Racial Differences in Predictors of Intensive End-of-Life Care in Patients With Advanced Cancer

Loggers, Elizabeth T.; Maciejewski, Paul K.; Paulk, Elizabeth; DeSanto‐Madeya, Susan; Nilsson, Matthew; Viswanath, Kasisomayajula; Wright, Alexi A.; Balboni, Tracy A.; Temel, Jennifer S.; Stieglitz, Heather; Block, Susan D.; Prigerson, Holly G.

doi:10.1200/jco.2009.22.4733

Cited by 183 publications

(201 citation statements)

References 42 publications

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“…30 African Americans, in far greater percentages than whites, often express the wish to preserve life at any cost, thus limiting their desire to draft LWs. 31 We also found that Medicaid patients had a lower frequency of LWs than patients covered by other insurers. This finding may reflect the more limited access of Medicaid recipients to health care professionals and their perceptions that LWs negatively influence quality of care.…”

Section: Discussionsupporting

confidence: 52%

Advance Directives in an Oncologic Intensive Care Unit: A Contemporary Analysis of their Frequency, Type, and Impact

Halpern¹,

Pastores²,

Chou

et al. 2011

Journal of Palliative Medicine

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Background: Our objective was to provide a contemporary analysis of the prevalence, types, and impact of advance health care directives in critically ill cancer patients. Methods: We retrospectively reviewed all intensive care unit (ICU) admissions ( January 1, 2006 to April 25, 2008 at an oncologic center and identified all patients who completed a living will (LW), or health care proxy (HCP), or neither prior to ICU admission. Demographics, clinical data, end-of-life (EOL) parameters and outcomes were compared among three groups: LWs, HCPs, and no LW or HCP. Results: Of 1,333 ICU admissions, 1,121 patients (84%) were included for analysis: 176 patients (15.7%) had LW, 534 (47.6%) had HCP and 411 (36.7%) had no LW or HCP. Patients with LW were significantly more likely to be older and white as compared to patients with HCP alone, or no LW or HCP. There were no significant demographic differences between patients with HCP or no LW or HCP. Patients with HCP alone, or no LW or HCP, were significantly more likely to have Medicaid than patients with LW. There were no differences noted in ICU care, EOL management, or outcomes among the three groups. Conclusions: The prevalence of LWs in patients admitted to our oncologic ICU is low. More than half of the remaining patients had designated HCPs. Older age and white race were associated with the presence of LWs. However, the presence of LWs or HCPs did not influence ICU care, EOL management or outcomes at our institution.

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Section: Discussionsupporting

confidence: 52%

Advance Directives in an Oncologic Intensive Care Unit: A Contemporary Analysis of their Frequency, Type, and Impact

Halpern¹,

Pastores²,

Chou

et al. 2011

Journal of Palliative Medicine

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Section: Discussionmentioning

confidence: 78%

“…This finding stands in stark contrast to a plethora of prior data showing disparity in advance care planning and end-of-life care across ethnicities. [15][16][17] These findings show that a broad, rather complex public health intervention can be disseminated widely and effectively in a relatively brief period of time across a large, racially diverse state.The California POLST dissemination was a broad-based statewide effort that included a coordinated effort among stakeholders throughout the state, a coordinating organization supported with funding from a grant-making organization focused on healthcare, combined with a grassroots initiative. California state law (Assembly Bill 3000) in 2008 authorized the use of POLST throughout the state, effective January 1, 2009.…”

mentioning

confidence: 78%

Use of the Physician Orders for Life-Sustaining Treatment among California Nursing Home Residents

Jennings

Zingmond²,

Louie³

et al. 2016

J GEN INTERN MED

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BACKGROUND: Physician Orders for Life-Sustaining Treatment (POLST) is a tool that facilitates the elicitation and continuity of life-sustaining care preferences. POLST was implemented in California in 2009, but how well it disseminated across a large, racially diverse population is not known and has implications for end-of-life care. OBJECTIVE: To evaluate the use of POLST among California nursing home residents, including variation by resident characteristics and by nursing home facility. DESIGN: Observational study using California Minimum Data Set Section S. PARTICIPANTS: A total of 296,276 people with a stay in 1,220 California nursing homes in 2011. MAIN MEASURES:The proportion of residents with a completed POLST (containing a resuscitation status order and resident/proxy and physician signatures) and relationship to resident characteristics; change in POLST use during 2011; and POLST completion and unsigned forms within nursing homes. KEY RESULTS: During 2011, POLST completion increased from 33 to 49 % of California nursing home residents. Adjusting for age and gender using a mixed-effects logistic model, long-stay residents were more likely than short-stay residents to have a completed POLST [OR = 2.36 (95 % CI 2.30, 2.42)]; severely cognitively impaired residents were less likely than unimpaired to have a completed POLST [OR = 0.89 (95 % CI 0.87, 0.92)]; and there was little difference by functional status. There was no difference in POLST completion among White non-Hispanic, Black, and Hispanic residents. Variation in POLST completion among nursing homes far exceeded that attributable to resident characteristics with 40 % of facilities having ≥80 % of long-stay residents with a completed POLST, while 20 % of facilities had ≤10 % of long-stay residents with a completed POLST. Thirteen percent of nursing home residents had a POLST containing a resuscitation preference but lacked a signature, rendering the POLST invalid. CONCLUSIONS: Statewide nursing home data show broad uptake of POLST in California without racial disparity. However, variation in POLST completion among nursing homes identifies potential areas for quality improvement.KEY WORDS: end-of-life care; nursing home; long-term care; quality improvement. J Gen Intern Med 31(10):1119-26 DOI: 10.1007/s11606-016-3728-9 © Society of General Internal Medicine 2016 INTRODUCTIONPhysician Orders for Life-Sustaining Treatment (POLST) facilitates elicitation of life-sustaining treatment preferences from patients and is designed to improve the transition of these preferences, in the form of physician orders, across care settings. POLST captures preferences concerning cardiopulmonary resuscitation, overall aggressiveness of care, hospital transfer, and artificial nutrition. 1 The document is particularly useful for residents of nursing facilities because many residents live in compromised health states and would not desire burdensome treatments 2 and also because it is common for nursing home residents to transition to the emergency room and the hospital 3 wh...

