What Explains Racial Differences in the Use of Advance Directives and Attitudes Toward Hospice Care?

TLDR

Cultural beliefs and values are believed to underlie racial differences in advance directive use and hospice attitudes, yet data clarifying which beliefs drive these disparities are scarce. A survey of 205 adults aged 65+ in Duke University Health System primary care used five validated scales—Hospice Beliefs and Attitudes, Preferences for Care, Spirituality, Healthcare System Distrust, and Beliefs About Dying and Advance Care Planning—to assess these factors. African Americans were less likely to have an advance directive and held less favorable hospice beliefs, expressed greater discomfort discussing death, preferred aggressive end‑of‑life care, had spiritual beliefs conflicting with palliative goals, and distrusted the healthcare system; multivariate analysis showed that when all these factors were combined, race no longer predicted either outcome, indicating that ethnicity reflects shared cultural beliefs that shape end‑of‑life decision‑making and informing culturally sensitive care models.

Abstract

Cultural beliefs and values are thought to account for differences between African Americans and whites in the use of advance directives and beliefs about hospice care, but few data clarify which beliefs and values explain these differences. Two hundred five adults aged 65 and older who received primary care in the Duke University Health System were surveyed. The survey included five scales: Hospice Beliefs and Attitudes, Preferences for Care, Spirituality, Healthcare System Distrust, and Beliefs About Dying and Advance Care Planning. African Americans were less likely than white subjects to have completed an advance directive (35.5% vs 67.4%, P<.001) and had less favorable beliefs about hospice care (Hospice Beliefs and Attitudes Scale score, P<.001). African Americans were more likely to express discomfort discussing death, want aggressive care at the end of life, have spiritual beliefs that conflict with the goals of palliative care, and distrust the healthcare system. In multivariate analyses, none of these factors alone completely explained racial differences in possession of an advance directive or beliefs about hospice care, but when all of these factors were combined, race was no longer a significant predictor of either of the two outcomes. These findings suggest that ethnicity is a marker of common cultural beliefs and values that, in combination, influence decision-making at the end of life. This study has implications for the design of healthcare delivery models and programs that provide culturally sensitive end-of-life care to a growing population of ethnically diverse older adults.