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J Clin Oncol. Sep 1, 2008; 26(25): 4131–4137.
PMCID: PMC2654372
Racial and Ethnic Differences in Advance Care Planning Among Patients With Cancer: Impact of Terminal Illness Acknowledgment, Religiousness, and Treatment Preferences
Alexander K. Smith, Ellen P. McCarthy, Elizabeth Paulk, Tracy A. Balboni, Paul K. Maciejewski, Susan D. Block, and Holly G. Prigerson
From the Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center; Division of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute; Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital; and Department of Psychiatry, Brigham and Women's Hospital, Boston, MA; Palliative Care Service, University of Texas, Southwestern Medical Center, Dallas, TX; and Department of Psychiatry, Womens’ Health Research and Magnetic Resonance Research Center, Yale University School of Medicine, New Haven, CT
Corresponding author: Alexander K. Smith, MD, MS, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 1309 Beacon St, Brookline, MA 02446; e-mail: asmith7/at/bidmc.harvard.edu
Received October 9, 2007; Accepted May 2, 2008.
Purpose
Despite well-documented racial and ethnic differences in advance care planning (ACP), we know little about why these differences exist. This study tested proposed mediators of racial/ethnic differences in ACP.
Patients and Methods
We studied 312 non-Hispanic white, 83 non-Hispanic black, and 73 Hispanic patients with advanced cancer in the Coping with Cancer study, a federally funded multisite prospective cohort study designed to examine racial/ethnic disparities in ACP and end-of-life care. We assessed the impact of terminal illness acknowledgment, religiousness, and treatment preferences on racial/ethnic differences in ACP.
Results
Compared with white patients, black and Hispanic patients were less likely to have an ACP (white patients, 80%; black patients, 47%; Hispanic patients, 47%) and more likely to want life-prolonging care even if he or she had only a few days left to live (white patients, 14%; black patients, 45%; Hispanic patients, 34%) and to consider religion very important (white patients, 44%; black patients, 88%; Hispanic patients, 73%; all P < .001, comparison of black or Hispanic patients with white patients). Hispanic patients were less likely and black patients marginally less likely to acknowledge their terminally ill status (white patients, 39% v Hispanic patients, 11%; P < .001; white v black patients, 27%; P = .05). Racial/ethnic differences in ACP persisted after adjustment for clinical and demographic factors, terminal illness acknowledgment, religiousness, and treatment preferences (has ACP, black v white patients, adjusted relative risk, 0.64 [95% CI, 0.49 to 0.83]; Hispanic v white patients, 0.65 [95% CI, 0.47 to 0.89]).
Conclusion
Although black and Hispanic patients are less likely to consider themselves terminally ill and more likely to want intensive treatment, these factors did not explain observed disparities in ACP.
Culturally sensitive end-of-life (EOL) care is a national priority. The National Quality Forum and National Consensus Project for Quality Palliative Care both identify provision of culturally sensitive care as one of eight core domains of high-quality palliative care.1,2 Yet little information exists on the ways in which different sociocultural beliefs, expectations, and behaviors influence EOL care, and the absence of such information limits a clinician's ability to provide culturally sensitive care. In this context, an Institute of Medicine report called for more research to examine underlying causes of variation in attitudes and practices toward EOL care across racial and ethnic groups.3
Advance care planning (ACP) is the process by which patients, in conjunction with their physicians and loved ones, establish goals and preferences for future care and codify these preferences in written documents such as a living will, durable power of attorney for health care decision making (health care proxy), or Do-Not-Resuscitate (DNR) order.4,5 Despite well-documented racial and ethnic differences in ACP,6-13 we know little about why these differences exist. Previous research suggest that differences in acknowledgment of terminal illness, religiousness, and treatment preferences are important in ACP, but none of these studies has evaluated the influence of these factors on racial/ethnic differences in ACP.14-20 Formal evaluation of these proposed mediators is important because finding a significant mediator could provide a starting point for a targeted intervention to reduce racial/ethnic differences in ACP, whereas finding a lack of mediation would encourage researchers to search for other potential mediating factors.
