discussions. Despite a preference for aggressive life-sustaining treatments, individuals with prior advance care planning discussions were significantly less likely to support aggressive end-of-life care. End-of-life care discussions that focus on the impact of life-extending care on patients' independence could be more concordant with the values and priorities of the African American patients.

Awareness of Palliative Care, Hospice Care, and Advance Directives in a Racially and Ethnically Diverse Sample of California Adults

BACKGROUND

Numerous studies have documented multilevel racial inequalities in health care utilization, medical treatment, and quality of care in minority populations in the United States. Palliative care for people with serious illness and hospice services for people approaching the end of life are no exception. It is also well established that Hispanics and non-Hispanic Blacks are more likely than non-Hispanic Whites to have less knowledge about advance care planning and directives, hospice, and palliative care. Both qualitative and quantitative research has identified lack of awareness of palliative and hospice services as one of the major factors contributing to the underuse of these services by minority populations. However, an insufficient number of racial/ethnic comparative studies have been conducted to examine associations among various independent factors in relation to awareness of end-of-life, palliative care and advance care planning and directives.

AIMS

The main objective of this analysis was to examine correlates of awareness of palliative, hospice care and advance directives in a racially and ethnically diverse large sample of California adults.

METHODS

This cross-sectional study includes 2,328 adults: Hispanics (31%); non-Hispanic Blacks (30%); and non-Hispanic Whites (39%) from the Survey of California Adults on Serious Illness and End-of-Life 2019. Using multivariate analysis, we adjusted for demographic and socio-economic variables while estimating the potential independent impact of health status, lack of primary care providers, and recent experiences of participants with a family member with serious illnesses.

RESULTS

Hispanic and non-Hispanic Black participants are far less likely to report that they have heard about palliative and hospice care and advance directives than their non-Hispanic White counterparts. In this study, 75%, 74%, and 49% of Hispanics, non-Hispanic Blacks, and non-Hispanic White participants, respectively, claimed that they have never heard about palliative care. Multivariate analysis of data show gender, age, education, and income all significantly were associated with awareness. Furthermore, being engaged with decision making for a loved one with serious illnesses and having a primary care provider were associated with awareness of palliative care and advance directives.

DISCUSSION

Our findings reveal that lack of awareness of hospice and palliative care and advance directives among California adults is largely influenced by race and ethnicity. In addition, demographic and socio-economic variables, health status, access to primary care providers, and having informal care giving experience were all independently associated with awareness of advance directives and palliative and hospice care. These effects are complex, which may be attributed to various historical, social, and cultural mechanisms at the individual, community, and organizational levels. A large number of factors should be addressed in order to increase knowledge and awareness of end-of-life and palliative care as well as completion of advance directives and planning. The results of this study may guide the design of multi-level community and theoretically-based awareness and training models that enhance awareness of palliative care, hospice care, and advance directives among minority populations.

Teaching end-of-life preparation to African Americans

OBJECTIVE

This is a pilot study with a primary goal to develop an effective, targeted educational intervention that can serve as a teaching tool to educate African American (AA) population, especially the elderly, on options of end of life (EOL) prior to critical care.

METHOD

We first assessed the level of preparation for EOL in the AA community through a survey instrument. The survey was used to determine the deficits in knowledge in AA population in Mid-Michigan regarding EOL choices before and after the educational intervention. Paired-sample t-test was used to assess changes in understanding about EOL planning options. Regressions analysis was used to assess these changes while including several demographic covariates. P < 0.05 was considered statistically significant.

RESULTS

Our pilot data indicated that the educational intervention could be used as an effective teaching tool in educating AA population on EOL choices.

SIGNIFICANCE OF RESULTS

AA patients are more likely to choose life-sustaining measures at the end of their lives compared to other ethnic groups despite terminal illness. This decision is partly based on lack of knowledge of the available options of care at the EOL. Due to multiple life-sustaining measures, the AA patients are not receiving the care to help them peacefully die. This study provides evidence that physicians will need to increase their educational efforts with the AA population to help them better understand EOL options. An educational tool like the one developed in this study may be helpful and lessen the time of education so that the physician can answer any questions at the end of the session and also empower individuals and communities to take an active role in creating a culture of wellness at the EOL and decreasing morbidity.

