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Qureshi AI, Baskett WI, Huang W, Shyu D, Myers D, Lobanova I, Naqvi SH, Thompson VS, Shyu CR. Effect of Race and Ethnicity on In-Hospital Mortality in Patients with COVID-19. Ethn Dis 2021; 31:389-398. [PMID: 34295125 PMCID: PMC8288468 DOI: 10.18865/ed.31.3.389] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective To identify differences in short-term outcomes of patients with coronavirus disease 2019 (COVID-19) according to various racial/ethnic groups. Design Analysis of Cerner de-identified COVID-19 dataset. Setting A total of 62 health care facilities. Participants The cohort included 49,277 adult COVID-19 patients who were hospitalized from December 1, 2019 to November 13, 2020. Main Outcome Measures The primary outcome of interest was in-hospital mortality. The secondary outcome was non-routine discharge (discharge to destinations other than home, such as short-term hospitals or other facilities including intermediate care and skilled nursing homes). Methods We compared patients' age, gender, individual components of Charlson and Elixhauser comorbidities, medical complications, use of do-not-resuscitate, use of palliative care, and socioeconomic status between various racial and/or ethnic groups. We further compared the rates of in-hospital mortality and non-routine discharges between various racial and/or ethnic groups. Results Compared with White patients, in-hospital mortality was significantly higher among African American (OR 1.5; 95%CI:1.3-1.6, P<.001), Hispanic (OR1.4; 95%CI:1.3-1.6, P<.001), and Asian or Pacific Islander (OR 1.5; 95%CI: 1.1-1.9, P=.002) patients after adjustment for age and gender, Elixhauser comorbidities, do-not-resuscitate status, palliative care use, and socioeconomic status. Conclusions Our study found that, among hospitalized patients with COVID-2019, African American, Hispanic, and Asian or Pacific Islander patients had increased mortality compared with White patients after adjusting for sociodemographic factors, comorbidities, and do-not-resuscitate/palliative care status. Our findings add additional perspective to other recent studies.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, MO
| | - William I. Baskett
- Institute for Data Science and Informatics, University of Missouri, Columbia, MO
| | - Wei Huang
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, MO
| | - Daniel Shyu
- Department of Medicine, University of Missouri, Columbia, MO
| | - Danny Myers
- Tiger Institute for Health Innovation, Cerner Corporation, Columbia, MO
| | - Iryna Lobanova
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, MO
| | - S. Hasan Naqvi
- Department of Internal Medicine, University of Missouri, Columbia, MO
| | - Vetta S. Thompson
- Brown School of Public Health Program, Washington University, St. Louis, MO
| | - Chi-Ren Shyu
- Institute for Data Science and Informatics, University of Missouri, Columbia, MO
- Department of Medicine, University of Missouri, Columbia, MO
- Department of Electrical Engineering and Computer Science, University of Missouri, Columbia, MO
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Longitudinal Pediatric Palliative Care: Quality of Life & Spiritual Struggle (FACE): design and methods. Contemp Clin Trials 2012; 33:1033-43. [PMID: 22664645 DOI: 10.1016/j.cct.2012.05.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Revised: 04/26/2012] [Accepted: 05/13/2012] [Indexed: 12/25/2022]
Abstract
As life expectancy increases for adolescents ever diagnosed with AIDS due to treatment advances, the optimum timing of advance care planning is unclear. Left unprepared for end-of-life (EOL) decisions, families may encounter miscommunication and disagreements, resulting in families being charged with neglect, court battles and even legislative intervention. Advanced care planning (ACP) is a valuable tool rarely used with adolescents. The Longitudinal Pediatric Palliative Care: Quality of Life & Spiritual Struggle study is a two-arm, randomized controlled trial assessing the effectiveness of a disease specific FAmily CEntered (FACE) advanced care planning intervention model among adolescents diagnosed with AIDS, aimed at relieving psychological, spiritual, and physical suffering, while maximizing quality of life through facilitated conversations about ACP. Participants will include 130 eligible dyads (adolescent and family decision-maker) from four urban cities in the United States, randomized to either the FACE intervention or a Healthy Living Control. Three 60-minute sessions will be conducted at weekly intervals. The dyads will be assessed at baseline as well as 3-, 6-, 12-, and 18-month post-intervention. The primary outcome measures will be in congruence with EOL treatment preferences, decisional conflict, and quality of communication. The mediating and moderating effects of threat appraisal, HAART adherence, and spiritual struggle on the relationships among FACE and quality of life and hospitalization/dialysis use will also be assessed. This study will be the first longitudinal study of an AIDS-specific model of ACP with adolescents. If successful, this intervention could quickly translate into clinical practice.