The Coping with Cancer study is a National Cancer Institute–funded, multisite, longitudinal investigation that was designed to fill these gaps in research on racial/ethnic disparities in EOL care. The present report uses data from the Coping with Cancer study to examine the impact of terminal illness acknowledgment, religiousness, and treatment preferences on racial/ethnic variation in ACP.
Sample
Patients were recruited from February 8, 2002, through December 20, 2006, as part of the Coping with Cancer study, a multi-institutional study of patients with advanced cancer and their primary caregivers. Participating sites include the Dana-Farber Cancer Institute/Harvard Cancer Center (Boston, MA), Yale Cancer Center (New Haven, CT), Veterans’ Affairs Connecticut Healthcare System Comprehensive Cancer Clinics (West Haven, CT), Memorial Sloan-Kettering Cancer Center (New York, NY), Simmons Comprehensive Cancer Care Center (Dallas, TX), Parkland Hospital Palliative Care Service (Dallas, TX), and New Hampshire Oncology and Hematology (South-Central NH).
Inclusion criteria were diagnosis of advanced cancer (clinician's estimate that the patient would live < 6 months and failure of first-line chemotherapy); age ≥ 20 years; having an unpaid caregiver; and adequate stamina to complete the interview. Patient-caregiver dyads in which either met criteria for dementia or delirium (by neurobehavioral cognitive status examination21) or could not speak English or Spanish were excluded. Potentially eligible patients were identified by clinicians. Interviews were conducted between February 2002 and December 2006 at a location chosen by the patient. All study participants provided written informed consent according to protocols approved by each institutional review board.
Of 928 eligible patients, 654 enrolled. Reasons for nonparticipation were “not interested” (n = 120), “caregiver refuses” (n = 36), “too upset” (n = 27), and other reasons (n = 91). Of participants, 593 self-identified as white, black, or Hispanic. Hispanic patients were more likely to participate than white or black patients (83% v 67% v 64%, respectively; overall P = .007). Nonparticipants were similar to participants in age, sex, and high school graduation status. On a 5-point rating of current distress (1 = “minimal, nonexistent,” 5 = “distraught”), nonparticipants reported higher ratings of distress than participants (3.8 v 2.5, respectively; P ≤ .001). Our analyses included the 449 white, black, and Hispanic patients with complete data on ACP, terminal illness acknowledgment, religion, and treatment preferences.
Measures
After informed consent was obtained, patients participated in a baseline interview ($25 compensation). Interviews were conducted by trained research staff in either English (91%) or Spanish (9%). Patient's race/ethnicity was self-reported as non-Hispanic white, non-Hispanic black, and Hispanic (hereafter referred to as white, black, and Hispanic for brevity). Our primary outcome variable was the presence of an ACP, defined as patient's report of one or more of the following: living will or durable power of attorney for health care decision making (health care proxy), completed DNR order, or having discussed wishes for EOL care with their physician. Measures assessing the potential mediators of terminal illness acknowledgment, religiousness, and treatment preferences were drawn from other studies.22,23 Terminal illness acknowledgment was assessed using the question, “How would you describe your current health status?” Participants selecting the response “seriously and terminally ill” were compared with those selecting “relatively healthy” or “seriously but not terminally ill.” Importance of religion (religiousness) was assessed using the question, “How important is religion to you?” Potential responses were “very important,” “somewhat important,” and “not important.” Treatment preferences for EOL care were assessed with the question, “Would you want the doctors here to do everything to keep you alive even if you were going to die in a few days anyway?” We considered those who responded “yes” as preferring life-prolonging care. Because terminal illness acknowledgment and preferences for life-prolonging treatment may be influenced by their understanding of their prognosis, we explored participants’ preference for prognostic disclosure using the question, “If your doctor knew how long you had left to live, would you want him or her to tell you?”
