Black-White Differences in Advanced Cancer Communication, Acceptance, and Care

描述（由申请人提供）：我们的“死亡质量：种族和社会心理影响”[“应对癌症”（CwC）]研究的结果表明，与白人相比，在生命末期（EOL），黑人癌症患者接受了更密集、更昂贵的非治愈性护理（例如，ICU住院、通气和复苏的比例更高）。我们发现重症监护不能延长生命，反而会降低生活质量。CwC的结果还显示，与白人相比，黑人晚期癌症患者不太可能认为自己身患绝症，更倾向于延长生命的治疗，并且不太可能参与提前护理计划。在完整的CwC样本中，与医生讨论EOL与患者对绝症的接受程度更高、更倾向于舒适护理而不是延长生命、更少的延长生命程序、更多的姑息治疗以及接受符合患者意愿的护理有关。然而，在黑人CwC患者中，讨论EOL与接受绝症、接受EOL护理或符合患者意愿的EOL护理的程度无关。这就提出了这样一个问题：肿瘤医生和患者之间的沟通可能会因患者是黑人还是白人而有所不同，这些差异如何导致EOL护理的差异。对于CwC更新，我们应用健康沟通的结构影响模型来确定EOL沟通过程（例如，肿瘤提供者的预后披露）如何根据患者是黑人还是白人而变化。它认为，与白人患者相比，黑人患者的沟通过程对实现沟通目标（例如，接受疾病）的影响要弱一些。同样，它假设沟通目标对EOL结果的影响（即接受的强化/姑息治疗，接受符合患者偏好的护理和生活质量）在黑人患者中比白人患者弱。我们建议招募400名预期寿命小于6个月的晚期癌症患者（200名黑人和200名白人）。患者和他们的主要家庭/朋友照顾者将从波士顿（MA），达拉斯（TX）和里士满（VA）的网站招募。在基线，入组患者将完成一个简短的门诊前访问调查。门诊访问将被录音，并在访问后对患者，护理人员和患者的主要肿瘤提供者进行访谈。一个月后，患者将在就诊前后接受面谈。诊所的访问也会被录音。生命最后一个月接受的医疗护理将通过图表提取记录下来。在基线接受采访的护理人员将在失去亲人一个月后接受采访，了解患者在最后一个月接受的卫生保健以及患者在生命最后一周的精神和身体状况。结果将表明哪些沟通过程和沟通目标是有希望的干预目标，以减少黑人和白人在EOL护理中的差异，并改善所有癌症患者的生活质量。

DESCRIPTION (provided by applicant): Results from our "Quality of Death: Ethnic and Psychosocial Influences" ["Coping with Cancer" (CwC)] study demonstrate that at the end-of-life (EOL) black, compared with white, cancer patients receive more intensive, expensive, non-curative care (e.g., higher rates of ICU stays, ventilation, and resuscitation). We find that intensive care does not prolong life, but does impair quality of life. CwC results also reveal that black, compared to white, advanced cancer patients are less likely to consider themselves terminally ill, are more likely to prefer life-prolonging treatments, and are less likely to engage in advance care planning. In the full CwC sample, EOL discussions with physicians are associated with greater patient acceptance of terminal illness, a preference for comfort care over life-extension, fewer life-prolonging procedures, more palliative care, and receipt of care consistent with patient wishes. However, among black CwC patients, EOL discussions are not associated with greater acceptance of terminal illness, EOL care received, or EOL care consistent with patient wishes. This raises the question of how communication between oncology providers and patients may differ by whether the patient is black or white, and how these differences contribute to disparities in EOL care. For this CwC renewal, we apply the Structural Influence Model of Health Communication to determine how EOL communication processes (e.g., oncology provider's prognostic disclosure) vary depending on whether the patient is black or white. It posits that the effects of communication processes on the achievement of communication goals (e.g., acceptance of illness) will be weaker for black compared with white patients. Likewise, it posits that the effects of communication goals on EOL outcomes (i.e., intensive/palliative care received, receipt of care consistent with patient preferences, and quality of life) will be weaker in black compared with white patients. We propose to enroll 400 advanced cancer patients (200 black and 200 white patients) with a less than 6 month life-expectancy. Patients and their primary family/friend caregiver will be recruited from sites in Boston (MA), Dallas (TX), and Richmond (VA). At baseline, enrolled patients will complete a brief pre-clinic visit survey. The clinic visit will be audio-taped and patients, caregivers and the patient's primary oncology provider will be interviewed after the visit. Patients will be interviewed before and after their clinic visit one month later. That clinic visit will also be audio-taped. Medical care received in the last month of life will be documented via chart extraction. The caregiver interviewed at baseline will be interviewed one month post-loss about the health care the patient received in the final month and about the patient's mental and physical status in the last week of life. Results will indicate which communication processes and communication goals are promising targets for interventions to reduce black-white disparities in EOL care and improve quality of life for all cancer patients.