Quality of Care at the End of Life: Applying the Intersection of Race and Gender.

BACKGROUND AND OBJECTIVES: Research on racial and gender disparities in end-of-life care quality has burgeoned over the past few decades, but few studies have incorporated the theory of intersectionality, which posits that membership in 2 or more vulnerable groups may result in increased hardships across the life span. As such, this study aimed to examine the intersectional effect of race and gender on the quality of care received at the end of life among older adults. RESEARCH DESIGN AND METHODS: Data were derived from the combined Round 3 to Round 10 of the National Health and Aging Trends Study. For multivariate analyses, 2 logistic regression models were run; Model 1 included the main effects of race and gender and Model 2 included an interaction term for race and gender. RESULTS: Results revealed that White men were the most likely to have excellent or good care at the end of life, followed by White women, Black men, and Black women, who were the least likely to have excellent or good care at the end of life. DISCUSSION AND IMPLICATIONS: These results point to a significant disadvantage for Black women, who had worse end-of-life care quality than their gender and racial peers. Practice interventions may include cultural humility training and a cultural match between patients and providers. From a policy standpoint, a universal health insurance plan would reduce the gap in end-of-life service access and quality for Black women, who are less likely to have supplemental health care coverage.

Social determinants of willingness to discuss end-of-life care with family and doctors among Korean American immigrants: Findings from a cross-sectional survey in Alabama.

Prior research reported lower engagement in end-of-life discussions and planning among Korean American (KA) immigrants; however, there is a dearth of research investigating factors associated with their willingness to discuss their end-of-life care wishes. This study aimed to examine the willingness to have end-of-life discussions with family and doctors among KA immigrants and social determinants of health (SDH) associated with willingness. A self-administered, cross-sectional survey was conducted with a convenience sample of 259 KA immigrants recruited from two counties in Alabama. Demographic, health, acculturation and SDH information were collected. Logistic regression analyses were conducted to examine associations between SDH and willingness for end-of-life discussion with family and doctors, respectively. The majority of the sample was willing to discuss end-of-life care with family (94%) and doctors (82%). Those with hospice awareness were more likely to have willingness for discussion with family (OR = 27.70, p < 0.001) and doctors (OR = 5.01, p < 0.001). Those who could not see a doctor because of cost (OR = 0.03, p < 0.01) and who had higher threats to interpersonal safety (OR = 0.74, p < 0.05) were less likely to have willingness for discussion with family. Those who had more chronic conditions (OR = 0.60, p < 0.05) and higher levels of social isolation (OR = 0.77, p < 0.05) were less likely to have willingness for discussion with doctors. The SDH identified in this study should be considered in developing interventions to promote end-of-life discussions in the KA immigrant community. Future research should investigate the associations explored in this study in a larger and more representative sample.

Willingness to Discuss End-of-Life Care Wishes Among Rural Black/African American Residents of the Alabama Black Belt.

Willingness for end-of-life discussion and related factors among rural Blacks/African Americans of the Alabama Black Belt have not been well-studied. This study aims to assess their willingness for the discussion and examine its relationship with social determinants of health (SDH) and demographic factors. A cross-sectional survey was conducted with a convenience sampling of 182 participants. Most participants were willing to discuss end-of-life wishes with family (77.1%) or doctors (72.1%). Controlling for demographics, results from binary logistic regressions showed those with hospice awareness were more likely to have willingness for discussion with family (OR = 10.07, p < .01) and doctors (OR = 7.23, p < .05). Those who were older (50+) were less likely to have willingness for discussion with doctors (OR = 0.19, p < .05), whereas those who were more socially isolated were less likely to have willingness for discussion with family (OR = 0.53, p < .05). Therefore, end-of-life discussion efforts should focus on older, socially isolated individuals and consider hospice awareness.

Examining Racial Differences in the Informal Discussion of Advance Care Planning Among Older Adults: Application of the Andersen Model of Health Care Utilization.