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Sharma RK, Dy SM. Cross-cultural communication and use of the family meeting in palliative care. Am J Hosp Palliat Care 2010; 28:437-44. [PMID: 21190947 DOI: 10.1177/1049909110394158] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Terminally-ill patients and their families often report poor communication and limited understanding of the patient's diagnosis, prognosis, and treatment plan; these deficits can be exacerbated by cross-cultural issues. Although family meetings are frequently recommended to facilitate provider-family communication, a more structured, evidence-based approach to their use may improve outcomes. Drawing on research and guidelines from critical care, palliative care, and cross-cultural communication, we propose a framework for conducting family meetings with consideration for cross-cultural issues.
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Affiliation(s)
- Rashmi K Sharma
- Division of Hospital Medicine, Northwestern University, Chicago, IL, USA.
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Mitchell BL, Mitchell LC. Review of the literature on cultural competence and end-of-life treatment decisions: the role of the hospitalist. J Natl Med Assoc 2010; 101:920-6. [PMID: 19806850 DOI: 10.1016/s0027-9684(15)31040-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine whether any associations exist between cultural (racial/ethnic, spiritual/religious) competence and end-of-life treatment decisions in hospitalized patients and the potential impact of those associations on hospitalists' provision of care. DATA SOURCES AND METHODS MEDLINE, PubMed, Embase, Psychlnfo, and CINAHL databases were searched using the following search terms: cultural competence, race, ethnicity, minority, African American, Hispanic, end of life, palliative care, advanced care planning, inpatient, religion, spirituality, faith, hospitalist, and hospice. We identified studies in which spirituality/religion or race/ethnicity was used as a variable to study their potential impact on end-of-life treatment decisions in hospitalized patients. RESULTS In only 13 studies was spirituality/religion or race/ ethnicity used to study its effect on end-of-life decisions in hospitalized patients. African American patients tended to prefer the use of life-sustaining treatments at the end of life, and race/ethnicity did not appear to affect decisions to withhold or withdraw certain types of life-sustaining technology. Specific spiritual needs were identified both within and outside organized religions when members of those religions were hospitalized at the end of life. CONCLUSIONS End-of-life care may present unique challenges and opportunities in culturally discordant hospitalist-patient relationships. Culturally competent health care in an increasingly diverse population requires awareness of the importance of culture, particularly spirituality/religion and race/ethnicity, in the care of hospitalized patients at the end of life.
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Affiliation(s)
- Bruce L Mitchell
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL 32224, USA.
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5
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Lyon ME, Garvie PA, Briggs L, He J, Malow R, D'Angelo LJ, McCarter R. Is it safe? Talking to teens with HIV/AIDS about death and dying: a 3-month evaluation of Family Centered Advance Care (FACE) planning - anxiety, depression, quality of life. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2010; 2:27-37. [PMID: 22096382 PMCID: PMC3218704 DOI: 10.2147/hiv.s7507] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose To determine the safety of engaging HIV-positive (HIV+) adolescents in a Family Centered Advance Care (FACE) planning intervention. Patients and methods We conducted a 2-armed, randomized controlled clinical trial in 2 hospital-based outpatient clinics from 2006–2008 with HIV+ adolescents and their surrogates (n = 76). Three 60–90 minutes sessions were conducted weekly. FACE intervention groups received: Lyon FCACP Survey©, the Respecting Choices® interview, and completion of The Five Wishes©. The Healthy Living Control (HLC) received: Developmental History, Healthy Tips, Future Planning (vocational, school or vocational rehabilitation). Three-month post-intervention outcomes were: completion of advance directive (Five Wishes©); psychological adjustment (Beck Depression, Anxiety Inventories); quality of life (PedsQL™); and HIV symptoms (General Health Self-Assessment). Results Adolescents had a mean age, 16 years; 40% male; 92% African-American; 68% with perinatally acquired HIV, 29% had AIDS diagnosis. FACE participants completed advance directives more than controls, using time matched comparison (P < 0.001). Neither anxiety, nor depression, increased at clinically or statistically significant levels post-intervention. FACE adolescents maintained quality of life. FACE families perceived their adolescents as worsening in their school (P = 0.018) and emotional (P = 0.029) quality of life at 3 months, compared with controls. Conclusions Participating in advance care planning did not unduly distress HIV+ adolescents.
