Hospice: concept and implementation in the black community

Older Asian Americans and Pacific Islanders dying of cancer use hospice less frequently than older white patients

PURPOSE

Cancer is the leading cause of death among Asian Americans, yet little is known about their use of hospice care. We examined hospice use by Asian patients compared with white patients, and assessed whether utilization differs among those born in the United States or abroad.

METHODS

We studied Asian and white Medicare beneficiaries registered in the Surveillance, Epidemiology, and End Results (SEER) Program who died of primary lung, colorectal, prostate, breast, gastric, or liver cancer between 1988 and 1998. We used logistic regression to determine the effects of race/ethnicity and birthplace on hospice use, adjusting for demographic characteristics, managed care insurance, year of diagnosis, tumor stage at diagnosis, and tumor registry.

RESULTS

Of the 184,081 patients, 5% (n = 8614) were Asian Americans, of whom 45% (n = 3847) were foreign born. Compared with whites, Asian Americans were more likely to be male, married, and enrolled in managed care. Compared with U.S.-born Asian Americans, foreign-born Asian Americans were more likely to reside in low-income areas. After adjustment, patients who were Asian American (odds ratio [OR] = 0.67; 95% confidence interval [CI]: 0.62 to 0.73) and born abroad (OR = 0.90; 95% CI: 0.86 to 0.94) were less likely to use hospice care than were white patients. These results were consistent across the six cancer diagnoses that were examined.

CONCLUSION

Older Asian Americans dying of cancer, especially those who are born abroad, are less likely than white patients to use hospice care at the end of life. Additional research is needed to understand the reasons for these differences and to eliminate potential barriers to hospice care.

The experience of living-dying in a nursing home: self-reports of black and white older adults

PURPOSE

The purpose of this study was to describe and compare the experiences, needs, priorities, and concerns reported by black and white nursing home residents during the living-dying interval. The living-dying interval is defined as the time between the knowledge of one's impending death and death itself.

DESIGN

This qualitative study was part of a larger ethnographic project. Residents participated in from one to four individual, in-depth, semi-structured, audiotaped interviews.

SETTING

Residents lived in two large county-financed nursing homes that have historically provided care to indigent black and white older adults.

PARTICIPANTS

Purposive sampling was used to identify eight black and five white residents with terminal cancer diagnoses who could serve as rich resources about the experience of living-dying in a nursing home.

MEASURES

Residents were asked open-ended questions about how things have been and what would make things better; what comforts them and would make them more comfortable; what dying means to them; and what things are important for nursing staff to know.

RESULTS

Verbatim transcripts of the interviews were coded using QRS NUD-IST software. Codes were placed in categories, categories were reviewed for common and different concepts, themes, and patterns, and a conceptual model was developed. The model identified six care needs: (1) day-to-day living; (2) inadequate pain relief for black residents; (3) difficulty chewing and swallowing; (4) importance of religious activities; (5) giving care to others; and (6) appreciation of respectful and prompt care. Residents validated all components of the conceptual model.

CONCLUSION

Black and white terminally ill residents focused on the quality of living rather than on dying, and black residents may be undertreated for pain. Important care needs for pain and religion are not routinely addressed by the Minimum Data Set (MDS) and Resident Assessment Protocol (RAP) triggers.

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.

Racial differences in attitudes toward hospice care

Two-hundred and fifty three adults in the Atlanta area completed a telephone survey regarding prospective personal use of hospice services. Race was found to be the only personal attribute relevant to a predisposition to use hospice care. Whites were more likely than blacks to have attitudes conducive to the choice of hospice care. Although there is evidence in the literature that black Americans are less likely to use hospice care than are white Americans, there are not yet detailed explanations of personal differences in attitudes toward using hospice care. This article suggests themes for future research on possible racial differences in attitudes toward use of hospice care.