OBJECTIVES: The purpose of this study was to examine racial differences in the discussion of advance care planning among older adults using Andersen's behavioral model of health care utilization. METHOD: This cross-sectional study utilized data from the 2018 National Health and Aging Trends Study. Weighted multivariable logistic regressions were used to predict advance care planning discussion (n = 1,326). RESULTS: After accounting for predisposing, enabling, and need factors, Black older adults were less likely to discuss end-of-life care (odds ratio [OR] = .527) and medical power of attorney (OR = .531) compared with Whites. Hispanic older adults were also less likely to discuss end-of-life care (OR = .389) and power of attorney (OR = .384) compared with Whites. DISCUSSION: These results point to significant racial disparities in advance care planning discussions among older adults and call for future examinations of cultural, historical, and systemic factors that could influence the discussion of advance care planning among this population.

Awareness of Hospice Care Among Rural African-Americans: Findings From Social Determinants of Health Framework.

Background: Despite the need for hospice care as our society ages, adults in the U.S.'s southern rural region have limited awareness of hospice care. Objective: This study aims to assess the rate of awareness of hospice care among rural residents living in Alabama's Black Belt region and examine social determinants of health (SDH) associated with the awareness. Methods: A cross-sectional survey was conducted among a convenience sample living in Alabama's Black Belt region (N = 179, age = 18-91). Participants' awareness of hospice care, demographic characteristics (ie, age and gender), and SDH (ie, financial resources strain, food insecurity, education and health literacy, social isolation, and interpersonal safety) were assessed. Lastly, a binary logistic regression was used to examine the association between SDH and hospice awareness among participants while controlling for demographic characteristics. Results: The majority of participants had heard of hospice care (n = 150, 82.1%), and older participants (50 years old or older) were more likely to report having heard of hospice care (OR = 7.35, P < 0.05). Participants reporting worries about stable housing (OR = 0.05, P < 0.05) and higher social isolation were less likely to have heard of hospice care (OR = 0.53, P < 0.05), while participants with higher health literacy had a higher likelihood to have heard of it (OR = 2.60, P < 0.01). Conclusions: Our study is the first study assessing the status of hospice awareness among residents of Alabama's Black Belt region. This study highlighted that factors including age and certain SDH (ie, housing status, health literacy, and social isolation) might be considered in the intervention to improve hospice awareness.

Access Barrier in Rural Older Adults' Use of Pain Management and Palliative Care Services: A Systematic Review.

BACKGROUND: Pain and symptom management is critical in ensuring quality of life for chronically ill older adults. However, while pain management and palliative care have steadily expanded in recent years, many underserved populations, such as rural older adults, experience barriers in accessing such specialty services, in part due to transportation issues. The purpose of this systematic review is to examine the specific types of transportation-related barriers experienced by rural older adults in accessing pain and palliative care. METHODS: Studies were searched through the following 10 databases: Abstracts in Social Gerontology, Academic Search Premier, CINAHL, MEDLINE, PsycINFO, SocINDEX with Full Text, Cochrane Database of Systematic Reviews, Nursing & Allied Health Database, Sociological Abstracts, and PubMED. Studies were chosen for initial review if they were written in English, full text, included older adults in the sample, and examined pain/palliative care/hospice, rural areas, and transportation. A total of 174 abstracts were initially screened, 15 articles received full-text reviews and 8 met the inclusion criteria. RESULTS: Findings of the 8 studies identified transportation-related issues as major access barrier to pain and palliative care among rural older adults: specifically, lack of public transportation; lack of wheelchair accessible vehicles; lack of reliable drivers; high cost of transportation services; poor road conditions; and remoteness to the closest pain and palliative care service providers. CONCLUSION: Results suggest that rural older adults have unique transportation needs due to the urban-centric location of pain and palliative care services. Implications for practice, policy and research with older adults are discussed.

A comparison of urban and non-urban African American older adults on health-related characteristics.

Although residential geographic health disparities have been noted in the previous literature, studies are specifically lacking on intra-group health comparisons of African American older adults by residential geography. The purpose of this study was to determine if health-related characteristics of African American older adults varied by residential geography. Socioeconomic demographics, medical conditions, primary care use, and self-ratings of general health, social activity, and physical activity were compared in a community-dwelling sample of 327 urban and non-urban African American older adults. Urban and non-urban African American older adults were compared on health-related factors. Compared to urban African American older adults, those in non-urban areas had lower incomes, lower self-ratings of general health, social activity, and physical activity, and a higher frequency of arthritis and gastroenterological and urological conditions. Despite poorer general health and medical conditions, non-urban African American older adults were less likely to visit the doctor when needed. Study findings suggest residential geography may be an underappreciated underlying contributing factor to inter-group health disparities between African American and white older adults and not race alone. Therefore, social workers in public health, health care, and clinical settings should be aware of the interaction between race and residential geography.

