End-of-life care in nursing home settings: do race or age matter?
ABSTRACT One-quarter of all U.S. chronic-disease deaths occur in nursing homes, yet few studies examine palliative care quality in these settings. This study tests whether racial and/or age-based differences in end-of-life care exist in these institutional settings.
We abstracted residents' charts (N = 1133) in 12 nursing homes. Researchers collected data on indicators of palliative care in two domains of care--advance care planning and pain management--and on residents' demographic and health status variables. Analyses tested for differences by race and age.
White residents were more likely than minorities to have DNR orders (69.5% vs. 37.3%), living wills (39% vs. 5%), and health care proxies (36.2% vs. 11.8%; p < .001 for each). Advance directives were highly and positively correlated with age. In-depth advance care planning discussions between residents, families, and health care providers were rare for all residents, irrespective of demographic characteristics. Nursing staff considered older residents to have milder and less frequent pain than younger residents. We found no disparities in pain management based on race.
To the extent that advance care planning improves care at the end of life, racial minorities in nursing homes are disadvantaged compared to their white fellow residents. Focusing on in-depth discussions of values and goals of care can improve palliative care for all residents and may help to ameliorate racial disparities in end-of-life care. Staff should consider residents of all ages as appropriate recipients of advance care planning efforts and should be cognizant of the fact that individuals of all ages can experience pain. Nursing homes may do a better job than other health care institutions in eliminating racial disparities in pain management.
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ABSTRACT: BACKGROUND: A growing body of scientific research is suggesting that end-of-life care and decision making may differ between age groups and that elderly patients may be the most vulnerable to exclusion of due care at the end of life. This study investigates age-related disparities in the rate of end-of-life decisions with a possible or certain life shortening effect (ELDs) and in the preceding decision making process in Flanders, Belgium in 2007, where euthanasia was legalised in 2002. Comparing with data from an identical survey in 1998 we also study the plausibility of the 'slippery slope' hypothesis which predicts a rise in the rate of administration of life ending drugs without patient request, especially among elderly patients, in countries where euthanasia is legal. METHOD: We performed a post-mortem survey among physicians certifying a large representative sample (n=6927) of death certificates in 2007, identical to a 1998 survey. Response rate was 58.4%. RESULTS: While the rates of non-treatment decisions (NTD) and administration of life ending drugs without explicit request (LAWER) did not differ between age groups, the use of intensified alleviation of pain and symptoms (APS) and euthanasia/assisted suicide (EAS), as well as the proportion of euthanasia requests granted, was bivariately and negatively associated with patient age. Multivariate analysis showed no significant effects of age on ELD rates. Older patients were less often included in decision making for APS and more often deemed lacking in capacity than were younger patients. Comparison with 1998 showed a decrease in the rate of LAWER in all age groups except in the 80+ age group where the rate was stagnant. CONCLUSION: Age is not a determining factor in the rate of end-of-life decisions, but is in decision making as patient inclusion rates decrease with old age. Our results suggest there is a need to focus advance care planning initiatives on elderly patients. The slippery slope hypothesis cannot be confirmed either in general or among older people, as since the euthanasia law fewer LAWER cases were found.BMC Public Health 06/2012; 12(1):447. · 2.08 Impact Factor
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ABSTRACT: Racial disparities in survival after out-of-hospital cardiac arrest have been reported, but their causes remain uncertain. We sought to determine if hospital racial composition accounted for survival differences for patients hospitalized after cardiac arrest. We evaluated hospitalizations of white and black Medicare beneficiaries (2000-2007) admitted from the emergency department to the intensive care unit with a diagnosis of cardiac arrest or ventricular fibrillation. We examined unadjusted survival rates and developed a multivariable logistic regression model that included patient and hospital factors. We analyzed 68,115 cardiac arrest admissions. Unadjusted survival to hospital discharge was worse for blacks (n = 7,942) compared with whites (n = 60,173) (30% vs 33%, P < .001). In multivariate analyses accounting for patient and hospital factors, adjusted probability of survival was worse for black patients at hospitals with higher proportions of black patients (31%, 95% CI 29%-32%) compared with predominately white hospitals (46%, 95% CI 36%-57%; P = .003). Similarly, whites had worse risk-adjusted survival at hospitals with higher proportions of black patients (28%, 95% CI 27%-30%) compared with predominately white hospitals (32%, 95% CI 31%-33%, P = .006). Blacks were more likely to be admitted to hospitals with low survival rates (23% vs 15%, P < .001). Hospitals with large black patient populations had worse cardiac arrest outcomes than predominantly white hospitals, and blacks were more likely to be admitted to these high-mortality hospitals. Understanding these differences in survival outcomes may uncover the causes for these disparities and lead to improved survival for all cardiac arrest victims.American heart journal 04/2011; 161(4):705-11. · 4.65 Impact Factor
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ABSTRACT: CONTEXT: Most patients with serious and life-limiting illness experience pain at some point in the illness trajectory. OBJECTIVES: To describe baseline pain management practices for imminently dying patients in Veterans Administration Medical Centers (VAMCs) and examine factors associated with these processes, including presence of opioid orders at the time of death and medication administration in the last seven days, 48 hours, and 24 hours of life. METHODS: Data on orders and administration of opioid pain medication at the end of life were abstracted from the medical records of veterans who died in six VAMC hospitals in 2005. RESULTS: Of 1068 patient records, 686 (64.2%) had an active order for an opioid medication at the time of death. Of these, 69.8% of patients had received the medication at some time within the last seven days of life, 61.2% within the last 48 hours, and 47.0% within the last 24 hours. In multivariable models, presence of an order for opioid pain medication at the time of death and administration within the last 24 hours were both significantly associated with having a Do Not Resuscitate (DNR) order (P<0.0001/0.0002), terminal condition (P<0.0001/<0.0001), family presence (P<0.0001/0.0023), location of death (P=0.003/0.0005), and having pain noted in the care plan (P=0.0073/0.0007). CONCLUSION: Findings indicate a need for improving availability of opioids for end-of-life care in the inpatient setting. Modifiable factors, such as family presence and goals-of-care discussions, suggest potential targets for intervention to improve recognition of the dying process and proactive planning for pain control.Journal of pain and symptom management 07/2012; · 2.42 Impact Factor