Racial differences in attitudes toward hospice care

Qualitative Study of Patients' and Caregivers' Perceptions and Information Preferences About Hospice

OBJECTIVE

The goal of this study is to assess perceptions about hospice among patients with metastatic cancer and their caregivers (i.e., family and/or friends).

DESIGN AND SETTING

We conducted semi-structured interviews with 16 adult patients with a prognosis ≤12 months and 7 of their caregivers. The interviews focused on perceptions, knowledge, and information preferences about hospice. Two raters coded interviews independently (κ > 0.85). We used a framework approach for data analysis.

RESULTS

Participants showed variable gaps in understanding about hospice, including who would benefit from hospice care and the extent of services provided. They all perceived that hospice involves a psychological transition to accepting imminent death and often referred to hospice from a relatively cognitive distance, using hypothetical scenarios of others for whom hospice would be more relevant. Participants' attitudes about hospice reflected their concerns about suffering, loss of dignity, and death, as well as their perceived understanding of hospice services. These attitudes along with the psychological barriers to projecting a need for hospice and lack of knowledge were all perceived as important barriers to hospice utilization. All participants felt they needed more information about hospice, yet they were mixed regarding the optimal timing of this information.

CONCLUSIONS

Study participants had misunderstandings about hospice and perceived end-of-life (EOL) concerns such as fear of suffering, loss of dignity, and death, as well as lack of knowledge as the main barriers to hospice utilization. Interventions are needed to educate patients and their families about hospice and to address their EOL concerns.

Predictors of Preference for Hospice Care Among Diverse Older Adults

The purpose of this study was to identify predictors of preference for hospice care and explore whether the effect of these predictors on preference for hospice care were moderated by race.

METHODS

An analysis of the North Carolina AARP End of Life Survey (N = 3035) was conducted using multinomial logistic modeling to identify predictors of preference for hospice care. Response options included yes, no, or don't know.

RESULTS

Fewer black respondents reported a preference for hospice (63.8% vs 79.2% for white respondents, P < .001). While the proportion of black and white respondents expressing a clear preference against hospice was nearly equal (4.5% and 4.0%, respectively), black individuals were nearly twice as likely to report a preference of "don't know" (31.5% vs 16.8%). Gender, race, age, income, knowledge of Medicare coverage of hospice, presence of an advance directive, end-of-life care concerns, and religiosity/spirituality predicted hospice care preference. Religiosity/spirituality however, was moderated by race. Race interacted with religiosity/spirituality in predicting hospice care preference such that religiosity/spirituality promoted hospice care preference among White respondents, but not black respondents.

CONCLUSIONS

Uncertainties about hospice among African Americans may contribute to disparities in utilization. Efforts to improve access to hospice should consider pre-existing preferences for end-of-life care and account for the complex demographic, social, and cultural factors that help shape these preferences.

Heterogeneity and changes in preferences for dying at home: a systematic review

BACKGROUND

Home-based models of hospice and palliative care are promoted with the argument that most people prefer to die at home. We examined the heterogeneity in preferences for home death and explored, for the first time, changes of preference with illness progression.

METHODS

We searched for studies on adult preferences for place of care at the end of life or place of death in MEDLINE (1966-2011), EMBASE (1980-2011), psycINFO (1967-2011), CINAHL (1982-2011), six palliative care journals (2006-11) and reference lists. Standard criteria were used to grade study quality and evidence strength. Scatter plots showed the percentage preferring home death amongst patients, lay caregivers and general public, by study quality, year, weighted by sample size.

RESULTS

210 studies reported preferences of just over 100,000 people from 33 countries, including 34,021 patients, 19,514 caregivers and 29,926 general public members. 68% of studies with quantitative data were of low quality; only 76 provided the question used to elicit preferences. There was moderate evidence that most people prefer a home death-this was found in 75% of studies, 9/14 of those of high quality. Amongst the latter and excluding outliers, home preference estimates ranged 31% to 87% for patients (9 studies), 25% to 64% for caregivers (5 studies), 49% to 70% for the public (4 studies). 20% of 1395 patients in 10 studies (2 of high quality) changed their preference, but statistical significance was untested.

CONCLUSIONS

Controlling for methodological weaknesses, we found evidence that most people prefer to die at home. Around four fifths of patients did not change preference as their illness progressed. This supports focusing on home-based care for patients with advanced illness yet urges policy-makers to secure hospice and palliative care elsewhere for those who think differently or change their mind. Research must be clear on how preferences are elicited. There is an urgent need for studies examining change of preferences towards death.

Race, treatment preferences, and hospice enrollment: eligibility criteria may exclude patients with the greatest needs for care

BACKGROUND

The requirement that patients give up curative treatment makes hospice enrollment unappealing for some patients and may particularly limit use among African-American patients. The current study was conducted to determine whether African-American patients with cancer are more likely than white patients to have preferences for cancer treatment that exclude them from hospice and whether they are less likely to want specific hospice services.

