Palliative and End-of-Life Care in Nephrology

Moving From Observations to Interventions

Nwamaka D. Eneanya; Michael K. Paasche-Orlow; Angelo Volandes


Curr Opin Nephrol Hypertens. 2017;26(4):327-334. 

In This Article

Racial and Ethnic Disparities in Palliative and End-of-life Care

Black and Hispanic patients have a higher prevalence of CKD and ESRD compared to other racial-ethnic groups and often differ on their treatment and EOL preferences.[13,23,64] For instance, studies have shown that Blacks have lower dialysis knowledge, engage less in advance care planning and prefer more aggressive EOL care compared to White patients.[12–14,64,74] In one retrospective study of adult ESRD decedents in the United States, Black patients were less likely to discontinue dialysis and also less likely to have received hospice referrals compared to White patients.[12] These differences varied greatly across different geographical regions based on EOL expenditures – which could reflect variability in clinician and hospital practice patterns. However, other studies within and outside of nephrology have determined that racial and ethnic differences in patient culture, language, spirituality, patterns of communication and health literacy/knowledge also contribute to racial and ethnic disparities in advance care planning and EOL care preferences.[55,75–80] Despite these observations, racial and ethnic differences in EOL continue to occur. One recent study showed that racial-ethnic differences in the receipt of EOL intensive procedures [including cardiopulmonary resuscitation (CPR), invasive mechanical ventilation and so on] among ESRD patients on hemodialysis in the United States persisted between 2000 and 2012 with non-Hispanic Black and Hispanic patients receiving more EOL procedures compared to non-Hispanic White patients.[64]

Unfortunately, few interventional studies have focused on racial and ethnic differences among patients with advanced CKD and ESRD in order to decrease disparities in EOL care.[81–83] Song et al.[82] recently demonstrated that a communication intervention to improve advance care planning among maintenance dialysis patients had more of an impact on Black patients in terms of improved patient and surrogate congruence on goals of care, higher surrogate decision-making confidence and reduced surrogate bereavement depressive symptoms compared to Whites. The inclusion of higher proportions of minority racial and ethnic patients with advanced CKD and ESRD in research studies is paramount to understanding diverse perspectives and expectations regarding care at the EOL. In addition, future interventional methods that include peer mentors, faith-based organizations, community advisory boards and educational tools that are sensitive to health literacy may be highly impactful in helping marginalized populations access more palliative care resources.[67,79,83–85]