Fragmentation of care as a barrier to optimal ESKD management

Caring for patients with end-stage kidney disease (ESKD) in the United States is challenging, due in part to the complex epidemiology of the disease's progression as well as the ways in which care is delivered. As CKD progresses toward ESKD, the number of comorbidities increases and care involves multiple healthcare providers from multiple subspecialties. This occurs in the context of a fragmented US healthcare delivery system that is traditionally siloed by provider specialty, organization, as well as systems of payment and administration. This article describes the role of care fragmentation in the delivery of optimal ESKD care and identifies research gaps in the evidence across the continuum of care. We then consider the impact of care fragmentation on ESKD care from the patient and health system perspectives and explore opportunities for system-level interventions aimed at improving care for patients with ESKD.

End-of-Life Wishes Among Non-Hispanic Black and White Middle-Aged and Older Adults

PURPOSE

Although some research has been done on end-of-life (EOL) preferences and wishes, our knowledge of racial differences in the EOL wishes of non-Hispanic White and non-Hispanic Black middle-aged and older adults is limited. Previous studies exploring such racial differences have focused mainly on EOL decision-making as reflected in advance healthcare directives concerning life-sustaining medical treatment. In need of examination are aspects of EOL care that are not decision-based and therefore not normally covered by written advance healthcare directives. This study focuses on racial differences in non-decision-based aspects of EOL care, that is, EOL care that incorporates patients' beliefs, culture, or religion.

AIM

To test the combined effects of race, socioeconomic status, health status, spirituality, perceived discrimination and medical mistrust on the EOL non-decision-based desires and wishes of a representative sample of non-Hispanic White and non-Hispanic Black older California adults.

METHODS

This cross-sectional study used data from the Survey of California Adults on Serious Illness and End-of-Life 2019. To perform data analysis, we used multiple logistic regression models.

RESULTS

Non-Hispanic Blacks reported more EOL non-decision-based desires and wishes than non-Hispanic Whites. In addition to gender, age, and education other determinants of EOL non-decision-based medical desires and wishes included perceived and objective health status, spirituality, and medical trust. Poverty level, perceived discrimination did not correlate with EOL medical wishes.

CONCLUSION

Non-Hispanic Blacks desired a closer relationship with their providers as well as a higher level of respect for their cultural beliefs and values from their providers compared with their White counterparts. Awareness, understanding, and respecting the cultural beliefs and values of older non-Hispanic Black patients, that usually are seen by non-Hispanic Black providers, is the first step for meaningful relationship between non-Hispanic Black patients and their providers that directly improve the end-of-life quality of life for this segment of our population.

The Black and White of Invasive Mechanical Ventilation in Advanced Dementia

BACKGROUND/OBJECTIVES

Over the past decade, feeding tube use in nursing home residents with advanced dementia has declined by 50% among white and black patients. Little is known about whether a similar reduction has occurred in other invasive interventions, such as mechanical ventilation.

DESIGN

Retrospective cohort study.

SETTING

Acute-care hospitals in the United States.

PARTICIPANTS

Medicare beneficiaries with advanced dementia who previously resided in a nursing home and were hospitalized between 2001 and 2014 with pneumonia and/or septicemia and of either black or white race.

MEASUREMENT

Invasive mechanical ventilation (IMV), as identified by International Classification of Diseases (ICD) procedure codes. Two multivariable logistic regression models examined the association between race and the likelihood of receiving IMV, adjusting for patients' demographics, physical function, and comorbidities. A hospital fixed-effects model examined the association of race within a hospital, whereas a random-effects logistic model was used to estimate the between-hospital variation in the probability of receiving IMV and examine the overall association of race and use of IMV.