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Affiliation(s)
- Maureen E Lyon
- Children's National Medical Center and George Washington School of Medicine and Health Sciences, Washington, District of Columbia
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6
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Factors associated with gastrostomy tube feeding in dementia: a structured literature review. Alzheimers Dement 2009; 2:234-42. [PMID: 19595892 DOI: 10.1016/j.jalz.2006.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2005] [Revised: 03/07/2006] [Accepted: 03/21/2006] [Indexed: 11/21/2022]
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Racial and ethnic differences in the treatment of seriously ill patients: a comparison of African-American, Caucasian and Hispanic veterans. J Natl Med Assoc 2008; 100:1041-51. [PMID: 18807433 DOI: 10.1016/s0027-9684(15)31442-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND No national data exist regarding racial/ethnic differences in the use of interventions for patients at the end of life. OBJECTIVES To test whether among 3 cohorts of hospitalized seriously ill veterans with cancer, noncancer or dementia the use of common life-sustaining treatments differed significantly by race/ethnicity. DESIGN Retrospective cohort study during fiscal years 1991-2002. PATIENTS Hospitalized veterans >55 years, defined clinically as at high-risk for 6-month mortality, not by decedent data. MEASUREMENTS Utilization patterns by race/ethnicity for 5 life-sustaining therapies. Logistic regression models evaluated differences among Caucasians, African Americans and Hispanics, controlling for age, disease severity and clustering of patients within Veterans Affairs (VA) medical centers. RESULTS Among 166,059 veterans, both differences and commonalities across diagnostic cohorts were found. African Americans received more or the same amount of end-of-life treatments across disease cohorts, except for less resuscitation [OR = 0.84 (0.77-0.92), p = 0.002] and mechanical ventilation [OR = 0.89 (0.85-0.94), p < or = 0.0001] in noncancer patients. Hispanics were 36% (cancer) to 55% (noncancer) to 88% (dementia) more likely to receive transfusions than Caucasians (p < 0.0001). They received similar rates as Caucasians for all other interventions in all other groups, except for 161% higher likelihood for mechanical ventilation in patients with dementia. Increased end-of-life treatments for both minority groups were most pronounced in the dementia cohort. Differences demonstrated a strong interaction with the disease cohort. CONCLUSIONS Differences in level of end-of-life treatments were disease specific and bidirectional for African Americans. In the absence of generally accepted, evidence-based standards for end-of-life care, these differences may or may not constitute disparities.
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Abbo ED, Volandes AE. A Forced Choice: The Value of Requiring Advance Directives. THE JOURNAL OF CLINICAL ETHICS 2008. [DOI: 10.1086/jce200819204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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"It's like crossing a bridge" complexities preventing physicians from discussing deactivation of implantable defibrillators at the end of life. J Gen Intern Med 2008; 23 Suppl 1:2-6. [PMID: 18095036 PMCID: PMC2150631 DOI: 10.1007/s11606-007-0237-x] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To understand potential barriers to physician-initiated discussions about Implantable Cardioverter Defibrillator (ICD) deactivation in patients with advanced illness. DESIGN Qualitative one-on-one interviews. PARTICIPANTS Four electrophysiologists, 4 cardiologists, and 4 generalists (internists and geriatricians) from 3 states. APPROACH Clinicians were interviewed using open-ended questions to elicit their past experiences with discussing deactivating ICDs and to determine what barriers might impede these discussions. Transcripts of these interviews were analyzed using the qualitative method of constant comparison. RESULTS Although many physicians believed that conversations about deactivating ICDs should be included in advance care planning discussions, they acknowledged that they rarely did this. Physicians indicated that there was something intrinsic to the nature of these devices that makes it inherently difficult to think of them in the same context as other management decisions at the end of a patient's life. Other explanations physicians gave as to why they did not engage in conversations included: the small internal nature of these devices and hence absence of a physical reminder to discuss the ICD, the absence of an established relationship with the patient, and their own general concerns relating to withdrawing care. CONCLUSION Whereas some of the barriers to discussing ICD deactivation are common to all forms of advance care planning, ICDs have unique characteristics that make these conversations more difficult. Future educational interventions will need to be designed to teach physicians how to improve communication with patients about the management of ICDs at the end of life.
