Minority patients face barriers to
optimum end-of-life care
BOSTON January 10, 2002 Minority groups in America
have less access to many medical treatments, one of which is end-of-life
care, according to a review article in the January Journal of
the American Geriatrics Society. The authors look at why this
is and what can be done to change it.
"There are many reports that provide evidence of ethnic differences
in access to medical services in general and to end-of-life care
in particular," says lead author Eric Krakauer, MD, PhD, of
Massachusetts General Hospitals Palliative Care Service. Among
his examples, Krakauer cites a study demonstrating that fewer resources
were used in caring for seriously ill African Americans than for
other patients with similar illness severity and other studies that
report lower use of analgesia for minority cancer patients with
One of the most obvious reasons for disparities in health care
involves health insurance, says Krakauer. He points out that minorities
are twice as likely to be uninsured as European Americans. "I
think our kids and grandkids will look back and wonder, how
could we allow forty million Americans, disproportionately minorities,
to be without health insurance? " he says. "We need
a better national plan."
Krakauer also says that theres a problem with medical education.
"Theres an under-representation of minorities in medicine,
and thats noteworthy because minority physicians are more
likely to care for minority patients," he says. He also notes
that affirmative action is being dismantled and minority applications
and admissions to medical schools have been declining. "So
the disparity is getting worse," he says.
Krakauer says another barrier to optimum end-of-life care for minorities
is mistrust due to a long history of racism in medicine the
most notorious example being the Tuskegee Syphilis Study. He says
that some patients may think that doctors will not make all treatment
options available to them. "Such mistrust of the medical community
is understandable because the medical community has not proven itself
entirely trustworthy. But this can adversely affect end-of-life
care, where trust is crucial."
Along those lines, cultural differences can complicate the patient-doctor
relationship and make communication difficult. Krakauer says that
physicians should seek to thoroughly understand each individual
patients preferences for end-of-life care and not impose on
them the values and goals of the dominant culture. Doctors may not
be aware that cultural differences have an impact on such preferences.
He points to several studies that found that African American patients
were more likely than white patients to desire aggressive life support
in the event of a terminal illness. Researchers have also found
that a family-centered style of medical decision-making is common
in some cultures. Therefore, physicians must be open to alternative
forms of decision-making and of obtaining informed consent.
Krakauer and his colleagues have no easy answers on how to remove
the barriers to end-of-life care for minorities. They do have some
suggestions for starting to tackle the problem, though. These include
implementing a single-payer health insurance program and reimbursement
policies that provide incentives to hospitals and hospices for serving
minorities and the poor. Their suggestions also include courses
for medical students and clinicians on cultural sensitivity and
affirmative action programs to improve access to medical education
for minority students. The authors stress that more research needs
to be done that takes into account all of the complexities of access
to end-of-life care.
The articles co-authors are Christopher Crenner, MD, PhD,
of the Department of History and Philosophy of Medicine at the University
of Kansas Medical School, and Ken Fox, MD, of the Department of
Pediatrics at Boston University School of Medicine and the Department
of Social Medicine at Harvard Medical School.
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