Other patient-reported characteristics included age (continuous), sex, marital status (married v not married), education (less than high school diploma v high school diploma or higher), insurance status, and native language. Type of cancer and Zubrod performance score were obtained from chart review (range, 0 [asymptomatic] to 4 [100% bedridden]). Participating sites were grouped by region (Southwestern and Northeastern) rather than by individual sites because not all sites had sufficiently large sample sizes to permit comparisons by site.
Statistical Analysis
Baseline demographic factors, ACP, terminal illness acknowledgment, religiousness, and treatment preferences were compared by race/ethnicity (white race as reference group) using student's t test for age and Fisher's exact test for all other variables. We used the method of Barron and Kenny to assess for mediation.24 In this method, after determining that the factor of interest (race/ethnicity) is associated with the outcome (ACP) and the potential mediator (terminal illness acknowledgment, religiousness, or treatment preferences), the potential mediator is then regressed on the outcome. If the potential mediator is significantly associated with the outcome, then a final model is fit to examine the association between race/ethnicity and the outcome after adjusting for the potentially mediating factor. Mediation holds if we find that no racial/ethnic differences in ACP after adjusting for the potential mediator. By comparing the estimated effect of race/ethnicity in models with and without the mediating factor, we examined the relative contribution of each mediating factor to racial/ethnic differences in ACP. All models adjusted for age, sex, education, health insurance status, geographic region, cancer diagnosis, and Zubrod performance score. These variables were selected for inclusion because they were shown to be clinically relevant to EOL care in other studies.18,25-29
Because many of these outcomes were common (> 10%), and in such cases the odds ratio may deviate substantially from the relative risk, we derived relative risks using a modified Poisson approach as recommended by Spiegelman, McNut, and Zou.30-32 We examined multiple outcomes and wanted to adjust the critical value. Recognizing that these outcomes are not strictly independent, we considered a two-sided P value of ≤ .01 to be statistically significant. All analyses were performed using SAS version 9.1 (SAS Institute, Cary, NC).
Sample Characteristics
Characteristics of the 449 participants are listed in Table 1. Black and Hispanic participants tended to be younger than white participants, were more likely to come from a Southwestern site, and were less likely to have a high school diploma or health insurance.
Table 1.
Table 1.
Characteristics of Sample Patients (n = 449)*
Table 2 lists bivariable associations of race/ethnicity with ACP and each potential mediator (terminal illness acknowledgment, religiousness, and treatment preferences). In unadjusted analysis, black and Hispanic patients were less likely than white patients to have an advance directive or durable power of attorney for health care or to have a DNR order. Overall, 29% of patients discussed plans for EOL care with their physician, which did not differ by race/ethnicity. Compared with white patients, both black and Hispanic patients were less likely to want to be told their prognosis by a physician (black patients, 58% v white patients, 77%, P = .001; Hispanic patients, 61% v white patients, P = .01).
Table 2.
Table 2.
Unadjusted Racial/Ethnic Differences in Advance Care Planning, Terminal Illness Acknowledgment, Religiousness, and Treatment Preferences (n = 449)*
Racial/ethnic differences in terminal illness acknowledgment and preference for life-prolonging treatment persisted after adjustment for age, sex, marital status, education, health insurance status, geographic region, type of cancer, and Zubrod performance score. Compared with white participants, black and Hispanic participants were less likely to acknowledge they were terminally ill (adjusted relative risk [aRR], black v white patients, 0.56 [95% CI, 0.36 to 0.86]; Hispanic v white patients, 0.24 [95% CI, 0.10 to 0.54]) and more likely to prefer life-prolonging care, although differences between white and Hispanic patients were not significant (aRR, black v white patients, 3.24 [95% CI, 2.05 to 5.12]; Hispanic v white patients, 1.95 [95% CI, 0.95 to 4.03]). Differences in religiousness persisted after adjustment for black patients compared with white patients, but differences for Hispanic patients compared with white patients were no longer statistically significant (aRR, religion considered “very important” v other responses, black v white patients, 1.65 [95% CI, 1.35 to 2.01]; Hispanic v white patients, 1.12 [95% CI, 0.82 to 1.52]).
