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Algu K, Wales J, Anderson M, Omilabu M, Briggs T, Kurahashi AM. Naming racism as a root cause of inequities in palliative care research: a scoping review. BMC Palliat Care 2024; 23:143. [PMID: 38858646 PMCID: PMC11163751 DOI: 10.1186/s12904-024-01465-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 05/22/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Racial and ethnic inequities in palliative care are well-established. The way researchers design and interpret studies investigating race- and ethnicity-based disparities has future implications on the interventions aimed to reduce these inequities. If racism is not discussed when contextualizing findings, it is less likely to be addressed and inequities will persist. OBJECTIVE To summarize the characteristics of 12 years of academic literature that investigates race- or ethnicity-based disparities in palliative care access, outcomes and experiences, and determine the extent to which racism is discussed when interpreting findings. METHODS Following Arksey & O'Malley's methodology for scoping reviews, we searched bibliographic databases for primary, peer reviewed studies globally, in all languages, that collected race or ethnicity variables in a palliative care context (January 1, 2011 to October 17, 2023). We recorded study characteristics and categorized citations based on their research focus-whether race or ethnicity were examined as a major focus (analyzed as a primary independent variable or population of interest) or minor focus (analyzed as a secondary variable) of the research purpose, and the interpretation of findings-whether authors directly or indirectly discussed racism when contextualizing the study results. RESULTS We identified 3000 citations and included 181 in our review. Of these, most were from the United States (88.95%) and examined race or ethnicity as a major focus (71.27%). When interpreting findings, authors directly named racism in 7.18% of publications. They were more likely to use words closely associated with racism (20.44%) or describe systemic or individual factors (41.44%). Racism was directly named in 33.33% of articles published since 2021 versus 3.92% in the 10 years prior, suggesting it is becoming more common. CONCLUSION While the focus on race and ethnicity in palliative care research is increasing, there is room for improvement when acknowledging systemic factors - including racism - during data analysis. Researchers must be purposeful when investigating race and ethnicity, and identify how racism shapes palliative care access, outcomes and experiences of racially and ethnically minoritized patients.
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Affiliation(s)
- Kavita Algu
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada.
| | - Joshua Wales
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
| | - Michael Anderson
- Waakebiness-Bryce Institute for Indigenous Health, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, ON, M5T 3M7, Canada
| | - Mariam Omilabu
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
| | - Thandi Briggs
- Home and Community Care Support Services Toronto Central, 250 Dundas St. W, Toronto, ON, M5T 2Z5, Canada
| | - Allison M Kurahashi
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
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Mooney KH, Coombs LA, Whisenant MS, Wilson CM, Moraitis AM, Steinbach MN, Sloss EA, Lloyd JLE, Alekhina N, Berry PH, Kang Y, Iacob E, Donaldson GW. Impact of an automated, remote monitoring and coaching intervention in reducing hospice cancer family caregiving burden: A multisite randomized controlled trial. Cancer 2024; 130:1171-1182. [PMID: 38009953 DOI: 10.1002/cncr.35131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/29/2023] [Accepted: 11/01/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Care for those with life-limiting cancer heavily involves family caregivers who may experience significant physical and emotional burden. The purpose of this study was to test the impact of Symptom Care at Home (SCH), an automated digital family caregiver coaching intervention, during home hospice, when compared to usual hospice care (UC) on the primary outcome of overall caregiver burden. Secondary outcomes included Caregiver Burden at weeks 1 and 8, Mood and Vitality subscales, overall moderate-to-severe caregiving symptoms, and sixth month spouse/partner bereavement outcomes. METHODS Using a randomized, multisite, nonblinded controlled trial, 332 cancer family caregivers were enrolled and analyzed (159 SCH vs. 173 UC). Caregivers were primarily White (92%), female (69%), and spouse caregivers (53%). Caregivers provided daily reports on severity levels (0-10 scale) for their anxiety, depressed mood, fatigue, disturbed sleep, and caregiving interference with normal activities. These scores combined constituted the Caregiver Burden primary outcome. Based on reported symptoms, SCH caregivers received automated, tailored coaching about improving their well-being. Reports of moderate-to-severe caregiving symptoms also triggered hospice nurse notification. Secondary outcomes of Mood and Vitality were subcomponents of the Caregiver Burden score. A combined bereavement adjustment tool captured sixth month bereavement. RESULTS The SCH intervention reduced overall Caregiver Burden compared to UC (p < .001), with a 38% reduction at 8 weeks and a medium-to-large effect size (d = .61). SCH caregivers experienced less (p < .001) disruption in both Mood and Vitality. There were higher levels of moderate-to-severe caregiving symptoms overtime in UC (OR, 2.722). All SCH caregivers benefited regardless of caregiver: sex, caregiver relationship, age, patient diagnosis and family income. SCH spouse/partner caregivers achieved better sixth month bereavement adjustment than UC (p < .007). CONCLUSIONS The SCH intervention significantly decreased caregiving burden over UC and supports the maintenance of family caregiver mood and vitality throughout caregiving with extended benefit into bereavement.
