Black Cancer Patients Less Likely than Whites to Receive the End-of-life Care They Prefer

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 didn’t matter.”

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 prolonging life.

“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 this study.”

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 interviewed separately.