We examined the relationship between ACP and each mediator. After adjustment, participants who acknowledge their terminal illness status were 26% more likely to have an ACP as those who did not (aRR, 1.26; 95% CI, 1.12 to 1.41). No difference in ACP was observed between participants reporting that religion was very important and those reporting that religion was somewhat important to them (aRR, 1.04; 95% CI, 0.90 to 1.21), but those who reported religion was not important were 23% more likely than those reporting religion was very important to have an ACP (aRR, 1.23; 95% CI, 1.04 to 1.44). Participants who preferred life-prolonging treatment even if they only had a few days to live were 23% less likely to have an ACP than those who did not prefer life-prolonging treatment (aRR, 0.77; 95% CI, 0.62 to 0.92).
Table 3 lists unadjusted and adjusted associations of race/ethnicity, confounders, and potential mediators with ACP. Table 4 lists adjusted associations of race/ethnicity with ACP in models with and without each potential mediator. In the base model, adjusted for known confounders, black patients were 41% and Hispanic patients 40% less likely than white patients to have an ACP (aRR, black v white patients, 0.59 [95% CI, 0.46 to 0.77]; Hispanic v white patients, 0.60 [95% CI, 0.45 to 0.82]). Further adjustment for terminal illness acknowledgment had a modest impact on the aRR (black v white patients, 0.61 [95% CI, 0.47 to 0.79]; Hispanic v white patients, 0.63 [95% CI, 0.47 to 0.86]). Similar reductions in aRR were observed for the other two mediators examined (religiousness and treatment preferences). None of the mediators examined met criteria for mediation. Examining a model with all three potential mediators included simultaneously similarly demonstrated modest impact on racial and ethnic differences in ACP (Table 3).
Table 3.
Table 3.
Bivariable and Multivariable Models of Advance Care Planning (n = 426)*
Table 4.
Table 4.
Multivariable Models of Racial/Ethnic Differences in Advance Care Planning Adjusted for Individual Potential Mediators (n = 426)*
Although we found important racial and ethnic differences in terminal illness acknowledgment, religiousness, and treatment preferences among patients with advanced cancer, none of these factors accounted for observed racial and ethnic differences in ACP. We found that black patients were nearly half and Hispanic patients nearly one quarter as likely as white patients to acknowledge their illness was terminal, black patients were nearly 70% more likely to consider religion very important, and black patients were three and Hispanic patients two times more likely than white patients to prefer life-prolonging care. Compared with white patients, black and Hispanic patients were 40% less likely to have an ACP. Yet this study was negative: these differences in ACP were not impacted by proposed mediators.
Previous research suggests that patients who acknowledge their terminal prognosis experience less aggressive EOL care than those who do not.33 We found that black and Hispanic patients were significantly less likely to acknowledge their terminal illness status or to want a physician to disclose their prognosis as compared with white patients. Yet terminal illness acknowledgment had no appreciable impact on racial/ethnic differences in ACP. Evidently, although racial/ethnic disparities in terminal illness acknowledgment and ACP exist, the lower rates of ACP by the minority patient groups cannot be explained by differences in understanding of life expectancy. Taken together, these findings suggest that efforts to improve ACP by informing patients of their terminal prognosis may not be sensitive to racial/ethnic differences in preferences for prognostic disclosure and acknowledgment.
Religious views within the African American community of the value or sanctity of life have been suggested as explanatory factors for differences in attitudes toward EOL care.20,34,35 Nevertheless, we did not find support for religiousness as a mediator of racial/ethnic differences in ACP. Several possible explanations exist. Our measure of religiousness was based on a single question and may not have captured differences in particular religious beliefs and values between black, Hispanic, and white participants, such as a belief in miracles, that God's power supersedes that of physicians, or that suffering is to be endured as part of a spiritual commitment.20,35-37 This measure also had only three possible response categories ranging from not at all important to very important and may have lacked sufficient variation or power to detect a difference. Therefore, future studies are warranted to confirm our findings with regard to religiousness.
