Smith Alexander K, McCarthy Ellen P, Paulk Elizabeth, Balboni Tracy A, Maciejewski Paul K, Block Susan D, Prigerson Holly G
Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 1309 Beacon St, Brookline, MA 02446, USA.
J Clin Oncol. 2008 Sep 1;26(25):4131-7. doi: 10.1200/JCO.2007.14.8452.
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.
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.
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]).
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.
尽管预先护理计划（ACP）中存在有充分记录的种族和民族差异，但我们对这些差异存在的原因知之甚少。本研究对所提出的ACP中种族/民族差异的中介因素进行了检验。
在“应对癌症”研究中，我们研究了312名非西班牙裔白人、83名非西班牙裔黑人以及73名西班牙裔晚期癌症患者。该研究是一项由联邦政府资助的多中心前瞻性队列研究，旨在研究ACP和临终护理中的种族/民族差异。我们评估了对终末期疾病的认知、宗教信仰和治疗偏好对ACP中种族/民族差异的影响。
与白人患者相比，黑人和西班牙裔患者制定ACP的可能性较小（白人患者为80%；黑人患者为47%；西班牙裔患者为47%），并且即使只剩下几天生命，他们更有可能希望延长生命的护理（白人患者为14%；黑人患者为45%；西班牙裔患者为34%），且更有可能认为宗教非常重要（白人患者为44%；黑人患者为88%；西班牙裔患者为73%；与白人患者相比，所有P<0.001）。西班牙裔患者认知自己终末期疾病状态的可能性较小，黑人患者认知自己终末期疾病状态的可能性略小（白人患者为39%，西班牙裔患者为11%；P<0.001；白人患者与黑人患者相比为27%；P=0.05）。在对临床和人口统计学因素、终末期疾病认知、宗教信仰和治疗偏好进行调整后，ACP中的种族/民族差异仍然存在（制定了ACP，黑人患者与白人患者相比，调整后的相对风险为0.64[95%CI，0.49至0.83]；西班牙裔患者与白人患者相比为0.65[95%CI，0.47至0.89]）。
尽管黑人和西班牙裔患者认为自己处于终末期疾病的可能性较小，且更有可能希望接受强化治疗，但这些因素并不能解释所观察到的ACP差异。
