Article of the Month

Reviewed by Dr Carla Ripamonti (Italy), an IAHPC Board Member

RACIAL DIFFERENCES IN PREDICTORS OF INTENSIVE END-OF-LIFE CARE IN PATIENTS WITH ADVANCED CANCER

Loggers ET, et al.

Journal of Clinical Oncology 2009; 27: 5559-64

Although the majority of Americans prefer to die at home, a small percentage of patients, particularly black patients, request and receive intensive life-prolonging care at the end of life (EOL). This includes cardiopulmonary resuscitation (CPR) and/or ventilation interventions after which they die in an intensive care unit (ICU).

Some hypotheses have been considered in order to understand the differences in EOL decisions of black compared to white patients. Do differences in the religion or spiritual beliefs of the two groups of cancer patients play a role? Is there a difference due to a lack of communication and/or a lack of knowledge about palliative care programs?

The aim of this study was to examine and compare putative predictors of intensive EOL care (CPR and/or ventilation and death in the ICU) among black and white patients with advanced cancer.

The authors carried out a prospective multicentre interview-based cohort study on 302 advanced cancer patients (68 black and 234 white) and their caregivers between September 2002 to August 2008. Caregivers took part in a post-mortem interview to determine if CPR and/or ventilation were performed in the last week of life and to determine the place of death.

At baseline, the EOL Care predictors collected were: 1. patient preference for intensive EOL care; 2. physician trust; 3. doctor-patient EOL care discussion; 4. completion of a Do Not Resuscitate (DNR) order; 5. positive religious coping. Also at baseline the following parameters were assessed: 1. QOL (McGill Quality of Life Questionnaire, 2. mental health (DSMMDS ed 4 Axis I Modules); 3. KPS; 4. Charlson comorbidity index; and 5. the Primary cancer.

Results:

• Black patients were three times more likely to receive intensive EOL care (13.2% vs 3.4%) (p=.037) and were approximately two times more likely to prefer this type of care than white patients under investigation (p = .034).

• Black patients were less likely to have a DNR order (p= .011).

• White patients who preferred intensive EOL care were approximately three times more likely than blacks to receive this type of care even though they reported similar preferences (p= .058).

Patients receiving EOL care are in an ICU for a median of 3 days (range 1-21 days) before death. Black patients had the same possibilities as white patients to discuss their EOL with their physicians and reported trusting their physician. White patients who had an EOL discussion or a DNR order did not receive intensive EOL care. This was not the same for black patients who were four times more likely than white patients to receive intensive care and to report positive religious coping (p= .005). The association between positive religious coping and receiving intensive EOL care was 4 time higher for white patients. DNR orders and EOL discussions are not associated with the care of black patients. This study highlights the need to improve communication between black patients and their clinicians.

Why I choose this article

In multiracial and multiculture societies we have to consider more and more the needs and preferences of different people about EOL care. This study is the first to show that race has an influence on intensive EOL care in patients with advanced cancer.

Dr. Ripamonti is a member of the IAHPC Board of Directors; her bio may be viewed at: http://www.hospicecare.com/Bio/c_ripamonti.htm