RESULTS

Between 2001 and 2014, 289,017 patients with advanced dementia were hospitalized for pneumonia or septicemia. Use of IMV increased from 3.7% to 12.1% in white patients and from 8.6% to 21.8% in blacks. Among those ventilated, 1-year mortality rates remained high, at 82.7% for whites and 84.2% for blacks dying in 2013. Compared with whites, blacks had a higher odds of receiving IMV in the fixed-effects (within-hospital) model (adjusted odds ratio (AOR) = 1.34; 95% confidence interval (CI) = 1.29-1.39) and in the random-effects (between-hospital) model (AOR = 1.46; 95% CI = 1.40-1.51).

CONCLUSION

IMV use in patients with advanced dementia has increased substantially, with black patients having a larger increase than whites, based, in part, on the hospitals where black patients receive care.

Goals-of-Care Consultations Are Associated with Lower Costs and Less Acute Care Use among Propensity-Matched Cohorts of African Americans and Whites with Serious Illness

Background: African Americans receive more aggressive end-of-life care than Whites. Little is known about how palliative care consultation to discuss goals-of-care ("PCC") is associated with acute care utilization and costs by race. Objective: To compare future acute care costs and utilization between propensity-matched cohorts of African Americans with and without PCC, and Whites with and without PCC. Design: Secondary analysis of a retrospective cohort study. Setting/Subjects: Thirty-five thousand one hundred and fifty-four African Americans and Whites age 18+ admitted for conditions other than childbirth or rehabilitation, who were not hospitalized at the end of the study, and did not die during index hospitalization (hospitalization during which the first PCC occurred). Measurements: Accumulated mean acute care costs and utilization (30-day readmissions, future hospital days, future intensive care unit [ICU] admission, future number of ICU days) after discharge from index hospitalization. Results: No significant difference between African Americans with or without PCC in mean future acute care costs ($11,651 vs. $15,050, p = 0.09), 30-day readmissions (p = 0.58), future hospital days (p = 0.34), future ICU admission (p = 0.25), or future ICU days (p = 0.30). There were significant differences between Whites with PCC and those without PCC in mean future acute care costs ($8,095 vs. $16,799, p < 0.001), 30-day readmissions (10.2% vs. 16.7%, p < 0.0001), and future days hospitalized (3.7 vs. 6.3 days, p < 0.0001). Conclusions: PCC decreases future acute care costs and utilization in Whites and, directionally but not significantly, in African Americans. Research is needed to explain why utilization and cost disparities persist among African Americans despite PCC.

Use of Do-Not-Resuscitate Orders for Critically Ill Patients with ESKD

BACKGROUND

Despite having high comorbidity rates and shortened life expectancy, patients with ESKD may harbor unrealistically optimistic expectations about their prognoses. Whether this affects resuscitation orders is unknown.

METHODS

To determine whether do-not-resuscitate (DNR) orders differ among patients with ESKD compared with other critically ill patients, including those with diseases of other major organs, we investigated DNR orders on admission to intensive care units (ICUs) among 106,873 patients in the United States.

RESULTS

Major organ disease uniformly associated with increased risk of hospital mortality, particularly for cirrhosis (adjusted odds ratio [aOR], 2.67; 95% confidence interval [95% CI], 2.30 to 3.08), and ESKD (aOR, 1.47; 95% CI, 1.31 to 1.65). Compared with critically ill patients without major organ disease, patients with stroke, cancer, heart failure, dementia, chronic obstructive pulmonary disease, and cirrhosis were statistically more likely to have a DNR order on ICU admission; those with ESKD were not. Findings were similar when comparing patients with a single organ disease with those without organ disease. The disconnect between prognosis and DNR use was most notable among Black patients, for whom ESKD (compared with no major organ disease) was associated with a 62% (aOR, 1.62; 95% CI, 1.27 to 2.04) higher odds of hospital mortality, but no appreciable difference in DNR utilization (aOR, 1.06; 95% CI, 0.66 to 1.62).

CONCLUSIONS

Unlike patients with diseases of other major organs, critically ill patients with ESKD were not more likely to have a DNR order than patients without ESKD. Whether this reflects a greater lack of advance care planning in the nephrology community, as well as a missed opportunity to minimize potentially needless patient suffering, requires further study.