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Affiliation(s)
- Kathi H Mooney
- Huntsman Cancer Institute, Salt Lake City, Utah, USA
- University of Utah, Salt Lake City, Utah, USA
| | - Lorinda A Coombs
- University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
| | | | | | | | - Mary N Steinbach
- Huntsman Cancer Institute, Salt Lake City, Utah, USA
- University of Utah, Salt Lake City, Utah, USA
| | | | - Jennifer L E Lloyd
- Huntsman Cancer Institute, Salt Lake City, Utah, USA
- University of Utah, Salt Lake City, Utah, USA
| | | | | | | | - Eli Iacob
- University of Utah, Salt Lake City, Utah, USA
| | - Gary W Donaldson
- Huntsman Cancer Institute, Salt Lake City, Utah, USA
- University of Utah, Salt Lake City, Utah, USA
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Rosa WE, Izumi S, Sullivan DR, Lakin J, Rosenberg AR, Creutzfeldt CJ, Lafond D, Tjia J, Cotter V, Wallace C, Sloan DE, Cruz-Oliver DM, DeSanto-Madeya S, Bernacki R, Leblanc TW, Epstein AS. Advance Care Planning in Serious Illness: A Narrative Review. J Pain Symptom Manage 2023; 65:e63-e78. [PMID: 36028176 PMCID: PMC9884468 DOI: 10.1016/j.jpainsymman.2022.08.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 02/03/2023]
Abstract
CONTEXT Advance care planning (ACP) intends to support person-centered medical decision-making by eliciting patient preferences. Research has not identified significant associations between ACP and goal-concordant end-of-life care, leading to justified scientific debate regarding ACP utility. OBJECTIVE To delineate ACP's potential benefits and missed opportunities and identify an evidence-informed, clinically relevant path ahead for ACP in serious illness. METHODS We conducted a narrative review merging the best available ACP empirical data, grey literature, and emergent scholarly discourse using a snowball search of PubMed, Medline, and Google Scholar (2000-2022). Findings were informed by our team's interprofessional clinical and research expertise in serious illness care. RESULTS Early ACP practices were largely tied to mandated document completion, potentially failing to capture the holistic preferences of patients and surrogates. ACP models focused on serious illness communication rather than documentation show promising patient and clinician results. Ideally, ACP would lead to goal-concordant care even amid the unpredictability of serious illness trajectories. But ACP might also provide a false sense of security that patients' wishes will be honored and revisited at end-of-life. An iterative, 'building block' framework to integrate ACP throughout serious illness is provided alongside clinical practice, research, and policy recommendations. CONCLUSIONS We advocate a balanced approach to ACP, recognizing empirical deficits while acknowledging potential benefits and ethical imperatives (e.g., fostering clinician-patient trust and shared decision-making). We support prioritizing patient/surrogate-centered outcomes with more robust measures to account for interpersonal clinician-patient variables that likely inform ACP efficacy and may better evaluate information gleaned during serious illness encounters.
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Affiliation(s)
- William E Rosa
- Department of Psychiatry and Behavioral Sciences (W.E.R.), Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Shigeko Izumi
- School of Nursing (S.I.), Oregon Health and Science University, Portland, Oregon
| | - Donald R Sullivan
- Division of Pulmonary and Critical Care Medicine (D.R.S.), School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Joshua Lakin
- Department of Psychosocial Oncology and Palliative Care (J.L., R.B.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Abby R Rosenberg
- Division of Hematology-Oncology, Department of Pediatrics (A.R.R.), University of Washington School of Medicine, Seattle, Washington; Palliative Care and Resilience Lab (A.R.R.), Seattle Children's Research Institute, Seattle, Washington
| | | | - Debbie Lafond
- Pediatric and Neonatal Needs Advanced (PANDA) Education Consultants (D.L.)
