Difficult Conversations


Several recently published studies have documented a variety of disparities in the provision of end-of-life care. In some cases, these disparities reflect socio-economic and cultural differences, information that could help hospitalists respond appropriately to different patients’ needs, says Tochi Iroku-Malize, MD, MPH, SFHM, chair of family medicine at North Shore-Long Island Jewish Health System in Great Neck, N.Y.

"One approach does not fit all patients," says Dr. Iroku-Malize, a former HM group director who is board-certified in hospice and palliative medicine. "If you understand that end-of-life care is important, and you know about disparities in care, you will understand the need to deal with these diverse populations."

Hospitalists should appreciate that even if they are not able to refer a seriously ill patient to palliative care or hospice during an initial acute encounter, they can plant a seed for subsequent conversations. They should also report these conversations back to the primary-care physician (PCP), as they would for other medical treatments, she adds.

Racial and ethnic differences independent of socio-economic status are seen in end-of-life care in ICUs, reports the journal Chest (2011;139(5):1025-1033). Nonwhite patients are less likely to have living wills and more likely to die on full life support, to have a documented family conference where prognosis was discussed, and to have discord within the family or with the physician over treatment choices.

A phone survey of cancer patients found that black patients are more likely than white patients to spend everything they have on aggressive treatments that might prolong their lives, regardless of how sick they are, their income, savings, or age. In addition, the Dartmouth Atlas of Health's recent report "Trends and Variations in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness" (PDF) found persistent evidence of widespread geographical differences in end-of-life care. In the last six months of their lives, chronically ill Medicare beneficiaries in some regions of the country spent three times as many days in the hospital and 10 times as many days in the ICU as patients in other regions.

Another survey found PCPs are more likely to choose for themselves treatments with higher rates of death but lower rates of adverse events than they would recommend to their patients (Arch Int Med 2011;171:630-634).

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