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Racial and Ethnic Differences in Advance Care Planning Among Patients With Cancer: Impact of Terminal Illness Acknowledgment, Religiousness, and Treatment Preferences

Alexander K. Smith, Ellen P. McCarthy, Elizabeth Paulk, Tracy A. Balboni, Paul K. Maciejewski, Susan D. Block, Holly G. Prigerson

From the Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center; Division of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute; Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital; and Department of Psychiatry, Brigham and Women's Hospital, Boston, MA; Palliative Care Service, University of Texas, Southwestern Medical Center, Dallas, TX; and Department of Psychiatry, Womens’ Health Research and Magnetic Resonance Research Center, Yale University School of Medicine, New Haven, CT

Corresponding author: Alexander K. Smith, MD, MS, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 1309 Beacon St, Brookline, MA 02446; e-mail: asmith7{at}bidmc.harvard.edu

Purpose Despite well-documented racial and ethnic differences in advance care planning (ACP), we know little about why these differences exist. This study tested proposed mediators of racial/ethnic differences in ACP.

Patients and Methods We studied 312 non-Hispanic white, 83 non-Hispanic black, and 73 Hispanic patients with advanced cancer in the Coping with Cancer study, a federally funded multisite prospective cohort study designed to examine racial/ethnic disparities in ACP and end-of-life care. We assessed the impact of terminal illness acknowledgment, religiousness, and treatment preferences on racial/ethnic differences in ACP.

Results Compared with white patients, black and Hispanic patients were less likely to have an ACP (white patients, 80%; black patients, 47%; Hispanic patients, 47%) and more likely to want life-prolonging care even if he or she had only a few days left to live (white patients, 14%; black patients, 45%; Hispanic patients, 34%) and to consider religion very important (white patients, 44%; black patients, 88%; Hispanic patients, 73%; all P < .001, comparison of black or Hispanic patients with white patients). Hispanic patients were less likely and black patients marginally less likely to acknowledge their terminally ill status (white patients, 39% v Hispanic patients, 11%; P < .001; white v black patients, 27%; P = .05). Racial/ethnic differences in ACP persisted after adjustment for clinical and demographic factors, terminal illness acknowledgment, religiousness, and treatment preferences (has ACP, black v white patients, adjusted relative risk, 0.64 [95% CI, 0.49 to 0.83]; Hispanic v white patients, 0.65 [95% CI, 0.47 to 0.89]).

Conclusion Although black and Hispanic patients are less likely to consider themselves terminally ill and more likely to want intensive treatment, these factors did not explain observed disparities in ACP.

Supported by the National Institutes of Health Grants No. MH63892 and CA106370 (grants to the Coping with Cancer study) and by an institutional National Research Service Award (Grant No. 5 T32 HP11001-19 to A.K.S.).

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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