Understanding the role of ethnic status in Intensive Care Unit (ICU) deaths among advanced cancer patients

Abstract

6506 Background: Studies suggest Blacks receive less aggressive, curative care for cancer but more aggressive care at end of life (EOL). This study investigated possible socio-cultural mediators (e.g. patient preference) of the relationship between ethnic status and aggressive care at EOL, defined as risk of death in the ICU, among advanced cancer patients. Methods: Location of death was established for 292 self-reported, Black (N=61) or White (N=231), Stage IV cancer patients interviewed at baseline as part of the prospective, multi-institutional Coping with Cancer study. We tested for mediators of the relationship between ICU death and ethnicity, controlling for possible confounding factors (e.g. socioeconomic status). Results: Blacks were more likely to die in the ICU than Whites (odds ratio, OR=4.40; 95% confidence interval, CI 1.81–10.72). Age, but no other sociodemographic factor (e.g. education), proved a confounder, reducing the ethnicity odds ratio to 3.65 (CI 1.47–9.08). Full mediators included religiousness/spirituality (OR=2.38, CI 0.69–8.31) and patient preference for a care plan emphasizing life extension despite pain or discomfort (OR=2.30, CI 0.78–6.77), with the latter being the only significant variable in the final model (OR 1.48, CI 0.31–7.15). Other factors investigated, but not found to be significant, included health, mental health status, social support, doctor-patient relationship and communication, terminal illness acknowledgement, and advance care planning (e.g. do-not-resuscitate orders). Conclusions: The increased risk of ICU death among Black advanced cancer patients compared to Whites was mediated by a disproportionate preference for care that focused on life extension among Blacks. Future studies should investigate whether this is an informed preference and therefore a true ethnic difference in values. Other prevailing hypotheses (e.g. trust) were not supported by this study. No significant financial relationships to disclose.