METHODS

Two hundred eighty-three patients who were receiving treatment for cancer at 6 oncology clinics within the University of Pennsylvania Cancer Network completed conjoint interviews measuring their perceived need for 5 hospice services and their preferences for continuing cancer treatment. Patients were followed for 6 months or until death.

RESULTS

African-American patients had stronger preferences for continuing their cancer treatments on a 7-point scale even after adjusting for age, sex, finances, education, Eastern Cooperative Oncology Group performance status, quality of life, and physical and psychologic symptom burden (adjusted mean score, 4.75 vs 3.96; beta coefficient, 0.82; 95% confidence interval, 0.22-1.41 [P = .007]). African-American patients also had greater perceived needs for hospice services after adjusting for these characteristics (adjusted mean score, 2.31 vs 1.83; beta coefficient, 0.51; 95% confidence interval, 0.11-0.92 [P = .01]). However, this effect disappeared after adjusting for household finances.

CONCLUSIONS

Hospice eligibility criteria may exclude African-American patients disproportionately despite greater perceived needs for hospice services in this population. The mechanisms driving this health disparity likely include both cultural differences and economic characteristics, and consideration should be given to redesigning hospice eligibility criteria.

Racial and ethnic differences in end-of-life care in fee-for-service Medicare beneficiaries with advanced cancer

OBJECTIVES

To examine racial and ethnic variation in use of hospice and high-intensity care in patients with terminal illness.

DESIGN

Retrospective, secondary data analysis.

SETTING

Surveillance, Epidemiology, and End Results-Medicare Database from 1992 to 1999 with follow-up data until December 31, 2001.

PARTICIPANTS

Forty thousand nine hundred sixty non-Hispanic white, non-Hispanic black, Asian, and Hispanic fee-for-service Medicare beneficiaries aged 65 and older with advanced-stage lung, colorectal, breast, and prostate cancer.

MEASURMENTS

Hospice use and indicators of high-intensity care at the end of life.

RESULTS

Whereas 42.0% of elderly white patients with advanced cancer enrolled in hospice, enrollment was lower for black (36.9%), Asian (32.2%), and Hispanic (37.7%) patients. Differences between white and Hispanic patients disappeared after adjustment for clinical and sociodemographic factors. Higher proportions of black and Asian patients than of white patients were hospitalized two or more times (11.7%, 15.0%, 13.7%, respectively), spent more than 14 days hospitalized (11.4%, 17.4%, 15.6%, respectively), and were admitted to the intensive care unit (ICU) (12.0%, 17.0%, 16.2%, respectively) in the last month of life and died in the hospital (26.5%, 31.3%, 33.7%, respectively). Unadjusted differences in receipt of high-intensity care according to race or ethnicity remained after adjustment.

CONCLUSION

Black and Asian patients with advanced cancer were more likely than whites to be hospitalized frequently and for prolonged periods, be admitted to the ICU, die in the hospital, and be enrolled in hospice at lower rates. Further research is needed to examine the degree to which patient preferences or other factors explain these differences.

Differences in hospice use between black and white patients during the period 1992 through 2000

PURPOSE

We examined differences in hospice use rates among blacks and whites and investigated trends in racial differences in hospice patients during the period 1992 through 2000. We tested differences in length of hospice survival from hospice enrollment to death between black and white patients during this period.

METHODS

We analyzed data from the 1991-2000 Underlying and Multiple Cause-of-Death Files and the 1992-2000 National Home and Hospice Care Surveys using z tests, chi tests, and Cox regression models.

RESULTS

Compared with 1992, the hospice use rate doubled for white patients (P < 0.0001) and increased almost 4-fold for black patients (P < 0.0001) in 2000. Hospice use rates among black patients were significantly lower than those among white patients from 1992 to 1994 but not from 1996 to 2000. Black hospice patients discharged throughout the 1990s were more likely to be younger, have Medicaid-only as their payment source, and have HIV/AIDS than their white counterparts. Black hospice patients were more likely to be referred by hospitals than white hospice patients during 1996 to 2000. Throughout the 1990s, length of hospice survival did not significantly differ between black and white hospice patients after adjusting for covariates.

CONCLUSIONS

Hospice use rates significantly increased for both whites and black patients. Black patients had lower hospice use rates than white patients from 1992 to 1994, but not from 1996 to 2000, which may reflect the diffusion of hospice care to black patients with the rapid growth in hospice programs. Despite differences in patient characteristics, the length of hospice survival was similar among both groups. Future research is needed to assess whether racial disparities exist in quality of hospice care.

Focus group findings about the influence of culture on communication preferences in end-of-life care

BACKGROUND

Little guidance is available for health care providers who try to communicate with patients and their families in a culturally sensitive way about end-of-life care.

OBJECTIVE

To explore the content and structure of end-of-life discussions that would optimize decision making by conducting focus groups with two diverse groups of patients that vary in ethnicity and socioeconomic status.