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Winter L, Parker B, Schneider M. Imagining the alternatives to life prolonging treatments: elders' beliefs about the dying experience. DEATH STUDIES 2007; 31:619-31. [PMID: 17847574 DOI: 10.1080/07481180701405162] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Deciding for or against a life-prolonging treatment represents a choice between prolonged life and death. When the death alternative is not described, individuals must supply their own assumptions. How do people imagine the experience of dying? We asked 40 elderly people open-ended questions about dying without 4 common life-prolonging treatments, eliciting beliefs about pain, length of time, loneliness, and palliative care. Beliefs were diverse, loneliness was commonly assumed, and palliation was rarely mentioned spontaneously. Results underscore needs for improved understanding of the dying process and palliative care and for fuller communication between patients and healthcare providers.
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Affiliation(s)
- Laraine Winter
- Center for Applied Research on Aging and Health, Thomas Jefferson University, Edison Building, Suite 500, 130 South 9th St., Philadelphia, PA 19107, USA.
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11
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Kelley CG, Daly BJ, Douglas SL, Standing T. Racial differences in perceptions held by caregivers of long-term ventilator patients at end of life. Int J Palliat Nurs 2007; 13:30-8. [PMID: 17353848 DOI: 10.12968/ijpn.2007.13.1.22778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM The purpose of this pilot study was to describe and compare perceptions of preparation for death and satisfaction with end-of-life care in African American and Caucasian caregivers of long-term ventilator (LTV) patients. DESIGN A comparative descriptive design was used to pilot test items from specific domains from the After-Death Bereaved Family Member Interview. Interviews were conducted on 37 bereaved caregivers of LTV patients who participated in a large experimental study. FINDINGS There was a statistically significant association between African American and Caucasian caregivers in the area of being informed of the patient's condition. African American caregivers felt more informed than Caucasian caregivers. Over half of African American and Caucasian caregivers reported feeling 'fairly to very confident' about what to expect when their loved one was dying. CONCLUSION Health care providers should be sensitive to potential differences between African American and Caucasian family caregivers in providing end-of-life care.
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Affiliation(s)
- Carol G Kelley
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio, USA.
