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Kimberly S. Johnson, MD, MHS; Maragatha Kuchibhatla, PhD; David Tanis, PhD; James A. Tulsky, MD

Arch Intern Med. 2008;168(2):218-224.

Background  Hospice provides supportive care to terminally ill patients at the end of life. However, some enrollees leave hospice before death in search of therapies that may prolong survival. Because of a greater preference for life-sustaining therapies at the end of life, African American patients may be more likely than white patients to withdraw from hospice to seek life-prolonging therapies.

Methods  In a secondary data analysis of African American and white patients discharged from VITAS hospice programs between January 1, 1999, and December 31, 2003, we used logistic regression to examine the association between race and discharge disposition defined as hospice revocation to pursue aggressive care (eg, emergency medical care, chemotherapy, or invasive medical intervention) vs all other discharges. We used a Cox proportional hazards model to examine survival at 1 year after hospice revocation in a subgroup of enrollees from Florida hospice programs.

Results  Of the 166 197 enrollees, 2.8% revoked hospice to pursue aggressive care, and African American patients were more likely than white patients to do so (4.5% vs 2.5%; P < .001). In multivariate analysis, African American patients had a 70% higher odds of leaving hospice to pursue life-prolonging therapies (odds ratio, 1.70; 95% confidence interval, 1.57-1.84). In the subgroup analysis, 48.4% of the enrollees who revoked hospice to pursue life-prolonging therapies were still alive at 1 year.

Conclusions  African American patients were more likely than white patients to revoke hospice to pursue life-prolonging therapies. Models of health care that couple curative and palliative therapies may be more attractive to African American patients and more effective at maximizing continuity throughout life-limiting illness.

Author Affiliations: Department of Medicine (Drs Johnson and Tulsky), Division of Geriatrics (Dr Johnson), Center for the Study of Aging and Human Development (Drs Johnson, Kuchibhatla, and Tulsky), Center for Palliative Care (Drs Johnson and Tulsky), and Department of Biostatistics and Bioinformatics (Dr Kuchibhatla), Duke University, Durham, North Carolina; and VITAS Healthcare Corporation, Miami, Florida (Dr Tanis).

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