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

描述(申请人提供)：我们的“死亡质量：种族和心理社会影响”[“应对癌症”(CWC)]研究的结果表明，与白人相比，在生命末期(EOL)，癌症患者接受更密集、更昂贵的非根治性护理(例如，更高的ICU住院、通风和复苏比率)。我们发现，重症监护不会延长生命，但会损害生活质量。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是绝症患者，更有可能倾向于延长生命的治疗，也不太可能参与提前护理计划。在完整的《化学武器公约》样本中，与医生进行的EOL讨论与患者对绝症的接受度更高、更倾向于舒适护理而不是延长生命、较少的延长生命的程序、更多的姑息治疗以及接受与患者意愿一致的治疗有关。然而，在黑人CWC患者中，EOL讨论与更多地接受晚期疾病、接受EOL护理或与患者意愿一致的EOL护理无关。这就提出了一个问题，即肿瘤提供者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，以及这些差异如何导致EOL护理中的差异。对于此次CWC更新，我们应用健康传播的结构性影响模型来确定EOL传播过程(例如，肿瘤学提供者的预后披露)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)的影响会更弱。同样，它假设沟通目标对EOL结果的影响(即接受强化/姑息治疗、接受与患者偏好一致的治疗以及生活质量)将比白人患者弱。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名黑人患者和200名白人患者)。患者和他们的主要家人/朋友照顾者将从波士顿(MA)、达拉斯(TX)和里士满(VA)的地点招募。在基线时，入选的患者将完成一次简短的门诊前访问调查。这次诊所访问将被录音，患者、护理人员和患者的主要肿瘤学提供者将在访问后接受采访。患者将在就诊前和就诊后一个月接受采访。那次诊所访问也将被录音。在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。根据基线接受采访的照顾者将在失去一个月后接受采访，了解患者在最后一个月接受的医疗保健，以及患者在生命最后一周的心理和身体状况。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EOL护理中的黑人和白人差异，并提高所有癌症患者的生活质量。 公共卫生相关性：黑人相对于白人晚期癌症患者在生命末期(EOL)接受密集、非根治、负担沉重的护理的比例高得不成比例，已被认为是一个严重的公共卫生问题。这项研究将考察晚期癌症患者、护理人员和肿瘤提供者之间的EOL沟通如何在以下方面促成非黑即白的差异：a)接受晚期疾病，b)了解EOL治疗结果的风险/益处，c)提前护理计划，以及这些“沟通目标”如何影响患者接受以下方面的比率：a)强化、延长生命的护理b)姑息护理，c)与患者喜好一致的护理，以及d)患者在EOL的生活质量。结果将有助于制定干预措施，以促进EOL沟通的文化能力，以增强知情决策，提高患者的生活质量，并减少EOL护理方面的差异。

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. PUBLIC HEALTH RELEVANCE: The disproportionately high rates of intensive, non-curative, burdensome care received by black relative to white advanced cancer patients at the end of life (EOL) has been recognized as a serious public health concern. This study will examine how EOL communications between advanced cancer patients, caregivers, and oncology providers contribute to black-white differences in: a) acceptance of terminal illness, b) knowledge of risks/benefits EOL treatment outcomes, and c) advance care planning, and how these "communication goals" affect the rates at which patients receive: a) intensive, life-prolonging care b) palliative care, c) care consistent with patient preferences, and d) the patient's quality of life at the EOL. Results will inform the development of interventions to promote the cultural-competence of EOL communications to enhance informed decision-making, promote patient quality of life, and reduce disparities in EOL care.