Researchers from Boston University and the Department of Bioethics of the National Institutes of Health have reported that African-American and Hispanic patients have higher end-of-life costs than White patients. The details of this study appeared in the March 9, 2009 issue of the Archives of Internal Medicine.[1]

End-of-life costs contribute significantly to the overall cost of healthcare in the United States. End-of-life costs are partially related to the intensity of terminal care. Some of the more costly treatments involve intensive-care hospital stays, gastrostomy tube feeding, and ventilator support. Helping patients and families cope with end-of-life palliative care is an important component of medicine, but very little is known about factors that affect choices to have intensive treatments or less intensive treatments at the end of life. However, recent research has addressed some of these issues.

For example, there has been a recent increase in the fraction of patients signing advanced directives and living wills in order to better provide end-of-life care. However, there are marked differences in populations signing advanced directives. In one study in cancer patients, less than half of African Americans and Hispanics signed advanced directives compared with 80% for the White population.[2] African-American and Hispanic patients were also more likely to want life-prolonging procedures even if this involved only a few more days of life. African-American and Hispanic patients were also more religious than White patients, which may have an impact end-of-life care decisions. The authors of this study concluded: “Although [African-American] and Hispanic patients are less likely to consider themselves terminally ill and more likely to want intensive treatment, these factors did not explain the observed disparities in advanced care planning.”

It is generally accepted that ethic minorities receive less medical care than Whites during their lifetime. However, little is known about end-of-life care in minority populations.

The current study sought to determine the end-of-life costs of White, African-American, and Hispanic patients with terminal cancer. These authors looked at a random sample of over 150,000 Medicare patients who had died in 2001. They found that in the last six months of life the costs for Whites averaged $20,166 compared with $26,704 for African Americans and $31,702 for Hispanics. They found that approximately half of the increased costs were due to differences in age, sex, cause of death, total morbidity burden, geography, socioeconomic, and hospice differences. By additional modeling they concluded that 85% of observed higher costs for non-Whites was due to greater-end-of life use of the intensive care unit and intensive procedures. For example, African Americans and Hispanics were twice as likely to have a feeding gastrostomy tube placed as comparable White patients. These authors concluded:  “At life’s end, [African-American] and Hispanic decedents have substantially higher costs than [W]hites. More than half of these cost differences are related to geographic, socio-demographic, and morbidity differences. Strikingly greater use of life-sustaining interventions accounts for most of the rest.”

Comments: This study suggests that half of the increased costs of end-of-life for African-American and Hispanic patients is possibly explained by sociodemographic and morbidity differences—for example, they may be sicker and suffer from prior lack of medical care. However, these authors also suggest that African-American and Hispanic patients receive more intensive end-of-life care than comparable White patients. This may partially be explained by the relatively low rate of advanced directives and lack of discussions about their illness in this minority population. As previously mentioned, religious coping may also increase the intensity of end-of-life care, and African Americans and Hispanics tend to be more religious than White patients. 

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