A greater preference for life-sustaining treatment among African American and Hispanic patients compared with white patients has been described previously,7,8,28,38-41 although to our knowledge, this is the first study to describe differences between Hispanic and white patients with advanced cancer. We were surprised to find that treatment preferences had no appreciable impact on the observed racial and ethnic differences in ACP. These findings suggest that although important racial/ethnic differences in treatment preferences exist, they are unlikely to be major explanatory factors in racial/ethnic differences in ACP.
Several limitations should be considered when interpreting these results. Most importantly, the number of black and Hispanic patients enrolled was low (83 black and 73 Hispanic participants), and the overwhelming majority of black and Hispanic patients were recruited from Texas. The extent to which these findings generalize to other areas of the country is unclear and requires further exploration in future studies. Furthermore, as mentioned previously, our measure of religiousness was limited and may not reflect the multidimensional nature of this construct. However, use of other measures such as church attendance is also problematic, because church attendance may decrease in states of ill health.
Our overarching goal in conducting this research was to develop more culturally sensitive approaches to ACP. After establishing that racial/ethnic differences exist, searching for potential mediators is the next step in advancing the field. In light of our negative findings, future research is needed to evaluate the impact of other factors on racial/ethnic differences in ACP and EOL care. Recent scholarship has uncovered a number of other promising and potentially explanatory factors. First, several recent studies highlighted the importance of health literacy in establishing preferences for care and ACP. Volandes et al42 demonstrated that use of video images of advanced dementia improved older patients’ choices for dementia care, and in a randomized controlled trial, Sudore et al43 demonstrated the effectiveness and usefulness of an advance directive redesigned for a fifth-grade reading level. Second, mistrust is often discussed as a potential mediator of disparities.44,45 Interpersonal trust in the patient-physician relationship does not seem to mediate racial differences in ACP46; however, the impact of distrust in the health care system on racial/ethnic differences in ACP has not been examined. Third, of great concern, implicit or unconscious racial bias has been shown to influence physician treatment of patients in hypothetical scenarios.47 However, the degree to which implicit bias influences physician attitudes and communication around ACP and EOL care is unknown.
In conclusion, we found that although black and Hispanic patients were less likely to consider themselves terminally ill and were more likely to want intensive and potentially futile treatment, these factors did not mediate the observed disparities in ACP, suggesting the need to identify other factors to promote patient-centered, culturally appropriate EOL care among black and Hispanic patients with cancer.
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The author(s) indicated no potential conflicts of interest.
Conception and design: Alexander K. Smith, Ellen P. McCarthy, Elizabeth Paulk, Tracy A. Balboni, Paul K. Maciejewski, Susan D. Block, Holly G. Prigerson
Financial support: Holly G. Prigerson
Provision of study materials or patients: Elizabeth Paulk, Susan D. Block, Holly G. Prigerson
Collection and assembly of data: Alexander K. Smith, Elizabeth Paulk, Susan D. Block, Holly G. Prigerson
Data analysis and interpretation: Alexander K. Smith, Ellen P. McCarthy, Tracy A. Balboni, Paul K. Maciejewski, Holly G. Prigerson
Manuscript writing: Alexander K. Smith, Ellen P. McCarthy, Tracy A. Balboni, Susan D. Block, Holly G. Prigerson
Final approval of manuscript: Alexander K. Smith, Ellen P. McCarthy, Elizabeth Paulk, Tracy A. Balboni, Paul K. Maciejewski, Susan D. Block, Holly G. Prigerson
Notes
Supported by the National Institutes of Health Grants No. MH63892 and CA106370 (grants to the Coping with Cancer study) and by an institutional National Research Service Award (Grant No. 5 T32 HP11001-19 to A.K.S.).
Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.
1. A National Framework and Preferred Practices for Palliative and Hospice Care Quality: A Consensus Report. www.qualityforum.org.
2. National Consensus Project For Quality Palliative Care. www.nationalconsensusproject.org.
3. Payne R: Palliative care for African-Americans and other vulnerable populations: Access and quality issues, in Foley KM, Gleband H (eds): Improving Palliative Care for Cancer. Washington, DC, National Academies Press, 2001, pp 153-160.