Management Options for an Older Adult With Advanced Chronic Kidney Disease and Dementia: Grand Rounds Discussion From Beth Israel Deaconess Medical Center

About 15% of adults in the United States-37 million persons-have chronic kidney disease (CKD). Chronic kidney disease is divided into 5 groups, ranging from stage 1 to stage 5 CKD, whereas end-stage kidney disease (ESKD) is defined as permanent kidney failure. The treatment options for ESKD are kidney replacement therapy (KRT) and conservative management. The options for KRT include hemodialysis (either in-center or at home), peritoneal dialysis, and kidney transplant. Conservative management, a multidisciplinary model of care for patients with stage 5 CKD who want to avoid dialysis, is guided by patient values, preferences, and goals, with a focus on quality of life and symptom management. In 2015, the Kidney Disease Outcomes Quality Initiative recommended that patients with an estimated glomerular filtration rate below 30 mL/min/1.73 m2 be educated about options for both KRT and conservative management. In 2018, the National Institute for Health and Care Excellence recommended that assessment for KRT or conservative management start at least 1 year before the need for therapy. It also recommended that in choosing a management approach, predicted quality of life, predicted life expectancy, patient preferences, and other patient factors be considered, because little difference in outcomes has been found among options. Here, 2 experts-a nephrologist and a general internist-palliative care physician-reflect on the care of a patient with advanced CKD and mild to moderate dementia. They discuss the management options for patients with advanced CKD, the pros and cons of each method, and how to help a patient choose among the options.

Caring for older patients with advanced chronic kidney disease and considering their needs: a qualitative study

BACKGROUND

Older patients with advanced chronic kidney disease often do not understand treatment options for renal replacement therapy, conservative kidney management, and advance care planning. It is unclear whether both clinicians and patients have similar perspectives on these treatments and end-of-life care. Thus, the aim of this study was to explore clinician and patient/caregiver perceptions of treatments for end-stage renal disease and advance care planning.

METHODS

This was a qualitative interview study of nephrologists (n = 8), primary care physicians (n = 8), patients (n = 10, ≥ 65 years and estimated glomerular filtration rate < 20), and their caregivers (n = 5). Interviews were conducted until thematic saturation was reached. Transcripts were transcribed using TranscribeMe. Using Nvivo 12, we identified key themes via narrative analysis.

RESULTS

We identified three key areas in which nephrologists', primary care physicians', and patients' expectations and/or experiences did not align: 1) dialysis discussions; 2) dialysis decision-making; and 3) processes of advance care planning. Nephrologist felt most comfortable specifically managing renal disease whereas primary care physicians felt their primary role was to advocate for patients and lead advance care planning discussions. Patients and caregivers had many concerns about the impact of dialysis on their lives and did not fully understand advance care planning. Clinicians' perspectives were aligned with each other but not with patient/caregivers.

CONCLUSIONS

Our findings highlight the differences in experiences and expectations between clinicians, patients, and their caregivers regarding treatment decisions and advance care planning. Despite clinician agreement on their responsibilities, patients and caregivers were unclear about several aspects of their care. Further research is needed to test feasible models of patient-centered education and communication to ensure that all stakeholders are informed and feel engaged.

Racial/Ethnic Differences in Dialysis Discontinuation and Survival after Hospitalization for Serious Conditions among Patients on Maintenance Dialysis

BACKGROUND

Racial and ethnic minorities on dialysis survive longer than whites, and are less likely to discontinue dialysis. Both differences have been attributed by some clinicians to better health among minorities on dialysis.

METHODS

To test if racial and ethnic differences in dialysis discontinuation reflected better health, we conducted a retrospective cohort study of survival and dialysis discontinuation among patients on maintenance dialysis in the US Renal Data System after hospitalization for either stroke (n=60,734), lung cancer (n=4100), dementia (n=40,084), or failure to thrive (n=42,950) between 2003 and 2014. We examined the frequency of discontinuation of dialysis and used simulations to estimate survival in minorities relative to whites if minorities had the same pattern of dialysis discontinuation as whites.

