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：种族和心理社会影响”[“应对癌症”（CwC）]研究的结果表明，与白色相比，黑人癌症患者在生命末期（EOL）接受了更密集、更昂贵的非治疗性护理（例如，更高的ICU停留率、通气率和复苏率）。我们发现，重症监护并不能延长生命，但确实会损害生活质量。CwC的结果还显示，与白色相比，黑人晚期癌症患者不太可能认为自己患上了绝症，更可能喜欢延长生命的治疗，也不太可能参与预先的护理计划。在完整的CwC样本中，与医生进行的EOL讨论与患者对绝症的接受程度更高、对舒适护理的偏好高于生命延长、更少的生命延长程序、更多的姑息治疗以及接受符合患者意愿的护理相关。然而，在黑人CwC患者中，EOL讨论与更大程度地接受终末期疾病、接受EOL护理或符合患者意愿的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因患者是黑人还是白色而不同，以及这些差异如何导致EOL护理的差异。对于此次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，肿瘤学提供者的预后披露）根据患者是黑人还是白色而变化。它假定沟通过程对沟通目标实现的影响（例如，对疾病的接受度）将比白色患者更弱。同样，它假定沟通目标对EOL结果的影响（即，接受的重症/姑息治疗、接受与患者偏好一致的治疗以及生活质量）在黑人患者中比在白色患者中弱。我们计划入组400例预期寿命不到6个月的晚期癌症患者（200例黑人和200例白色患者）。将从波士顿（MA）、达拉斯（TX）和里士满（VA）的研究中心招募患者及其主要家庭/朋友护理者。基线时，入组患者将完成简短的临床前访视调查。门诊访视将进行录音，访视后将采访患者、护理人员和患者的主要肿瘤学提供者。患者将在一个月后的诊所访视前后接受采访。该诊所的访问也将被录音。生命最后一个月接受的医疗护理将通过图表提取进行记录。在基线时接受访谈的护理人员将在失去后一个月接受访谈，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，以减少在终末期护理和改善所有癌症患者的生活质量的黑白差距。

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.