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12
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Barnato AE, Berhane Z, Weissfeld LA, Chang CCH, Linde-Zwirble WT, Angus DC. Racial variation in end-of-life intensive care use: a race or hospital effect? Health Serv Res 2007; 41:2219-37. [PMID: 17116117 PMCID: PMC1955321 DOI: 10.1111/j.1475-6773.2006.00598.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To determine if racial and ethnic variations exist in intensive care (ICU) use during terminal hospitalizations, and, if variations do exist, to determine whether they can be explained by systematic differences in hospital utilization by race/ethnicity. DATA SOURCE 1999 hospital discharge data from all nonfederal hospitals in Florida, Massachusetts, New Jersey, New York, and Virginia. DESIGN We identified all terminal admissions (N = 192,705) among adults. We calculated crude rates of ICU use among non-Hispanic whites, blacks, Hispanics, and those with "other" race/ethnicity. We performed multivariable logistic regression on ICU use, with and without adjustment for clustering of patients within hospitals, to calculate adjusted differences in ICU use and by race/ethnicity. We explored both a random-effects (RE) and fixed-effect (FE) specification to adjust for hospital-level clustering. DATA COLLECTION The data were collected by each state. PRINCIPAL FINDINGS ICU use during the terminal hospitalization was highest among nonwhites, varying from 64.4 percent among Hispanics to 57.5 percent among whites. Compared to white women, the risk-adjusted odds of ICU use was higher for white men and for nonwhites of both sexes (odds ratios [ORs] and 95 percent confidence intervals: white men = 1.16 (1.14-1.19), black men = 1.35 (1.17-1.56), Hispanic men = 1.52 (1.27-1.82), black women = 1.31 (1.25-1.37), Hispanic women =1.53 (1.43-1.63)). Additional adjustment for within-hospital clustering of patients using the RE model did not change the estimate for white men, but markedly attenuated observed differences for blacks (OR for men =1.12 (0.96-1.31), women = 1.10 (1.03-1.17)) and Hispanics (OR for men =1.19 (1.00-1.42), women = 1.18 (1.09-1.27)). Results from the FE model were similar to the RE model (OR for black men = 1.10 (0.95-1.28), black women = 1.07 (1.02-1.13) Hispanic men = 1.17 (0.96-1.42), and Hispanic women = 1.14 (1.06-1.24)) CONCLUSIONS The majority of observed differences in terminal ICU use among blacks and Hispanics were attributable to their use of hospitals with higher ICU use rather than to racial differences in ICU use within the same hospital.
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Affiliation(s)
- Amber E Barnato
- Department of Medicine, School of Medicine, Graduate School of Public Health, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA 15213, USA
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Abstract
Past efforts in the palliative and end-of-life care field have been laudably directed at increasing the cultural competence of providers and institutions and improving outreach to multicultural communities. Today, however, we face new challenges with regard to racial, cultural, and ethnic factors at the end of life. We now have documented evidence of disparities in almost every area of health care. In addition, breakthroughs in genomics research, including "race-based therapeutics," have redefined the meaning of our human differences. These trends, unfolding in an increasingly polarized post-9/11 world, greatly challenge our understanding of concepts of race, culture, and ethnicity. By definition, when considering these concepts, our focus shifts from the individual to that of group membership. In turn, this suggests using a population-based or epidemiological approach, which at once reveals inequalities and inequities in mortality patterns across diverse groups. Understanding and serving the needs of specific populations requires us to apply a framework of equity and to consider strategies to eliminate disparities. These include identifying sources of bias and discrimination in health care; enhancing the collection of racial, ethnic, and other demographic data; and increasing the representation of a range of diverse population groups in well designed qualitative and quantitative research. Using an epidemiological framework does not suggest, however, that we lose sight of dying individuals and their families. At the end of life, an individualized approach to care with a focus on quality is paramount for any patient, regardless of racial, ethnic, or cultural background.
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Affiliation(s)
- LaVera M Crawley
- Stanford University Center for Biomedical Ethics, Palo Alto, California 94304, USA.
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Kwak J, Haley WE. Current Research Findings on End-of-Life Decision Making Among Racially or Ethnically Diverse Groups. THE GERONTOLOGIST 2005; 45:634-41. [PMID: 16199398 DOI: 10.1093/geront/45.5.634] [Citation(s) in RCA: 405] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE We reviewed the research literature on racial or ethnic diversity and end-of-life decision making in order to identify key findings and provide recommendations for future research. DESIGN AND METHODS We identified 33 empirical studies in which race or ethnicity was investigated as either a variable predicting treatment preferences or choices, where racial or ethnic groups were compared in their end-of-life decisions, or where the end-of-life decision making of a single minority group was studied in depth. We conducted a narrative review and identified four topical domains of study: advance directives; life support; disclosure and communication of diagnosis, prognosis, and preferences; and designation of primary decision makers. RESULTS Non-White racial or ethnic groups generally lacked knowledge of advance directives and were less likely than Whites to support advance directives. African Americans were consistently found to prefer the use of life support; Asians and Hispanics were more likely to prefer family-centered decision making than other racial or ethnic groups. Variations within groups existed and were related to cultural values, demographic characteristics, level of acculturation, and knowledge of end-of-life treatment options. Common methodological limitations of these studies were lack of theoretical framework, use of cross-sectional designs, convenience samples, and self-developed measurement scales. IMPLICATIONS Although the studies are limited by methodological concerns, identified differences in end-of-life decision-making preference and practice suggest that clinical care and policy should recognize the variety of values and preferences found among diverse racial or ethnic groups. Future research priorities are described to better inform clinicians and policy makers about ways to allow for more culturally sensitive approaches to end-of-life care.
