Advance Directive Discussions: Lost in Translation or Lost Opportunities?

Abstract

Background: Previous studies have shown that minority populations have low rates of documented advance directives and express preferences for more life-prolonging interventions at the end of life. We sought to determine the impact of Latino ethnicity on patients' self-report of having an advance directive discussion and having a completed advance directive in the medical record at an index hospitalization for serious medical illness. Methods: This was a prospective observational cohort study of 458 adults admitted to the general medical services of a safety net hospital, an academic medical center, and a Veterans' Affairs (VA) hospital. Patients were asked if they had discussed advance directives, and we reviewed medical records for documented advance directives. Results: Overall, 45% of patients reported having had a discussion about advance directives (29% of Latinos compared with 54% of Caucasians, p = 0.0002) and 24% of patients had a completed advance directive in their medical record (25% Latinos and 26% of Caucasians, p = not significant [ns]). Using logistic regression modeling and adjusting for socioeconomic status (SES), education level, and language spoken, Latinos (odds ratio [OR] 0.42, confidence interval [CI] 0.24-0.75) were less likely to report having advance directive discussions compared with Caucasians (referent). However, modeling of a completed advance directive in the medical record showed no significant difference between Latinos (OR 1.44, CI 0.73-2.85) and Caucasians (referent). Conclusions: The unexpected discrepancy we found highlights the need for more effective communication in advance care planning that includes education that is culturally sensitive and accessible to persons with low health literacy.

The Relationship of Faith-Related Characteristics to Attitudes and Behaviors Regarding End-of-Life Care

“…This is consistent with prior research (e.g., Balboni et al, 2007;Caralis, Davis, Wright, & Marcial, 1993;Fischer et al, 2012;Hopp & Duffy, 2000;Johnson et al, 2008;Karches et al, 2012;Kwak & Haley, 2005;Smith et al, 2008;True et al, 2005), and the current study found this effect of ethnicity to be robust even after controlling for other personal characteristics such education, marital status, satisfaction with finances, and perceived health. Although not the primary focus of the present study, this suggests that sociocultural, familial, or relational aspects that could foster these differential views and behaviors are important to consider, and sensitivity to these factors is warranted when discussing EOL issues, particularly for health care providers, ministerial professionals, and those in the legal profession.…”

“…A number of studies have observed that ethnicity is related to views and behaviors involving end-oflife issues (e.g., Balboni et al, 2007;Fischer, Sauaia, Min, & Kutner, 2012;Johnson, Kuchibhatla, & Tulsky, 2008;Karches, Chung, Arora, Meltzer, & Curlin, 2012;Smith et al, 2008;True et al, 2005). Kwak and Haley (2005), in their review of 33 empirical studies, observed that non-White individuals were less likely than White persons to support advance directives, and that African American individuals consistently favored the use of life support.…”

Race, Income, and Education: Associations with Patient and Family Ratings of End-of-Life Care and Communication Provided by Physicians-in-Training

“…Available information would suggest findings similar to those experienced in the broader healthcare context, where minority individuals and those with lower income perceive a lack of communication about end-oflife care. [16][17][18] However, we replicated these results for only some of the associations we tested. Family members from racial/ethnic minority groups rated their physicians significantly lower on the QEOLC score and the general communication component of the QOC.…”

Advanced Care Directives: Overcoming the Obstacles

“…2 Residents are exposed to these discussions at a greater degree and urgency in the inpatient setting, but it has been shown that outpatient discussions regarding ACD could facilitate better decisions during inpatient hospitalizations. 3,4 Residents may find it difficult to assess which patients would benefit from discussions of ACDs, unless they have a current, life-limiting illness. Residents also may perceive that patient satisfaction will be negatively affected by discussions regarding ACDs, yet data show that patient satisfaction in academic primary care general internal medicine practice improves with ACD discussions.…”