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Racial Disparities in the Outcomes of Communication on Medical Care Received Near Death
Jennifer W. Mack, MD, MPH;
M. Elizabeth Paulk, MD;
Kasisomayajula Viswanath, PhD;
Holly G. Prigerson, PhD
Arch Intern Med. 2010;170(17):1533-1540. doi:10.1001/archinternmed.2010.322
Background Black patients tend to receive more life-prolonging care at the end of life (EOL) than white patients. This study aimed to evaluate whether differences in patient-physician communication contribute to disparities in EOL care between black patients and white patients.
Methods Multi-institutional prospective longitudinal cohort study of 71 black patients and 261 white patients with advanced cancer. The main outcome measures were differences between black patients and white patients in relationships among EOL discussions and communication goals (terminal illness awareness, treatment preferences, and do-not-resuscitate [DNR] orders) and EOL care outcomes (life-prolonging care, hospice care, and receipt of EOL care consistent with preferences).
Results End-of-life discussions between physicians and their white patients were associated with less life-prolonging EOL care compared with their black patients (adjusted odds ratio [aOR], 0.11; P = .04). Despite similar rates of EOL discussions (black vs white patients 35.3% vs 38.4%, P = .65), more black patients than white patients received life-prolonging EOL care (19.7% vs 6.9%, P = .001). End-of-life discussions were associated with attainment of some communication goals among black patients, including placement of DNR orders (aOR, 4.25; P = .04), but these communication goals were not consistently associated with EOL care received by black patients. For example, black patients with DNR orders were no less likely than black patients without DNR orders to receive life-prolonging EOL care (aOR, 1.57; P = .58).
Conclusions End-of-life discussions and communication goals seem to assist white patients in receiving less life-prolonging EOL care, but black patients do not experience the same benefits of EOL discussions. Instead, black patients tend to receive life-prolonging measures at the EOL even when they have DNR orders or state a preference for symptom-directed care.
Author Affiliations: Department of Pediatric Oncology and Center for Outcomes and Policy Research (Dr Mack), Center for Community-Based Research (Dr Viswanath), and Center for Psycho-oncology and Palliative Care Research (Dr Prigerson), Dana-Farber Cancer Institute, Department of Medicine, Children's Hospital (Dr Mack), and Department of Society, Human Development, and Health, Harvard School of Public Health (Dr Viswanath), Boston, Massachusetts; and Palliative Care Service, Southwestern Medical Center, University of Texas (Dr Paulk), Dallas.
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