| | - Jennifer Tjia
- Chan Medical School, University of Massachusetts (J.T.), Worcester, Massachusetts
| | - Valerie Cotter
- School of Nursing, Johns Hopkins University (V.C.), Baltimore, Maryland; School of Medicine, Johns Hopkins University (V.C.), Baltimore, Maryland
| | - Cara Wallace
- College for Public Health and Social Justice (C.W.), Saint Louis University, St. Louis, Missouri
| | - Danetta E Sloan
- Department of Health (D.E.S.), Behavior and Society, Johns Hopkins University, Baltimore, Maryland
| | - Dulce Maria Cruz-Oliver
- Geriatric Medicine and Gerontology (D.M.C.O.), Beacham Center for Geriatric Medicine, Johns Hopkins Medicine, Baltimore, Maryland
| | | | - Rachelle Bernacki
- Department of Psychosocial Oncology and Palliative Care (J.L., R.B.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Thomas W Leblanc
- Department of Medicine (T.W.L.), Duke University School of Medicine, Durham, North Carolina
| | - Andrew S Epstein
- Department of Medicine (A.S.E.), Memorial Sloan Kettering Cancer Center, New York, New York
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Ali H, Pamarthy R, Bolick NL, Leland W, Lee T. Inpatient outcomes and racial disparities of palliative care consults in mechanically ventilated patients in the United States. Proc (Bayl Univ Med Cent) 2022; 35:762-767. [DOI: 10.1080/08998280.2022.2106537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Affiliation(s)
- Hassam Ali
- Department of Internal Medicine, East Carolina University/Vidant Medical Center, Greenville, North Carolina
| | - Rahul Pamarthy
- Department of Internal Medicine, East Carolina University/Vidant Medical Center, Greenville, North Carolina
| | | | - William Leland
- Department of Gastroenterology, East Carolina University/Vidant Medical Center, Greenville, North Carolina
| | - Tae Lee
- Department of Palliative Care, East Carolina University/Vidant Medical Center, Greenville, North Carolina
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Sullivan SS, Bo W, Li CS, Xu W, Chang YP. Predicting Hospice Transitions in Dementia Caregiving Dyads: An Exploratory Machine Learning Approach. Innov Aging 2022; 6:igac051. [PMID: 36452051 PMCID: PMC9701063 DOI: 10.1093/geroni/igac051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Indexed: 10/19/2023] Open
Abstract
Background and Objectives Hospice programs assist people with serious illness and their caregivers with aging in place, avoiding unnecessary hospitalizations, and remaining at home through the end-of-life. While evidence is emerging of the myriad of factors influencing end-of-life care transitions among persons living with dementia, current research is primarily cross- sectional and does not account for the effect that changes over time have on hospice care uptake, access, and equity within dyads. Research Design and Methods Secondary data analysis linking the National Health and Aging Trends Study to the National Study of Caregiving investigating important social determinants of health and quality-of-life factors of persons living with dementia and their primary caregivers (n = 117) on hospice utilization over 3 years (2015-2018). We employ cutting-edge machine learning approaches (correlation matrix analysis, principal component analysis, random forest [RF], and information gain ratio [IGR]). Results IGR indicators of hospice use include persons living with dementia having diabetes, a regular physician, a good memory rating, not relying on food stamps, not having chewing or swallowing problems, and whether health prevents them from enjoying life (accuracy = 0.685; sensitivity = 0.824; specificity = 0.537; area under the curve (AUC) = 0.743). RF indicates primary caregivers' age, and the person living with dementia's income, census division, number of days help provided by caregiver per month, and whether health prevents them from enjoying life predicts hospice use (accuracy = 0.624; sensitivity = 0.713; specificity = 0.557; AUC = 0.703). Discussion and Implications Our exploratory models create a starting point for the future development of precision health approaches that may be integrated into learning health systems that prompt providers with actionable information about who may benefit from discussions around serious illness goals-for-care. Future work is necessary to investigate those not considered in this study-that is, persons living with dementia who do not use hospice care so additional insights can be gathered around barriers to care.
