Racial and Ethnic Differences in Preferences for End-of-Life Treatment

BACKGROUND  Studies using local samples suggest that racial minorities anticipate a greater preference for life-sustaining treatment when faced with a terminal illness. These studies are limited by size, representation, and insufficient exploration of sociocultural covariables. OBJECTIVE  To explore racial and ethnic differences in concerns and preferences for medical treatment at the end of life in a national sample, adjusting for sociocultural covariables. DESIGN  Dual-language (English/Spanish), mixed-mode (telephone/mail) survey. PARTICIPANTS  A total of 2,847 of 4,610 eligible community-dwelling Medicare beneficiaries age 65 or older on July 1, 2003 (62% response). MEASUREMENTS  Demographics, education, financial strain, health status, social networks, perceptions of health-care access, quality, and the effectiveness of mechanical ventilation (MV), and concerns and preferences for medical care in the event the respondent had a serious illness and less than 1 year to live. RESULTS  Respondents included 85% non-Hispanic whites, 4.6% Hispanics, 6.3% blacks, and 4.2% “other” race/ethnicity. More blacks (18%) and Hispanics (15%) than whites (8%) want to die in the hospital; more blacks (28%) and Hispanics (21.2%) than whites (15%) want life-prolonging drugs that make them feel worse all the time; fewer blacks (49%) and Hispanics (57%) than whites (74%) want potentially life-shortening palliative drugs, and more blacks (24%, 36%) and Hispanics (22%, 29%) than whites (13%, 21%) want MV for life extension of 1 week or 1 month, respectively. In multivariable analyses, sociodemographic variables, preference for specialists, and an overly optimistic belief in the effectiveness of MV explained some of the greater preferences for life-sustaining drugs and mechanical ventilation among non-whites. Black race remained an independent predictor of concern about receiving too much treatment [adjusted OR = 2.0 (1.5–2.7)], preference for dying in a hospital [AOR = 2.3 (1.6–3.2)], receiving life-prolonging drugs [1.9 (1.4–2.6)], MV for 1 week [2.3 (1.6–3.3)] or 1 month’s [2.1 (1.6–2.9)] life extension, and a preference not to take potentially life-shortening palliative drugs [0.4 (0.3–0.5)]. Hispanic ethnicity remained an independent predictor of preference for dying in the hospital [2.2 (1.3–4.0)] and against potentially life-shortening palliative drugs [0.5 (0.3–0.7)]. CONCLUSIONS  Greater preference for intensive treatment near the end of life among minority elders is not explained fully by confounding sociocultural variables. Still, most Medicare beneficiaries in all race/ethnic groups prefer not to die in the hospital, to receive life-prolonging drugs that make them feel worse all the time, or to receive MV. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users. Source of support: Funding was provided by the National Institute on Aging (NIA) grant P01 AG19783 and the Robert Wood Johnson Foundation 050488. Dr. Barnato was supported by NIA career-development grant K08 AG021921.