Racial Differences in Associations of Perceived Health and Social and Physical Activities With Advance Care Planning, End-of-Life Concerns, and Hospice Knowledge.

Associations of perceived health and social and physical activities with end-of-life (EOL) issues have been rarely studied, not to mention racial disparities in such associations. To address this gap, this study examined racial differences in the associations of perceived health and levels of social and physical activities with advance care planning, EOL concerns, and knowledge of hospice care among community-dwelling older adults in Alabama. Data from a statewide survey of 1044 community-dwelling older adults on their long-term care needs were analyzed using descriptive statistics and logistic and linear regressions. Results showed that black older adults were less likely to know about or document advance care planning and to have accurate knowledge of hospice care; however, despite their poorer perceived health, black older adults reported fewer EOL concerns. Higher levels of perceived health and social and physical activities were associated with knowledge about advance care planning among white older adults but not among black older adults. Both black and white older adults with poorer perceived health and lower levels of social and physical activities tended to have more EOL concerns and less knowledge of hospice care. These findings suggest that interventions to address suboptimal levels of perceived health and social and physical activities among black older adults may increase knowledge of advance care planning. Also, supportive services to address EOL concerns should be targeted at older adults with poorer perceived health and limited participation in social and physical activities.

Terminally ill African American elders' access to and use of hospice care.

The underuse of hospice care by terminally ill African American elders suggests they are suffering when hospice care could offer quality end of life care. Guided by the Behavioral Model for Vulnerable Populations, this study sought understanding of structural barriers faced when seeking access to hospice care and reasons for using it when access is possible. Data was collected through interviews with 28 African American hospice patients. Themes from directed content analysis provide insights into strategies used to overcome access barriers posed by income, health insurance and administrative procedure, as well as the role religion, family, information and health beliefs played in using it. Distributing educational materials and addressing spiritual/religious concerns in choosing hospice care are key in promoting African Americans' use of hospice care.

Values important to terminally ill African American older adults in receiving hospice care.

While racial disparity in the use of hospice care by older African Americans is widely acknowledged, little is known about the values that they consider as important in receiving health care services along with direct experiences with having these values respected by hospice care providers. Using individual, face-to-face interviews, data were collected directly from 28 African American hospice patients about their experiences in hospice care. Content analysis was used to identify and categorize themes from multiple readings of the qualitative data. Resulting themes included: dying at home, open communications, independent decision-making, autonomy in daily life, unwillingness to be a burden, and relationships. Through the initial assessment, value preferences can be explored and then shared with hospice team members to ensure that services are provided in such a way that their values and preferences are respected.

An assessment of AKIN criteria for hospital-acquired acute kidney injury: a prospective observational cohort study.

BACKGROUND AND AIMS: The Acute Kidney Injury Network (AKIN) criteria assert a new definition for acute kidney injury (AKI). We investigated the incidence of hospital-acquired AKI, along with the clinical characteristics and outcomes in hospitalized patients according to AKIN stage. METHODS: We performed a prospective, observational, single-center study. We monitored serum creatinine everyday for all patients using a hospital data survey system during the study period from September 2007 to February 2008. RESULTS: Hospital-acquired AKI occurred in 1.2% of all hospitalized patients during the study period. Among patients with AKI, 29.2% were in stage 1, 36.5% were in stage 2 and 34.4% were in stage 3. A significantly higher rate of renal recovery was observed in patients with lower-stage injuries (71.4, 60.0, and 21.2% for stages 1, 2, and 3, respectively). Mortality for patients with stage 3 AKI (51.5%) was significantly higher than that for patients with stages 1 or 2 (p < 0.013). Independent risk factors for mortality in patients with AKI included malignancy, stage 3 AKI, diuretic use, and intensive care unit admission prior to AKI. CONCLUSIONS: Our findings support the utility of the AKIN criteria for hospital-acquired AKI, and demonstrate that stage 3 AKI poses a significant risk for poor patient and renal outcomes.