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Affiliation(s)
- Jung Kwak
- School of Aging Studies, University of South Florida, Tampa, 33620, USA.
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Welch LC, Teno JM, Mor V. End-of-life care in black and white: race matters for medical care of dying patients and their families. J Am Geriatr Soc 2005; 53:1145-53. [PMID: 16108932 DOI: 10.1111/j.1532-5415.2005.53357.x] [Citation(s) in RCA: 180] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To compare the end-of-life medical care experienced by African-American and white decedents and their families. DESIGN Cross-sectional, retrospective survey with weighted results based on a two-stage probability sampling design. SETTING Hospitals, nursing homes, and home-based medical services across the United States. PARTICIPANTS Surrogates (N=1,447; primarily family members) for decedents from 22 states. MEASUREMENTS Validated end-of-life care outcomes concerning symptom management, decision-making, informing and supporting families, individualized care, coordination, service utilization, and financial impact. RESULTS Family members of African-American decedents were less likely than those of white decedents to rate the care received as excellent or very good (odds ratio (OR)=0.4). They were more likely to report absent (OR=2.4) or problematic (OR=1.9) physician communication, concerns with being informed (OR=2.5), and concerns with family support (OR=2.6). Family members of African Americans were less likely than those of whites to report that the decedent had treatment wishes (OR=0.3) or written advance care planning documents (OR=0.4). These differences persist when limiting the sample to respondents whose expectations for life-sustaining treatments matched treatments received. Family members of African-American decedents also were more likely to report financial hardship due to savings depletion (OR=2.1) or difficulty paying for care (OR=2.0) and that family/friends (OR=2.0) or home health workers (OR=1.9) provided home care. CONCLUSION This national study brings evidence that racial disparities persist into end-of-life care, particularly regarding communication and family needs. Results also suggest different home care patterns and levels of financial impact.
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Affiliation(s)
- Lisa C Welch
- Department of Community Health, Brown Medical School, Providence, Rhode Island, USA
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Bardach N, Zhao S, Pantilat S, Johnston SC. Adjustment for do-not-resuscitate orders reverses the apparent in-hospital mortality advantage for minorities. Am J Med 2005; 118:400-8. [PMID: 15808138 DOI: 10.1016/j.amjmed.2005.01.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2003] [Accepted: 09/21/2004] [Indexed: 12/21/2022]
Abstract
PURPOSE The use of do-not-resuscitate (DNR) orders may differ by sex or ethnicity, and DNR status may be associated with outcomes for hospitalized patients. Thus, we sought to determine whether differences in rates of DNR by sex and ethnicity influenced differences in mortality. SUBJECTS AND METHODS We included all patients admitted to nonfederal California hospitals in 1999 with stroke, congestive heart failure, pneumonia, chronic obstructive pulmonary disease, chronic renal failure, angina, or diabetes mellitus. Rates of physician orders for DNR written within 24 hours of hospital admission and in-hospital mortality were compared between sexes and ethnicities after adjustment for age, admission source and diagnosis, payment type, and comorbidity scores in multivariable logistic regression models. RESULTS Of 327890 patients included, 25196 (7.7%) had DNR orders. In adjusted models, women were more likely to have DNR orders than men (odds ratio [OR] 1.19; 95% confidence interval 1.16-1.23; P <0.001) and non-Hispanic whites were more likely to have DNR orders than other ethnicities (OR 1.75; 1.69-1.82; P <0.001). Overall, 13549 (4.1%) patients died in the hospital. Risk of death was greater in those with a DNR order (OR 7.0; 6.7-7.3; P <0.001). Non-Hispanic whites appeared to have a greater risk of in-hospital death in adjusted models (OR 1.09; 1.04-1.12; P <0.001) when DNR status was ignored; however, the risk of death appeared to be lower in non-Hispanic whites in the complete model with DNR included (OR 0.94; 0.90-0.99; P = 0.01). A survival advantage for women was also more apparent after including DNR status in the adjusted model. CONCLUSIONS Women and non-Hispanic whites are more likely to have DNR orders. DNR status affected the measurement of sex-ethnic differences in mortality risk.