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“…11,[25][26][27][28][29][30][31][32][33][34] Previous research suggests multifactorial causes for this difference, including diverse cultural beliefs and values, geographic variation in advance directive use, 32,[35][36][37] and disparities in patient-clinician communication about advance care planning. 12,14,15,26,34 Recent data support the potential value of advance directives in assuring that patients receive the care they would want. [38][39][40] The present study is one of the few to examine advance directives among patients who died in the ICU, a setting where advance directives are particularly important because most critically ill patients are unable to make decisions.…”

Section: Discussionmentioning

confidence: 99%

“…[11][12][13] There is evidence of disparities in end-of-life care, with racial minorities receiving lower quality of care than whites. 14,15 Eliminating racial and ethnic disparities in end-of-life care will require a better understanding of the sources of these differences. 1 We hypothesized that a better understanding of differences in end-oflife care in the ICU will help to inform the discrepancies previously reported in the literature regarding racial and ethnic differences in ICU care and guide future research to identify, understand, and eliminate disparities.…”

Section: Data Collection and Variablesmentioning

confidence: 99%

The Influence of Race/Ethnicity and Socioeconomic Status on End-of-Life Care in the ICU

Muni

Engelberg

Treece

et al. 2011

Chest

172

130

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A growing body of evidence demonstrates the existence of important racial and ethnic differences in health care. Although many studies report on disparities in health care for acute and chronic conditions, 1-5 relatively few address racial disparities in the ICU, and those report confl icting fi ndings. Some have reported that black patients receive fewer medical interventions, 6,7 have shorter lengths of stay, and use fewer resources. 7 In contrast, others have found increased resource utilization, including larger numbers of ICU admissions and higher numbers of medical interventions for minority than for white patients. 8,9 Background: There is confl icting evidence about the infl uence of race/ethnicity on the use of intensive care at the end of life, and little is known about the infl uence of socioeconomic status. Methods: We examined patients who died in the ICU in 15 hospitals. Race/ethnicity was assessed as white and nonwhite. Socioeconomic status included patient education, health insurance, and income by zip code. To explore differences in end-of-life care, we examined the use of (1) advance directives, (2) life-sustaining therapies, (3) symptom management, (4) communication, and (5) support services. Results: Medical charts were abstracted for 3,138/3,400 patients of whom 2,479 (79%) were white and 659 (21%) were nonwhite (or Hispanic). In logistic regressions adjusted for patient demographics, socioeconomic factors, and site, nonwhite patients were less likely to have living wills (OR, 0.41; 95% CI, 0.32-0.54) and more likely to die with full support (OR, 1.59; 95% CI, 1.30-1.94). In documentation of family conferences, nonwhite patients were more likely to have documentation that prognosis was discussed (OR, 1.47; 95% CI, 1.21-1.77) and that physicians recommended withdrawal of life support (OR, 1.57; 95% CI, 1.11-2.21). Nonwhite patients also were more likely to have discord documented among family members or with clinicians (OR, 1.49; 95% CI, 1.04-2.15). Socioeconomic status did not modify these associations and was not a consistent predictor of end-of-life care. Conclusions: We found numerous racial/ethnic differences in end-of-life care in the ICU that were not infl uenced by socioeconomic status. These differences could be due to treatment preferences, disparities, or both. Improving ICU end-of-life care for all patients and families will require a better understanding of these issues.

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Racial Differences in Predictors of Intensive End-of-Life Care in Patients With Advanced Cancer

Cited by 183 publications

References 42 publications

Advance Directives in an Oncologic Intensive Care Unit: A Contemporary Analysis of their Frequency, Type, and Impact

Advance Directives in an Oncologic Intensive Care Unit: A Contemporary Analysis of their Frequency, Type, and Impact

Use of the Physician Orders for Life-Sustaining Treatment among California Nursing Home Residents

The Influence of Race/Ethnicity and Socioeconomic Status on End-of-Life Care in the ICU

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