Racial/ethnic differences in inpatient end-of-life communication

Background: Reducing racial/ethnic disparities in end-of-life care for patients with advanced cancer has grown increasingly important as African Americans continue to suffer disproportionately from cancer. Prior research has identified racial/ethnic differences in end-of-life communication as one of the modifiable factors associated with disparities in care. In the inpatient setting, end-of-life communication is particularly important because it often directly affects end-of-life decision making. Yet, little is known about what racial/ethnic differences in end-of-life communication exist in the inpatient setting for patients with advanced cancer and why these differences exist. A primary barrier to understanding and resolving these differences is the lack of data on inpatient end-of-life discussion content. Objective: The objective of the proposed study is to examine racial/ethnic differences in inpatient end-of-life communication for patients with advanced cancer and use this information to develop and test a patient-centered and culturally sensitive intervention to help improve communication. Specific Aims: The aims of this proposal are to: 1) Evaluate and compare the communication content and processes in inpatient EOL discussions between clinicians and African-American and Non-Hispanic White patients with advanced cancer, 2) Assess patient perceptions of the inpatient EOL discussion to explore factors affecting decision making, and 3) Develop and pilot a patient-centered intervention to improve inpatient EOL communication for African-American and Non-Hispanic White patients with advanced cancer. Study Design: This is a cross-sectional, observational study of racial/ethnic differences in inpatient EOL discussion between clinicians and African American and Non-Hispanic White patients hospitalized with advanced cancer. In Aim 1 we will audiotape 60 inpatient EOL discussions between clinicians and African American (N=30) and Non-Hispanic White (N=30) patients with advanced cancer recruited from oncology, hospitalist, and palliative care consult services. We will use established coding frameworks to compare discussion content (e.g., discussion of prognosis) and communication processes (e.g., responds to emotion) between African American and Non-Hispanic White patients and their clinicians. Following these EOL discussions, we will interview a sequentially recruited subset of 15 African Americans and 15 Non-Hispanic White patients to explore factors affecting how the discussion influenced EOL decision making from their perspective. Using results from Aims 1 and 2, we will develop and pilot test a culturally sensitive, patient-centered intervention to help patients identify their information and decision-making preferences before an EOL discussion and facilitate transfer of this information to the physician. We will use clinician focus groups and patient cognitive interviews to refine the intervention and assess usability and feasibility. We will then conduct a pilot randomized controlled trial (N=60 with 30 patients randomized to intervention vs. control) which will provide data on effect sizes to inform a full scale randomized controlled trial of an intervention in an R01 application. Cancer Relevance: The results of this work will inform a larger study to test a culturally-sensitive intervention to improve inpatient end-of-life communication, with the ultimate goal of helping to improve the quality of care for all patients with advanced cancer.