4. Gillick MR: Advance care planning. N Engl J Med 350:7-8, 2004. [PubMed]
5. Tulsky JA: Beyond advance directives: Importance of communication skills at the end of life. JAMA 294:359-365, 2005. [PubMed]
6. Degenholtz HB, Arnold RA, Meisel A, et al: Persistence of racial disparities in advance care plan documents among nursing home residents. J Am Geriatr Soc 50:378-381, 2002. [PubMed]
7. Caralis PV, Davis B, Wright K, et al: The influence of ethnicity and race on attitudes toward advance directives, life-prolonging treatments, and euthanasia. J Clin Ethics 4:155-165, 1993. [PubMed]
8. Phipps E, True G, Harris D, et al: Approaching the end of life: Attitudes, preferences, and behaviors of African-American and white patients and their family caregivers. J Clin Oncol 21:549-554, 2003. [PubMed]
9. Hopp FP, Duffy SA: Racial variations in end-of-life care. J Am Geriatr Soc 48:658-663, 2000. [PubMed]
10. Shepardson LB, Gordon HS, Ibrahim SA, et al: Racial variation in the use of do-not-resuscitate orders. J Gen Intern Med 14:15-20, 1999. [PMC free article] [PubMed]
11. Welch LC, Teno JM, Mor V: End-of-life care in black and white: Race matters for medical care of dying patients and their families. J Am Geriatr Soc 53:1145-1153, 2005. [PubMed]
12. Eleazer GP, Hornung CA, Egbert CB, et al: The relationship between ethnicity and advance directives in a frail older population. J Am Geriatr Soc 44:938-943, 1996. [PubMed]
13. Morrison RS, Zayas LH, Mulvihill M, et al: Barriers to completion of health care proxies: An examination of ethnic differences. Arch Intern Med 158:2493-2497, 1998. [PubMed]
14. Bullock K: Promoting advance directives among African Americans: A faith-based model. J Palliat Med 9:183-195, 2006. [PubMed]
15. True G, Phipps EJ, Braitman LE, et al: Treatment preferences and advance care planning at end of life: The role of ethnicity and spiritual coping in cancer patients. Ann Behav Med 30:174-179, 2005. [PubMed]
16. Phipps EJ, True G, Murray GF: Community perspectives on advance care planning: Report from the Community Ethics Program. J Cult Divers 10:118-123, 2003. [PubMed]
17. Ray A, Block SD, Friedlander RJ, et al: Peaceful awareness in patients with advanced cancer. J Palliat Med 9:1359-1368, 2006. [PubMed]
18. Balboni TA, Vanderwerker LC, Block SD, et al: Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life. J Clin Oncol 25:555-560, 2007. [PMC free article] [PubMed]
19. Hauser JM, Kleefield SF, Brennan TA, et al: Minority populations and advance directives: Insights from a focus group methodology. Camb Q Healthc Ethics 6:58-71, 1997. [PubMed]
20. Johnson KS, Elbert-Avila KI, Tulsky JA: The influence of spiritual beliefs and practices on the treatment preferences of African Americans: A review of the literature. J Am Geriatr Soc 53:711-719, 2005. [PubMed]
21. Kiernan RJ, Mueller J, Langston JW, et al: The Neurobehavioral Cognitive Status Examination: A brief but quantitative approach to cognitive assessment. Ann Intern Med 107:481-485, 1987. [PubMed]
22. Prigerson HG: Socialization to dying: Social determinants of death acknowledgment and treatment among terminally ill geriatric patients. J Health Soc Behav 33:378-395, 1992. [PubMed]
23. Williams DR: Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research: A Report of the Fetzer Institute/National Institute on Aging Working Group. Kalamazoo, MI, Fetzer Institute, 2003.