RESULTS

Blacks, Hispanics, and Asians had substantially lower frequencies of dialysis discontinuation than whites in each hospitalization cohort. Observed risks of mortality were also lower for blacks, Hispanics, and Asians. In simulations that assigned discontinuation patterns similar to those found among whites across racial and ethnic groups, differences in survival were markedly attenuated and hazard ratios approached 1.0. Survival and dialysis discontinuation frequencies among American Indians and Alaska Natives were close to those of whites.

CONCLUSIONS

Racial and ethnic differences in dialysis discontinuation were present among patients hospitalized with similar health events. Among these patients, survival differences between racial and ethnic minorities and whites were largely attributable to differences in the frequency of discontinuation of dialysis.

Health Literacy Matters More Than Experience for Advance Care Planning Knowledge Among Older Adults

BACKGROUND

Advance care planning (ACP) engagement is low among vulnerable populations, including those with limited health literacy (LHL). Limited knowledge about ACP may be a modifiable mediator of the relationship between LHL and ACP. Our goal was to determine whether health literacy is associated with ACP knowledge.

DESIGN

Cross-sectional design.

SETTING

A public health delivery system and Veterans Affairs Medical Center in San Francisco, CA.

PARTICIPANTS

English- and Spanish-speaking patients (N = 1400).

MEASUREMENTS

ACP knowledge was assessed with seven validated multiple-choice questions. Health literacy was measured using a validated scale. Sociodemographic measures included age, sex, language, education, race, health status, and social support. Prior ACP experience was defined as having documented legal forms and/or goals-of-care discussions in the medical record. We used Kruskal-Wallis tests and linear regression to examine associations of ACP knowledge with LHL, prior ACP experience, and sociodemographic factors.

RESULTS

Mean age of participants was 65 (±10) years, 48% were women, 34% had LHL, 32% were Spanish speaking, 47% had high school education or less, and 70% were nonwhite. Mean 7-point knowledge scores were lower for those with limited vs adequate health literacy (3.8 [SD = 1.9 vs 5.5 (SD = 1.7); P < .001). In multivariable analysis, ACP knowledge scores were 1.0 point lower among those with LHL; 0.6 points lower among Spanish speakers and those with high school education or less; and 0.5 points lower among individuals of nonwhite race (P < .001 for all). Knowledge scores were 0.02 points lower per year of older age (P = .007) and 0.01 points higher per point of greater social support (P = .005). Prior ACP experience was not associated with knowledge after adjustment (P = .7).

CONCLUSIONS

Health literacy and sociodemographics are stronger predictors than prior ACP experience of ACP knowledge. This study suggests that providing easy-to-understand ACP materials is paramount and should be offered even if patients have previous experience with the ACP process. J Am Geriatr Soc 67:2151-2156, 2019.

Outcomes of in-hospital cardiopulmonary resuscitation for patients with end-stage liver disease

BACKGROUND AND AIMS

There have been improving survival trends after in-hospital cardiac arrest for the general population, but there is limited information on the outcomes of hospitalized patients with end-stage liver disease (ESLD) who undergo cardiopulmonary resuscitation (CPR). We aimed to examine survival to hospital discharge after receipt of in-hospital CPR in patients with ESLD using a nationally representative sample.

METHODS

We used the Nationwide Inpatient Sample database from 2006 to 2014 to identify adult patients who underwent in-hospital CPR. Using multivariate modelling, we compared survival to hospital discharge for patients with ESLD to those without ESLD. We also compared outcomes of patients with ESLD to patients with metastatic cancer.

RESULTS

A total of 177 533 patients underwent in-hospital CPR, of which 1474 (0.8%) had ESLD. Patients with ESLD had lower rates of survival to hospital discharge compared to patients without ESLD (10.7% vs 28.6%, P < 0.01). In multivariate modelling, ESLD was significantly associated with lower odds of survival to hospital discharge after in-hospital CPR (OR 0.35, 95% CI 0.28-0.44, P < 0.01). Among survivors of in-hospital CPR, ESLD patients had a significantly lower chance of discharge to home compared to patients without ESLD (3.2% vs 8.0%, P < 0.05). Patients with ESLD also had lower rates of survival to hospital discharge compared to those with metastatic cancer (10.7% vs 15.5%, P < 0.01).

