Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
Deparment of Community and Family Medicine, Duke University School of Medicine, Durham, North Carolina.
J Palliat Med. 2019 Sep;22(S1):90-100. doi: 10.1089/jpm.2019.0146.
Advance care planning (ACP) improves end-of-life care for patients and their caregivers. However, only one-third of adults have participated in ACP and rates are substantially lower among African Americans than among whites. Importantly, ACP improves many domains of care where there are racial disparities in outcomes, including receipt of goal-concordant care, hospice use, and provider communication. Yet, few studies have examined the effectiveness of ACP interventions among African Americans. The objectives of reducing disparities in the quality of palliative care for older African Americans through improved advance care planning (EQUAL ACP) are as follows: to compare the effectiveness of two interventions in (1) increasing ACP among African Americans and whites and (2) reducing racial disparities in both ACP and end-of-life care; and to examine whether racial concordance of the interventionist and patient is associated with ACP. EQUAL ACP s a longitudinal, multisite, cluster randomized trial and a qualitative study describing the ACP experience of participants. The study will include 800 adults ≥65 years of age (half African American and half white) from 10 primary care clinics in the South. Eligible patients have a serious illness (advanced cancer, heart failure, lung disease, etc.), disability in activities of daily living, or recent hospitalization. Patients are followed for one year and participate in either a patient-guided, self-management ACP approach, including a Five Wishes form or structured ACP with Respecting Choices First Steps. The primary outcome is formal or informal ACP-completion of advance directives, documented discussions with clinicians, and other written or verbal communication with surrogate decision makers about care preferences. Secondary outcomes assessed through after-death interviews with surrogates of patients who die during the study include receipt of goal-concordant care, health services use in the last year of life, and satisfaction with care. EQUAL ACP is the first large study to assess which strategies are most effective at both increasing rates of ACP and promoting equitable palliative care outcomes for seriously ill African Americans.
预先医疗指示计划（ACP）可改善患者及其护理人员的临终关怀。然而，仅有三分之一的成年人参与过 ACP，非裔美国人的参与率明显低于白人。重要的是，ACP 改善了许多在结果方面存在种族差异的护理领域，包括接受与目标一致的护理、使用临终关怀服务和医护人员的沟通。然而，很少有研究调查 ACP 干预措施在非裔美国人中的有效性。通过改进预先医疗指示计划减少老年非裔美国人姑息治疗质量方面的差异（EQUAL ACP）的目标如下：（1）比较两种干预措施在增加非裔美国人和白人的 ACP 方面的有效性，以及（2）减少 ACP 和临终关怀方面的种族差异；并研究干预者和患者的种族一致性是否与 ACP 相关。EQUAL ACP 是一项纵向、多地点、集群随机试验和一项描述参与者 ACP 体验的定性研究。该研究将包括来自南部 10 个初级保健诊所的 800 名年龄在 65 岁及以上的成年人（一半是非裔美国人，一半是白人）。符合条件的患者患有严重疾病（晚期癌症、心力衰竭、肺部疾病等）、日常生活活动能力残疾或最近住院。患者将被随访一年，并参与患者指导的自我管理 ACP 方法，包括五愿望表或具有尊重选择第一步骤的结构化 ACP。主要结果是正式或非正式的 ACP-完成预先指示、与临床医生进行记录讨论以及与代理人就护理偏好进行其他书面或口头沟通。通过对研究期间死亡的患者代理人进行死后访谈评估次要结果，包括接受与目标一致的护理、在生命的最后一年使用卫生服务以及对护理的满意度。EQUAL ACP 是第一项评估哪些策略在提高 ACP 率和促进严重非裔美国人公平的姑息治疗结果方面最有效的大型研究。