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Affiliation(s)
| | - Wei Bo
- Department of Computer Science Engineering, University at Buffalo, Buffalo, New York, USA
| | - Chin-Shang Li
- School of Nursing, University at Buffalo, Buffalo, New York, USA
| | - Wenyao Xu
- Department of Computer Science Engineering, University at Buffalo, Buffalo, New York, USA
| | - Yu-Ping Chang
- School of Nursing, University at Buffalo, Buffalo, New York, USA
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Starr LT, Bullock K, Washington K, Aryal S, Parker Oliver D, Demiris G. Anxiety, Depression, Quality of Life, Caregiver Burden, and Perceptions of Caregiver-Centered Communication among Black and White Hospice Family Caregivers. J Palliat Med 2022; 25:596-605. [PMID: 34793244 PMCID: PMC8982115 DOI: 10.1089/jpm.2021.0302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Anxiety, depression, and reduced quality of life (QOL) are common problems for hospice family caregivers, but it is unknown if disparities in these experiences exist among Black and White caregivers. Objectives: To compare anxiety, depression, QOL, caregiver burden, and perceptions of caregiver-centered hospice team communication between Black and White hospice family caregivers. Design: Secondary analysis of baseline data from two randomized clinical trials. Setting/Subjects: Seven hundred twenty-two Black and White hospice family caregivers ages 18+ from Midwestern and Northeastern United States. Measurements: Measures included the Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire (PHQ-9), Caregiver Quality-of-Life Index-Revised (CQLI-R), Zarit Burden Interview (ZBI-7), and Caregiver-Centered Communication Questionnaire (CCCQ). Results: Black and White caregivers differed across demographic and socioeconomic variables. Nearly one-third of hospice family caregivers reported moderate-to-severe anxiety (32.1%) and moderate-to-severe depressive symptoms (32.0%). White caregivers reported lower QOL than Black caregivers (p = 0.04), specifically in emotional (p = 0.02) and social (p = 0.0005) domains. In multiple regression analyses controlling for caregiver and patient factors, we found no racial differences in depression, anxiety, QOL, caregiver burden, or perceptions of caregiver-centered hospice communication. Conclusions: Despite demographic and socioeconomic differences, Black and White hospice family caregivers experience similarly high levels of anxiety, depression, burden, and perceptions of hospice communication. Interventions to support hospice family caregivers across racial groups and research that identifies factors that mediate social determinants of health in this population are needed. The development and validation of culture-concordant mental health screening tools in racially diverse populations is recommended. Trial registration: ClinicalTrials.gov NCT02929108 and ClinicalTrials.gov NCT01444027.
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Affiliation(s)
- Lauren T. Starr
- Department of Biobehavioral and Health Sciences, NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karen Bullock
- Department of Social Work, College of Humanities and Social Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - Karla Washington
- Division of Palliative Medicine, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Subhash Aryal
- BECCA (Biostatistics * Evaluation * Collaboration * Consultation * Analysis) Lab, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Debra Parker Oliver
- Division of Palliative Medicine, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Barnes Jewish College, Goldfarb School of Nursing, St. Louis, Missouri, USA
| | - George Demiris
- Department of Biobehavioral and Health Sciences, NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Jones KF, Laury E, Sanders JJ, Starr LT, Rosa WE, Booker SQ, Wachterman M, Jones CA, Hickman S, Merlin JS, Meghani SH. Top Ten Tips Palliative Care Clinicians Should Know About Delivering Antiracist Care to Black Americans. J Palliat Med 2022; 25:479-487. [PMID: 34788577 PMCID: PMC9022452 DOI: 10.1089/jpm.2021.0502] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Racial disparities, including decreased hospice utilization, lower quality symptom management, and poor-quality end-of-life care have been well documented in Black Americans. Improving health equity and access to high-quality serious illness care is a national palliative care (PC) priority. Accomplishing these goals requires clinician reflection, engagement, and large-scale change in clinical practice and health-related policies. In this article, we provide an overview of key concepts that underpin racism in health care, discuss common serious illness disparities in Black Americans, and propose steps to promote the delivery of antiracist PC.
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Affiliation(s)
| | - Esther Laury
- Louise Fitzpatrick College of Nursing, Villanova University, Villanova, Pennsylvania, USA.,Address correspondence to: Esther Laury, PhD, RN, Merck Sharp & Dohme Corp., US Outcomes Research, 351 N. Sumneytown Pike, North Wales, PA 19454, USA
| | - Justin J. Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren T. Starr
- New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - William E. Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Staja Q. Booker
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, Gainesville, Florida, USA
| | - Melissa Wachterman
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Christopher A. Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Susan Hickman
- Department of Community and Health Systems, Indiana University School of Nursing, Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Jessica S. Merlin
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Salimah H. Meghani
- Department of Biobehavioral Health Sciences, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,New Courtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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