CONCLUSIONS

Outcomes are poor after in-hospital CPR in patients with ESLD and are worse than for patients with metastatic cancer. The current analysis can be used to inform goals of care discussions for patients with ESLD.

Patients' perspectives on dialysis decision-making and end-of-life care

BACKGROUND

Few studies have explored dialysis patients' perspectives on dialysis decision-making and end-of-life-care (EoLC) preferences. We surveyed a racially diverse cohort of maintenance dialysis patients in the Cleveland, OH, USA, metropolitan area.

MATERIALS AND METHODS

In this cross-sectional study, we administered a 41-item questionnaire to 450 adult chronic dialysis patients. Items assessed patients' knowledge of their kidney disease as well as their attitudes toward chronic kidney disease (CKD) treatment issues and EoLC issues.

RESULTS

The cohort included 67% Blacks, 27% Caucasians, 2.8% Hispanics, and 2.4% others. The response rate was 94% (423/450). Most patients considered it essential to obtain detailed information about their medical condition (80.6%) and prognosis (78.3%). Nearly 19% of respondents regretted their decision to start dialysis. 41% of patients would prefer treatment(s) aimed at relieving pain rather than prolonging life (30.5%), but a majority would want to be resuscitated (55.3%). Only 8.4% reported having a designated healthcare proxy, and 35.7% reported completing a living will. A significant percentage of patients wished to discuss their quality of life (71%), psychosocial and spiritual concerns (50.4%), and end-of-life issues (38%) with their nephrologist.

CONCLUSION

Most dialysis patients wish to have more frequent discussions about their disease, prognosis, and EoLC planning. Findings from this study can inform the design of future interventions.
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Health Literacy Mediates Racial Disparities in Cardiopulmonary Resuscitation Knowledge among Chronic Kidney Disease Patients

Black patients with chronic kidney disease (CKD) receive more cardiopulmonary resuscitation (CPR) than other racial groups, and knowledge of CPR influences preferences for care. As limited health literacy disproportionately affects Blacks and contributes to disparities in end-of-life (EOL) care, we investigated whether health literacy mediates racial disparities in CPR knowledge. Black and White adult patients with advanced CKD completed CPR knowledge surveys. Health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine. Among 149 patients, Black patients were more likely to have limited health literacy and lower mean CPR knowledge scores than White patients. In adjusted analyses, health literacy mediated racial differences in CPR knowledge. Knowledge of CPR is lower among Black compared with White CKD patients and health literacy is a mediator of this difference. Future CPR educational interventions should target health literacy barriers to improve informed decision-making and decrease racial disparities at the end of life.

Association of Race and Poverty With Mortality Among Nursing Home Residents on Maintenance Dialysis

OBJECTIVES

The association of race, ethnicity, and socioeconomic factors with survival rates of nursing home (NH) residents with treated end-stage renal disease (ESRD) is unclear. We examined whether race/ethnicity, ZIP code-level, and individual-level indicators of poverty relate to mortality of NH residents on dialysis.

DESIGN

Retrospective cohort study.

PARTICIPANTS/SETTING

Using the United States Renal Data System database, we identified 56,194 nursing home residents initiated on maintenance dialysis from January 1, 2007 through December 31, 2013, followed until May 31, 2014.

MEASUREMENTS

We evaluated baseline characteristics of the NH cohort on dialysis, including race and ethnicity. We assessed the Medicare-Medicaid dual eligibility status as an indicator of individual-level poverty and ZIP code-level median household income (MHI) data. We conducted Cox regression analyses with all-cause mortality as the outcome variable, adjusted for clinical and sociodemographic factors including end-of-life preferences.