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Affiliation(s)
- Naomi Bardach
- Department of Neurology, University of California-San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
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Affiliation(s)
- Malcolm Fisher
- Northern Sydney Area Health, Departments of Medicine and Anesthesia, University of Sydney, Australia.
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Cintron A, Hamel MB, Davis RB, Burns RB, Phillips RS, McCarthy EP. Hospitalization of Hospice Patients with Cancer. J Palliat Med 2003; 6:757-68. [PMID: 14622455 DOI: 10.1089/109662103322515266] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To identify factors associated with hospitalization of elderly hospice patients with cancer and to describe their hospital experiences. DESIGN Retrospective analysis of the last year of life. SETTING Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. PARTICIPANTS Medicare beneficiaries dying of lung or colorectal cancer between 1988 and 1998 who enrolled in hospice. MEASUREMENTS Hospitalization after hospice entry. For hospitalized patients, we describe admission diagnoses, aggressiveness of care, and in-hospital death. RESULTS Of the 23608 patients, 1423 (6.0%) were hospitalized after hospice enrollment. Hospitalization declined over time by 7.0% per year of hospice enrollment. Factors associated with higher hospitalization rates were younger age, male gender, black race/ethnicity, local cancer stage at diagnosis, and hospice enrollment within 4 months of cancer diagnosis. The most common reasons for hospital admission were lung cancer, metastatic disease, bone fracture, pneumonia, and volume depletion. Of the 1423 patients hospitalized, 34.6% received aggressive care and 35.8% died in the hospital. CONCLUSION The rates of hospitalization for elderly hospice patients with lung or colorectal cancer appear to be declining. However, patients who are hospitalized undergo aggressive care and often die in the hospital rather than at home. This aggressive care may be consistent with changes in patients' care preferences, but could also reflect the current culture of acute care hospitals, which focuses on curative treatment and is ill-equipped to provide palliative care.
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Affiliation(s)
- Alexie Cintron
- Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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Chlan LL. Description of anxiety levels by individual differences and clinical factors in patients receiving mechanical ventilatory support. Heart Lung 2003; 32:275-82. [PMID: 12891169 DOI: 10.1016/s0147-9563(03)00096-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Though anxiety is a common experience for patients receiving mechanical ventilatory support, little is known about how it may vary among patients on the basis of individual or clinical factors. There is an absence of data objectively describing anxiety levels in ventilated patients on the basis of salient factors that could be useful in designing and tailoring interventions. PURPOSE The purpose of this study was to describe anxiety levels in a sample of mechanically ventilated patients by individual differences (eg, gender or ethnicity) and clinical factors (eg, medical indication for and length of mechanical ventilation). SAMPLE Two hundred alert, mechanically ventilated adult patients were recruited from 9 intensive care units in the urban Midwest. METHODS This study was a secondary analysis of existing data that used a descriptive design. Anxiety was assessed via the 20-item Spielberger State Anxiety Inventory. RESULTS Whereas state anxiety varied widely, participants receiving mechanical ventilatory support reported moderate anxiety (mean = 49.2) with comparable levels by gender and ethnicity. Patients receiving ventilatory support for greater than 22 days tended to report slightly higher state anxiety (mean = 54.2) compared with those chronically ventilator dependent (mean = 45.8). Those participants with primarily respiratory diagnoses reported the highest levels (50.5) among the diagnostic groups. Findings from this study document the individual, variable nature of state anxiety. Additional research is needed to further elucidate whether these and other important clinical factors, such as illness severity or dyspnea, affect state anxiety ratings in ventilated patients to guide the researcher and clinician in appropriately testing and tailoring interventions.
