Disparities in access to, and utilization of, treatment for depression among African-American and Caucasian elderly adults have been well-documented. Less fully explored are the multidimensional factors responsible for these disparities. The intersection of cultural constructs, socioeconomic factors, multiple levels of racism, and stigma attending both mental health issues and older age may help to explain disparities in the treatment of the depressed elderly. Personalized medicine with its promise of developing interventions tailored to an individual's health needs and genetically related response to treatment might seem a promising antidote to the documented underutilization of standard depression treatments by African Americans. However, this paper examines the multidimensional factors associated with disparities in effective treatment of depression among African-American and Caucasian elderly adults and argues the scientific and ethical importance of pursuing various paths to address multiple levels and sources of stigma and mistrust if pharmacogenomics is to help, rather than exacerbate, disparities in depression treatment. Seven recommendations are offered to increase the likelihood that developments in pharmacogenomics will reduce disparities in depression treatment.

Despite many believing that there is no ethical, medical, or moral difference between withholding and withdrawing of life-sustaining treatment, there is no denying it is emotionally taxing, particularly withdrawal of ANH. Upholding the patient's values during high-quality shared decision making, facilitating rapport, and utilizing time limited trials will help, even when treatment is considered medically ineffective.

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Few would debate that thoughtful advance care planning conversations between providers, patients, and patients’ loved ones reflect a respect for the right to direct one’s end-of-life care based upon personal values, preferences, and goals. Previous research suggests that advance directives and medical orders are the vehicles to enable patient wishes to be known. However, without ensuring clinician access to those documents, the chances that a patient will receive the desired level of treatment at the end of life diminish significantly. This chapter explores the impediments to accessing and acting upon advance directives and medical orders and suggests a comprehensive system that improves access to completed advance care planning documents for providers and patients. It reviews the successes with such a system in a state—West Virginia—and the positive outcomes with employing components of the proposed system with chronic kidney disease and dialysis patients.

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