RESULTS

Adjusted Cox analysis showed a significantly lower risk of death among black vs nonblack NH residents [adjusted hazard ratio (AHR) 0.91, 95% confidence interval (CI) 0.89, 0.94]. Dual-eligibility status was significantly associated with lower risk of death compared to those with Medicare alone (AHR 0.80, 95% CI 0.78, 0.82). Compared to those in higher MHI quintile levels, NH ESRD patients in the lowest quintile were significantly associated with higher risk of death (AHR 1.09, 95% CI 1.06, 1.13).

CONCLUSIONS/IMPLICATIONS

Black and Hispanic NH residents on dialysis had an apparent survival advantage. This "survival paradox" occurs despite well-documented racial/ethnic disparities in ESRD and NH care and warrants further exploration that could generate new insights into means of improving survival of all NH residents on dialysis. Area-level indicator of poverty was independently associated with mortality, whereas dual-eligibility status for Medicare and Medicaid was associated with lower risk of death, which could be partly explained by improved access to care.

A Systematic Review of Race/Ethnicity and Parental Treatment Decision-Making

Patient race/ethnicity affects health care utilization, provider trust, and treatment choice. It is uncertain how these influences affect pediatric care. We performed a systematic review (PubMed, Scopus, Web of Science, PsycINFO, Cochrane, and Embase) for articles examining race/ethnicity and parental treatment decision-making, adhering to PRISMA methodology. A total of 9200 studies were identified, and 17 met inclusion criteria. Studies focused on treatment decisions concerning end-of-life care, human papillomavirus vaccination, urological surgery, medication regimens, and dental care. Findings were not uniform between studies; however, pooled results showed (1) racial/ethnic minorities tended to prefer more aggressive end-of-life care; (2) familial tradition of neonatal circumcision influenced the decision to circumcise; and (3) non-Hispanic Whites were less likely to pursue human papillomavirus vaccination but more likely to complete the vaccine series if initiated. The paucity of studies precluded overarching findings regarding the influence of race/ethnicity on parental treatment decisions. Further investigation may improve family-centered communication, parent engagement, and shared decision-making.

Perceptions of Family Decision-makers of Nursing Home Residents With Advanced Dementia Regarding the Quality of Communication Around End-of-Life Care

OBJECTIVES

(1) Compare family decision-makers' perceptions of quality of communication with nursing home (NH) staff (nurses and social workers) and clinicians (physicians and other advanced practitioners) for persons with advanced dementia; (2) determine the extent to which characteristics of NH residents and family decision-makers are associated with those perceptions.

DESIGN

Secondary analysis of baseline data from a cluster randomized trial of the Goals of Care intervention.

SETTING

Twenty-two NHs in North Carolina.

PARTICIPANTS

Family decision-makers of NH residents with advanced dementia (n = 302).

MEASUREMENTS

During the baseline interviews, family decision-makers rated the quality of general communication and communication specific to end-of-life care using the Quality of Communication Questionnaire (QoC). QoC item scores ranged from 0 to 10, with higher scores indicating better quality of communication. Linear models were used to compare QoC by NH provider type, and to test for associations of QoC with resident and family characteristics.

RESULTS

Family decision-makers rated the QoC with NH staff higher than NH clinicians, including average overall QoC scores (5.5 [1.7] vs 3.7 [3.0], P < .001), general communication subscale scores (8.4 [1.7] vs 5.6 [4.3], P < .001), and end-of-life communication subscale scores (3.0 [2.3] vs 2.0 [2.5], P < .001). Low scores reflected failure to communicate about many aspects of care, particularly end-of-life care. QoC scores were higher with later-stage dementia, but were not associated with the age, gender, race, relationship to the resident, or educational attainment of family decision-makers.

CONCLUSION

Although family decision-makers for persons with advanced dementia rated quality communication with NH staff higher than that with clinicians, they reported poor quality end-of-life communication for both staff and clinicians. Clinicians simply did not perform many communication behaviors that contribute to high-quality end-of-life communication. These omissions suggest opportunities to clarify and improve interdisciplinary roles in end-of-life communication for residents with advanced dementia.