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Affiliation(s)
- Linda L Chlan
- University of Minnesota School of Nursing, Minneapolis, Minnesota 55455, USA
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Degenholtz HB, Thomas SB, Miller MJ. Race and the intensive care unit: disparities and preferences for end-of-life care. Crit Care Med 2003; 31:S373-8. [PMID: 12771586 DOI: 10.1097/01.ccm.0000065121.62144.0d] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Howard B Degenholtz
- Center for Bioethics and Health Law, and Department of Health Policy and Management, University of Pittsburgh, PA 15213, USA
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Abstract
PURPOSE The volume of research on end-of-life care, death, and dying has exploded during the past decade. This article reviews the conceptual and methodological adequacy of end-of-life research to date, focusing on limitations of research to date and ways of improving future research. DESIGN AND METHODS A systematic search was conducted to identify the base of end-of-life research. Approximately 400 empirical articles were identified and are the basis of this review. RESULTS Although much has been learned from research to date, limitations in the knowledge base are substantial. The most fundamental problems identified are conceptual and include failure to define dying; neglect of the distinctions among quality of life, quality of death, and quality of end-of-life care. Methodologically, the single greatest problem is the lack of longitudinal studies that cover more than the time period immediately before death. IMPLICATIONS Gaps in the research base include insufficient attention to psychological and spiritual issues, the prevalence of psychiatric disorder and the effectiveness of the treatment of such disorders among dying persons, provider and health system variables, social and cultural diversity, and the effects of comorbidity on trajectories of dying.
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Affiliation(s)
- Linda K George
- Department of Sociology, Institute for Care at the End of Life, Duke University, Durham, NC 27708, USA.
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Diringer MN, Edwards DF, Aiyagari V, Hollingsworth H. Factors associated with withdrawal of mechanical ventilation in a neurology/neurosurgery intensive care unit. Crit Care Med 2001; 29:1792-7. [PMID: 11546988 DOI: 10.1097/00003246-200109000-00023] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to identify factors associated with the decision to withdraw mechanical ventilation from patients in a neurology/neurosurgery intensive care unit. Specifically, the following factors were considered: the severity of the neurologic illness, the healthcare delivery system, and social factors. DESIGN Retrospective analysis of prospectively collected clinical database. SETTING Neurology/neurosurgery intensive care unit of a large academic tertiary care hospital. PATIENTS Patients were 2,109 nonelective admissions to the neurology/neurosurgery intensive care unit who received mechanical ventilation over a period of 82 months. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The average age was 56 +/- 19.7 yrs, 53% were male, and 81% were functionally normal before admission. The median Glasgow Coma Scale score was 14, the average Acute Physiology and Chronic Health Evaluation II severity of illness score was 13.5 +/- 8.3, and probability of death was 18.2 +/- 22.0%. Mechanical ventilation was withdrawn from 284 (13.5%). Factors that were independently associated with withdrawal of mechanical ventilation were as follows: more severe neurologic injury [admission Glasgow Coma Scale score (odds ratio 0.86/point, confidence interval 0.82-0.90), diagnosis of subarachnoid hemorrhage (odds ratio 2.44, confidence interval 1.50-3.99), or ischemic stroke (odds ratio 1.72, confidence interval 1.13-2.60)], older age (odds ratio 1.04/yr, confidence interval 1.03-1.05), and higher Acute Physiology and Chronic Health Evaluation II probability of death (odds ratio 1.03/%, confidence interval 1.02-1.04). Mechanical ventilation was less likely to be withdrawn if patients were African-American (odds ratio 0.50, confidence interval 0.36-0.68) or had undergone surgery (odds ratio 0.44, confidence interval 0.2- 0.67). Marital status, premorbid functional status, clinical service (neurology vs. neurosurgery), attending status (private vs. academic), and type of health insurance were not associated with decisions to withdraw mechanical ventilation. CONCLUSIONS We conclude that decisions to withdraw mechanical ventilation in the neurology/neurosurgery intensive care unit are based primarily on the severity of the acute neurologic condition and age but not on characteristics of the healthcare delivery system. Care is less likely to be withdrawn from African-American patients or those who had surgery.
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Affiliation(s)
- M N Diringer
- Neurology/Neurosurgery Intensive Care Unit, Department of Neurology and Neurological Surgery, Washington University, St. Louis, MO, USA
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