"Palliative Care Is the Only Medical Field That I Feel Like I'm Treated As a Person, Not As a Black Person": A Mixed-Methods Study of Minoritized Patient Experiences with Palliative Care

The Impact of Allyship on Minoritized Patients and Providers in Palliative Practice

Many minoritized patients experience discrimination in health care. The same is true for minoritized health care clinicians, including the advanced practice registered nurse (APRN). Specifically, Black Americans have historically and disproportionally been privy to both structural racism and interpersonal racial discrimination (J Subst Abuse Treat 2022;133:108551). For patients, such exposure is associated with physical and mental health consequences, including hypertension, obesity, depression, anxiety, psychological distress, and mortality (Health Serv Res 2019;54 suppl 2(suppl 2):1399-1408). For minoritized clinicians, the subsequent result of discrimination additionally includes poor job satisfaction, decreased productivity, and high turnover (JAMA Health Forum 2023;4(12):e235249). Allyship, the act of supporting minoritized individuals while not being a member of that group, is potentially useful in improving the practice experience of minoritized APRNs, as well as positively impacting minoritized patients' outcomes. This article aims to provide actionable and practical skills for the APRN to create safe spaces for minoritized patients and partners in palliative practice. Explicitly, the role of the palliative care APRN as an ally will be reviewed as well as guidance on how to implement changes that will affect the health care experience for both patients and clinicians.

The Impact of Palliative Decompressive Gastrostomy Tube Placement on Patients and Their Caregivers: A Mixed Methods Analysis

BACKGROUND

Palliative decompressive gastrostomy tubes are intended to relieve the severe physical symptoms of malignant small bowel obstruction (SBO) near the end of life. The objective of this study was to assess the impact of palliative decompressive gastrostomy tube on patient and caregiver well-being.

PATIENTS AND METHODS

We prospectively enrolled patients with a malignant SBO and their caregivers at the time of informed consent for decompressive gastrostomy tube placement. We collected the Edmonton Symptom Assessment Scale (ESAS) and the Functional Assessment of Chronic Illness Therapy-Palliative (FACIT-Pal-14) surveys from patients at baseline and at 2-week post-procedure follow-up. The Caregiver Burden Scale survey was administered to caregivers at baseline. Survey scores were compared using paired t-tests. We also conducted semistructured interviews with patients and their caregivers at two-week follow-up until thematic saturation was reached. Content analysis was used to identify themes with two independent coders.

RESULTS

We enrolled 15 patient-caregiver dyads. Preprocedure, the median caregiver burden scale score was 37.5 (significant burden ≥ 21). Eight patients (53%) survived to 2 weeks; among these patients, median ESAS scores (51 versus 43.5, p < 0.001) and median FACIT-Pal-14 scores (22 versus 32, p = 0.015) were significantly improved at 2-week follow-up. Interviews revealed three major themes: improved symptom management, new stressors, and opportunities for better education and resources.

CONCLUSIONS

Decompressive gastrostomy tubes effectively alleviated symptoms in patients with inoperable malignant SBOs. This palliative intervention may provide greater benefit if performed earlier, and caregivers and patients need improved resources and education for tube management to minimize added stressors.

Cultural Values Influence on Rural Family Caregivers' Decision-Making for Ill Older Adult Loved Ones

CONTEXT

Rural older adult Americans receive more intense treatment at end of life. Studies indicate that those who participate in goals of care conversations receive care more concordant with their values. Yet, rates of documented goals of care discussions are lower in rural and Black communities. Although multi-factorial, the role that rural family caregivers (FCGs) play in decision-making for ill loved ones is understudied.

OBJECTIVE

This study aimed to explore rural FCGs cultural values, beliefs, and attitudes about serious illness and treatment decision-making and to understand how these factors influence their decision-making around goals of care for their family members.

METHODS

This is an embedded qualitative study within a tele-palliative care consult randomized trial that the PEN-3 theoretical model guided. Semi-structured interviews were conducted with FCGs who had completed study participation. Thematic analysis was used to analyze the data.

RESULTS

Twelve rural FCGs center their decisions around core values, and the decision-making experience was supported by faith. A model of how the key themes and subthemes interact around the central space of supporting the seriously ill loved to demonstrate the complexity of caregiving when race and rurality intersect is presented.

CONCLUSION

This study is a foundational step in understanding how rural FCGs beliefs and values influence decision-making. We recommend incorporating those constructs into the development of culturally responsive decision-support interventions.

Naming racism as a root cause of inequities in palliative care research: a scoping review

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.