How does ethnicity affect presence of advance care planning in care records for individuals with advanced disease? A mixed-methods systematic review

Abstract

BackgroundAdvance care planning (ACP) is the process supporting individuals with life-limiting illness to make informed decisions about their future healthcare. Ethnic disparities in ACP have been widely highlighted, but interpretation is challenging due to methodological heterogeneity. This review aims to examine differences in the presence of documented ACP in individuals’ care records for people with advanced disease by ethnic group, and identify patient and clinician related factors contributing to this.MethodsMixed-methods systematic review. Keyword searches on six electronic databases were conducted (01/2000–04/2022). The primary outcome measure was statistically significant differences in the presence of ACP in patients’ care records by ethnicity: quantitative data was summarised and tabulated. The secondary outcome measures were patient and clinician-based factors affecting ACP. Data was analysed qualitatively through thematic analysis; themes were developed and presented in a narrative synthesis. Feedback on themes was gained from Patient and Public Involvement (PPI) representatives. Study quality was assessed through Joanna Briggs Institute Critical Appraisal tools and Gough’s Weight of Evidence.ResultsN=35papers were included in total; all had Medium/High Weight of Evidence. Fifteenpapers (comparing two or more ethnic groups) addressed the primary outcomemeasure. Twelve of the fifteen papers reported White patients had statisticallyhigher rates of formally documented ACP in their care records than patientsfrom other ethnic groups. There were no significant differences in the presenceof informal ACP between ethnic groups. Nineteen papers addressed the secondaryoutcome measure; thirteen discussed patient-based factors impacting ACPpresence with four key themes: poor awareness and understanding of ACP; financialconstraints; faith and religion; and family involvement. Eight papers discussedclinician-based factors with three key themes: poor clinician confidence aroundcultural values and ideals; exacerbation of institutional constraints; andpre-conceived ideas of patients’ wishes.ConclusionsThis review found differences in the presence of legal ACP across ethnic groups despite similar presence of informal end of life conversations. Factors including low clinician confidence to deliver culturally sensitive, individualised conversations around ACP, and patients reasons for not wishing to engage in ACP (including, faith, religion or family preferences) may begin to explain some documented differences.Trial registrationPROSPERO-CRD42022315252.