Ineffective communication, discontinuity of care may explain disparities
A new study of racial disparities in end-of-life (EOL) care revealed
that black cancer patients' treatment preferences were less likely to be
observed than were white patients' preferences, according to
researchers from Dana-Farber Cancer Institute.
Some black patients who had opted not to be resuscitated or put on a
ventilator in a life-or-death crisis received the treatment anyway, and
died in an intensive care unit. Conversely, white patients who had
expressed a preference for aggressive care in end-of-life discussions
with a doctor were three times more likely to receive it than were black
patients who had voiced the same wishes.
"End-of-life care discussions appeared to be more effective in
ensuring that white patients' treatment preferences were honored," said
Holly Prigerson, PhD, senior author of the report in The Journal of Clinical Oncology. The study is posted on the journal's web site and will be published in a future print edition.
"We are not saying that black treatment preferences were ignored,"
she emphasized. "Black patients did want, and did receive, more
aggressive care than whites. The disparity was in the effect of
treatment preferences on care received — not that black preferences
The study, which Prigerson and colleagues undertook to explore
previously reported racial disparities in end-of-life care, such as the
use of hospice and desire to undergo intensive treatments in hope of
Holly Prigerson, PhD
"None of the white patients who reported the completion of a
do-not-resuscitate order, or a DNR, order at baseline subsequently
received intensive care in the last week of life," said Prigerson. "This
did not prove to be the case for black patients. DNR orders did not
significantly protect black patients from intensive end-of-life care in
She said the black-white disparity in adherence to advance directives
may be linked to gaps in communication, some of which resulted from
discontinuities in care that may have been more prevalent in the
treatment of black patients.
For example, the researchers identified a few instances where DNR
orders completed for black patients fell through the cracks because
their informal caregivers (friend or family member) changed over the
course of their illness, or because a critically ill patient was treated
at a different hospital from the one that normally provided their care.
In such cases where documentation was lacking, doctors forced into
quick decisions felt obligated to do everything possible for the
patient, even if the situation seemed hopeless, said Prigerson.
The researchers, including lead author Elizabeth Trice Loggers, MD,
of Dana-Farber and scientists at several other institutions, interviewed
234 white and 68 black patients with advanced cancer. The initial
interview included questions about the patients' preference for
end-of-life care; the level of trust in their physicians; whether they
had had an end-of-life care discussion with a doctor; and whether they
had completed a DNR order. The patients' informal caregivers were
Each patient was monitored until their death, which on average was
3.5 months later. A patient was considered to have received intensive
end-of-life care if he or she had undergone cardiopulmonary
resuscitation (CPR) and/or been placed on a ventilator in the last week
of life, followed by death in an intensive care unit (ICU).
Based on the initial interviews, black and white patients were
similar in their trust of their physicians and having had an end-of-life
discussion with the doctor.
Blacks tended to prefer intensive end-of-life care, were less likely
to report that a DNR order was completed for them, and much more likely
to be "positive religious copers" — believing that their outcome would
ultimately be determined by God.
None of these factors, the scientists said, explained black-white
disparities in end-of-life care. Instead, it appears that "social
forces," such as disruptions in continuity of care and cultural
differences that impaired patient-physician communication, might be to
Prigerson said the study's findings highlight the need to improve
clinical communication between black patients and their oncology care
providers. Enhanced communication would help to ensure that patients
appreciate the risks and benefits of intensive care and that the
providers are better informed of their patients' wishes, she said.
The cases in which patients' medical information wasn't available in
critical situations underscores the need for improvements, said
Prigerson, such as a centralized medical recording system where code
status could be universally accessed.
"We are continuing to analyze the data," she added, "and we hope to
identify strategies to ensure that patients and healthcare providers
make informed end-of-life decisions."
The research was supported by grants from the National Institutes of Health.
Dana-Farber Cancer Institute (www.dana-farber.org)
is a principal teaching affiliate of the Harvard Medical School and is
among the leading cancer research and care centers in the United States.
It is a founding member of the Dana-Farber/Harvard Cancer Center
(DF/HCC), designated a comprehensive cancer center by the National
Cancer Institute. It is the top ranked cancer center in New England,
according to U.S. News & World Report, and one of the
largest recipients among independent hospitals of National Cancer
Institute and National Institutes of Health grant funding.