DESIGN

Six focus groups were conducted; 3 included non-Hispanic white patients recruited from a University hospital (non-Hispanic white groups) and 3 included African-American patients recruited from a municipal hospital (African-American groups). A hypothetical scenario of a dying relative was used to explore preferences for the content and structure of communication.

PARTICIPANTS

Thirty-six non-Hispanic white participants and 34 African-American participants.

APPROACH

Content analysis of focus group transcripts.

RESULTS

Non-Hispanic white participants were more exclusive when recommending family participants in end-of-life discussions while African-American participants preferred to include more family, friends and spiritual leaders. Requested content varied as non-Hispanic white participants desired more information about medical options and cost implications while African-American participants requested spiritually focused information. Underlying values also differed as non-Hispanic white participants expressed more concern with quality of life while African-American participants tended to value the protection of life at all costs.

CONCLUSIONS

The groups differed broadly in their preferences for both the content and structure of end-of-life discussions and on the values that influence those preferences. Further research is necessary to help practitioners engage in culturally sensitive end-of-life discussions with patients and their families by considering varying preferences for the goals of end-of-life care communication.

Hospice use by Hispanic and non-Hispanic white cancer decedents

OBJECTIVE

To investigate rates of hospice use between Hispanic and non-Hispanic white Medicare beneficiaries diagnosed with cancer using data from a large, population-based study.

DATA SOURCES

Secondary data from the linked SEER-Medicare database including the SEER areas of Los Angeles, San Francisco, and San Jose-Monterey, California, and the state of New Mexico. All subjects were Hispanic or non-Hispanic whites, aged 67 and older, had a cancer diagnosis of breast, colorectal, lung, or prostate cancer from 1991-1996, and died of cancer from 1991-1998.

STUDY DESIGN

This study employed a retrospective cohort design to compare rates of hospice use between Hispanics and non-Hispanic whites across patient characteristics and over time.

PRINCIPAL FINDINGS

Rates of hospice use were similar for Hispanics (39.2 percent) and non-Hispanic whites (41.5 percent). In a bivariate logistic regression model, Hispanics were significantly less likely to use hospice than non-Hispanic whites (OR 0.91; 95 percent CI 0.85-0.97). However, after adjusting for age, marital status, sex, educational attainment, income, urban versus rural residence, and type of insurance using multivariate logistic regression analysis, the estimated odds for being a hospice user among Hispanics is similar to the odds of being a hospice user among non-Hispanic whites (OR 1.05; 95 percent CI 0.98-1.13). Stratified analyses revealed significant differences between ethnic groups in the use of hospice by type of insurance and SEER area, indicating interactions between ethnicity and these variables.

CONCLUSIONS

Our findings indicate similar rates of hospice use for Hispanics and non-Hispanic whites diagnosed with one of the four leading cancers. Additional studies from other national registries may be necessary to confirm these findings.

Hospice care for persons with AIDS: findings from a national study

Hospices are in a position to play major roles in the care of terminally ill patients with AIDS. These findings from a national survey of hospices in the United States show that the majority of hospices have cared for at least one PWA. Major factors determining hospice involvement include geographic location and resources. In comparison to other patients in hospice, PWAs are younger, more likely to be male, Black or Hispanic, and covered by Medicaid. The results indicate that hospices are reaching women with AIDS and IVDUs but that minorities continue to be underrepresented in comparison to their distribution among the total AIDS cases in the United States.

Hispanic American elders: caregiving norms surrounding dying and the use of hospice services

The purpose of this review is to (1) provide an overview of health and demographic characteristics common to the Hispanic elder population, (2) address family caregiving issues surrounding the terminal illness of a loved one, (3) understand resource utilization by Hispanic elderly and their family caregivers, and (4) make recommendations for the provision of information and education about hospice services. Case examples will illustrate patterns and themes unique to Hispanic caregiving.

Deterrents to access and service for blacks and Hispanics: the Medicare Hospice Benefit, healthcare utilization, and cultural barriers

The Medicare Hospice Benefit may limit access for Blacks and Hispanics because of its requirement of continuity of care, entailing the availability of a primary caregiver. The literature on utilization of healthcare services by Blacks and Hispanics shows these groups were likely to receive too little care, too late. Kalish and Reynolds' (1976) research on attitudes of Blacks, Mexican-Americans, and Whites toward dying shows cultural differences that could affect acceptance of hospice philosophy. In other research reviewed in this paper distrust of White service providers was a significant cultural barrier for Blacks in using health services. Lack of familiarity with the health care system and language barriers were barriers most often for Hispanics. Black caregivers are more likely than Whites to have dying persons living with them, to be extended family members or nonrelated, and to be more limited in their ability to provide caregiving support because of a lack of economic resources. Hispanics appear to have a circumscribed support system, narrowly defined by blood kinship, with females as the expected caregivers.