What Explains Racial Differences in the Use of Advance Directives and Attitudes Toward Hospice Care?

Authors

  • Kimberly S. Johnson MD, MHS,

    1. From the *Department of Medicine, Division of Geriatrics, Center for the Study of Aging and Human Development, §Center for Palliative Care, and Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina.
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  • Maragatha Kuchibhatla PhD,

    1. From the *Department of Medicine, Division of Geriatrics, Center for the Study of Aging and Human Development, §Center for Palliative Care, and Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina.
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  • James A. Tulsky MD

    1. From the *Department of Medicine, Division of Geriatrics, Center for the Study of Aging and Human Development, §Center for Palliative Care, and Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina.
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  • What explains racial differences in beliefs and attitudes about hospice care? Paper presentation at the American Academy of Hospice and Palliative Medicine (AAHPM) National Meeting, February 2008, Tampa, Florida.
    What explains racial differences in completion of advance directives? Abstract accepted for paper plenary session at American Geriatrics Society National Meeting, May 2008, Washington, DC.

Address correspondence to Kimberly S. Johnson, MD, Duke University Medical Center, Division of Geriatrics, DUMC Box 3003, Durham, NC 27710. E-mail: johns196@mc.duke.edu

Abstract

Cultural beliefs and values are thought to account for differences between African Americans and whites in the use of advance directives and beliefs about hospice care, but few data clarify which beliefs and values explain these differences. Two hundred five adults aged 65 and older who received primary care in the Duke University Health System were surveyed. The survey included five scales: Hospice Beliefs and Attitudes, Preferences for Care, Spirituality, Healthcare System Distrust, and Beliefs About Dying and Advance Care Planning. African Americans were less likely than white subjects to have completed an advance directive (35.5% vs 67.4%, P<.001) and had less favorable beliefs about hospice care (Hospice Beliefs and Attitudes Scale score, P<.001). African Americans were more likely to express discomfort discussing death, want aggressive care at the end of life, have spiritual beliefs that conflict with the goals of palliative care, and distrust the healthcare system. In multivariate analyses, none of these factors alone completely explained racial differences in possession of an advance directive or beliefs about hospice care, but when all of these factors were combined, race was no longer a significant predictor of either of the two outcomes. These findings suggest that ethnicity is a marker of common cultural beliefs and values that, in combination, influence decision-making at the end of life. This study has implications for the design of healthcare delivery models and programs that provide culturally sensitive end-of-life care to a growing population of ethnically diverse older adults.

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