24. Baron RM, Kenny DA: The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. J Pers Soc Psychol 51:1173-1182, 1986. [PubMed]
25. Wenger NS, Pearson ML, Desmond KA, et al: Epidemiology of do-not-resuscitate orders: Disparity by age, diagnosis, gender, race, and functional impairment. Arch Intern Med 155:2056-2062, 1995. [PubMed]
26. Virnig BA, Kind S, McBean M, et al: Geographic variation in hospice use prior to death. J Am Geriatr Soc 48:1117-1125, 2000. [PubMed]
27. Virnig BA, Marshall McBean A, Kind S, et al: Hospice use before death: Variability across cancer diagnoses. Med Care 40:73-78, 2002. [PubMed]
28. Phillips RS, Wenger NS, Teno J, et al: Choices of seriously ill patients about cardiopulmonary resuscitation: Correlates and outcomes—SUPPORT Investigators: Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Am J Med 100:128-137, 1996. [PubMed]
29. Gansler T, Henley SJ, Stein K, et al: Sociodemographic determinants of cancer treatment health literacy. Cancer 104:653-660, 2005. [PubMed]
30. Spiegelman D, Hertzmark E: Easy SAS calculations for risk or prevalence ratios and differences. Am J Epidemiol 162:199-200, 2005. [PubMed]
31. McNutt LA, Wu C, Xue X, et al: Estimating the relative risk in cohort studies and clinical trials of common outcomes. Am J Epidemiol 157:940-943, 2003. [PubMed]
32. Zou G: A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol 159:702-706, 2004. [PubMed]
33. Weeks JC, Cook EF, O'Day SJ, et al: Relationship between cancer patients’ predictions of prognosis and their treatment preferences. JAMA 279:1709-1714, 1998. [PubMed]
34. Krakauer EL, Crenner C, Fox K: Barriers to optimum end-of-life care for minority patients. J Am Geriatr Soc 50:182-190, 2002. [PubMed]
35. Crawley L, Payne R, Bolden J, et al: Palliative and end-of-life care in the African American community. JAMA 284:2518-2521, 2000. [PubMed]
36. Blackhall LJ, Frank G, Murphy ST, et al: Ethnicity and attitudes towards life sustaining technology. Soc Sci Med 48:1779-1789, 1999. [PubMed]
37. Klessig J: The effect of values and culture on life-support decisions. West J Med 157:316-322, 1992. [PMC free article] [PubMed]
38. Garrett JM, Harris RP, Norburn JK, et al: Life-sustaining treatments during terminal illness: Who wants what? J Gen Intern Med 8:361-368, 1993. [PubMed]
39. Gramelspacher GP, Zhou XH, Hanna MP, et al: Preferences of physicians and their patients for end-of-life care. J Gen Intern Med 12:346-351, 1997. [PMC free article] [PubMed]
40. O'Brien LA, Grisso JA, Maislin G, et al: Nursing home residents’ preferences for life-sustaining treatments. JAMA 274:1775-1779, 1995. [PubMed]
41. McKinley ED, Garrett JM, Evans AT, et al: Differences in end-of-life decision making among black and white ambulatory cancer patients. J Gen Intern Med 11:651-656, 1996. [PubMed]
42. Volandes AE, Lehmann LS, Cook EF, et al: Using video images of dementia in advance care planning. Arch Intern Med 167:828-833, 2007. [PubMed]
43. Sudore RL, Landefeld CS, Barnes DE, et al: An advance directive redesigned to meet the literacy level of most adults: A randomized trial. Patient Educ Couns 69:165-195, 2007. [PMC free article] [PubMed]
44. Corbie-Smith G, Ford CL: Distrust and poor self-reported health. Canaries in the coal mine? J Gen Intern Med 21:395-397, 2006. [PMC free article] [PubMed]
45. Dula A, Williams S: When race matters. Clin Geriatr Med 21:239-253, 2005. [PubMed]
46. Smith AK, Davis RB, Krakauer EL: Differences in the quality of the patient-physician relationship among terminally ill African-American and white patients: Impact on advance care planning and treatment preferences. J Gen Intern Med 22:1579-1582, 2007. [PMC free article] [PubMed]
47. Green AR, Carney DR, Pallin DJ, et al: Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med 22:1231-1238, 2007. [PMC free article] [PubMed]
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