Deprescribing. Deprescribing. Webinar #12 Webinar #1 Developing Cultural Competency. Addressing EOL Issues Jessica Visco, PharmD, CGP

Transcription

1 August 24, 2016 Webinar #12 Webinar #1 Developing Cultural Competency in Deprescribing Addressing EOL Issues Jessica Visco, PharmD, CGP SeniorPharmAssist Kimberly S. Johnson MD MHS Associate Professor of Medicine Division of Geriatrics Deprescribing Jessica Visco, PharmD, CGP SeniorPharmAssist

2 Disclosures No commercial support has influenced the planning of the educational objectives and content of the activity. Any commercial support will be used for events that are not CE related. There is no endorsement of any product by DUHS associated with the session. No influential financial relationships have been disclosed by planners or presenters which would influence the planning of the activity. If any arise, an announcement will be made at the beginning of the session. This program is supported by a Geriatric Workforce Enhancement Program (GWEP) grant (U1QHP28708) from the U.S. Bureau of Health Professions Health Resources and Services Administration (HRSA).

3 Objectives Describe disparities in health and healthcare that extend throughout the life course, including at the end of life Using African Americans as an example, describe cultural beliefs and preferences which may influence end-of-life care Discuss strategies for assessing and responding to cultural beliefs and preferences at the end of life

4 Older Adults are Becoming More Diverse

5 Why consider culture in EOL Care? Cultural differences influence health and healthcare throughout the continuum of illness Culture shapes the way that we make meaning of illness, suffering, and death Culture influences the experience of dying and EOLC decision-making. Culture is one of many influences Kagawa-Singer et al. JAMA 2001;286:

6 Everyone is in certain respects like all others, like some others, and like no others. -Clyde Kluckhohn und Henry Murray in»personality in Nature, Society and Culture«, 1953

7 Mrs. Jones 67 year old lady with metastatic cervical cancer Nausea, vomiting, abdominal pain small bowel obstruction due to peritoneal carcinomatosis Diagnosed 2 years prior; liver mets 10 months prior Enrolled in Phase II clinical trial; disease progression. Mrs. Jones refuses to discuss hospice with oncologist That s where they put you to die. 7

8 African Americans as an example? You ll be happy to know that race played no part in this decision. 8

9 Disparities in health and healthcare What is the reality for patients like Mrs. Jones?

10 Higher risk of Death

11 AFRICAN-AMERICAN HEALTH DISPARITIES 2X as likely to die of asthma 3X more likely to have ESRD 2X as likely to die from prostate cancer 2X as likely to die from cervical cancer 8X as likely to die from with HIV 40% more likely to die from CVA 30% more likely to die of CVD 40% more likely to die from breast cancer 60% more likely to have diabetes 11

12 Unequal Treatment Even when income, insurance, and access to care are similar, racial and ethnic minorities and are less likely to receive: Cardiac procedures Cancer treatments Pain medications HIV medications Kidney transplantation Diabetes care 12

13 Experience of Serious Illness and End-of-Life Care

14 Finding Good Pain Treatment Is Hard. If You re Not White, It s Even Harder. By ABBY GOODNOUGH AUG. 9, 2016

15 Disparities in Pain Management Outcome # of Studies Odds Ratio Rx for any analgesic ( ) Rx for opioids ( Rx for nonopioids ( ) Across settings, diagnoses, and age groups, Blacks are less likely than whites to have pain adequately assessed and treated. Meghani et al. Pain Medicine 2012;13: ; Green et al. Pain Medicine 1003;4: ; Morrison et al. NEJM; 342;

16 Lower rates of ACP Kaiser Family Foundation: Available at:

17 At Duke too Johnson et al. J Am Geriatr Soc 2008;56(10):1953-8

18 Lower Quality Communication Communication less informative, partnering, supportive Communication more challenging in racediscordant patient/family-clinician pairings More unmet needs for communication Patients are less likely to discuss preferences for care with providers Periyakoil VS et al. PLoS One 2015;10(4):e Cooper LA et al. Ann Intern Med 2003;139(11): Gordon HS et al. J Clin Oncol. 2006; 24(6):904-9 Welch et al. J Am Geriatr Soc 2005;53;

19 Communication Outcomes Less Favorable Even when end-of-life discussions occur: Less likely to receive preference concordant care Less likely to use hospice More likely to receive life-prolonging therapies DNR orders not associated with use of life-prolonging therapies Whites who preferred intensive EOL care, 3X more likely to receive it than blacks with same preferences Mack et al. Arch Intern Med 2010;170: Loggers et al. J Clin Oncol 2009;27:

20 More likely to spend time in hospital and ICU

21 Less Likely to use Hospice

22 Palliative Care Reduces Disparities Hospice Emotional Support Spiritual Support Communication Satisfaction Attention to Symptoms Less Aggressive Care/ Lower costs Palliative Care Pain/Pain Meds Other Symptoms ACP Hospice Referral Less Aggressive Care/ Lower costs Rhodes et al. J Pain Symptom Manage 2007; Sharma et al. J Clin Oncol 2015;33: Laguna J et al. J Am Geriatr Soc. 2014; 62: Smith et al. J Pain Symptom Manage 2015;49:397 Smith et al. J Pain Symptom Manage 2015;

23 ACP Improves EOL Care Higher rates of advance directive completion Increased likelihood patients receive care consistent with preferences Fewer hospitalizations/receipt of less intensive costly therapies Increased hospice use Higher ratings of satisfaction, communication, quality Caregivers of decedents who participated in ACP have less depression, anxiety, decisional conflict and stress Weathers E et al. Maturitas 91 (2016)

24 Differences in Knowledge, Beliefs and Attitudes

25 African Americans have less exposure to information about hospice 100% Whites Blacks Have you ever heard of hospice? 80% 60% 40% 33% 72% 48% 20% 19% 24% 0% 4% Never Heard A Little Heard A Lot OR = 2.24 [1.17, 4.27] Johnson et al, J Palliat Med 2009;12:

26 Race and Beliefs about Hospice 100% Whites Blacks P< % % Agree or Strongly Agree 60% 40% 50% 41% 28% 20% 21% 14% 10% 0% not as good as tx in hospital get no tx causes people to die before their time Johnson et al, J Palliat Med 2009;12:

27 African Americans have less favorable beliefs about hospice 100% 90% Whites Blacks P<.05 % Agree/ Strongly Agree) 80% 60% 40% 20% 76% 0% If I were dying, I would want hospice. Johnson et al, J Palliat Med 2009;12:

28 Does exposure to information about hospice matter? % with favorable response Never Heard of Hospice Heard A Little Heard a Lot 100% 80% 60% 71% 83% 64% 86% 81% 40% 45% 30% 40% 45% 20% 0% causes people to die before their time not as good as tx in hospital if dying, would want hospice P<

29 African Americans prefer more aggressive care even when prognosis is poor Mechanical ventilation for 1 week life extension 13% 24% Life-prolonging drugs that make you feel bad all the time 15% 28% Blacks Whites Die in the hospital 8% 18% 0% 10% 20% 30% 40% 50% Barnato et al. J Gen Intern Med 2009;24:

30 African Americans have less trust in the healthcare system 30

31 African Americans more often endorse spiritual beliefs which may seem to conflict with hospice philosophy of care Only God can decide life and death Religious prohibitions against limiting therapies Divine Intervention and Miracles Occur Doctor is God s Instrument Accepting that you are going to die means you have no faith God sometimes wants us to suffer while we are dying Pain and suffering is sometimes part of God s plan for my life Johnson et al. J Am Geriatr Soc 2008;56(10): Johnson et al. J Am Geriatr Soc 2005;53:

32 32 Why cross the cultural divide? Great Divide Over ¾ of African Americans would want if dying. Beliefs change with increase exposure to information. Many have preferences c/w a palliative approach to care. Hospice, palliative care improve, and ACP improve quality.

33 Cultural Competency the ability of providers and organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of patients

34 Cultural Competency Training Articles Showing Benefit Beach et al. Med Care 2005;43:

35 Assessing Cultural Influence Attitudes of patients and families about serious illness General Awareness about groups Specific Attitudes of patients you serve Truth telling, diagnosis, prognosis What would you like to know about your illness? What would you like to know about what is likely to happen based on our medical knowledge? What do you think is going on? (meaning of disease and illness) Kagawa-Singer et al. JAMA 2001;286:

36 Assessing Cultural Influence Beliefs General Awareness about groups Specific Beliefs of patient Is religion or spirituality important to you? What is important for us to know about your faith? How does you faith help you to deal with your illness? How does your faith help you to make decisions about your care? How can we support your faith? Be open to involvement of chaplains and community clergy/faith community Kagawa-Singer et al. JAMA 2001;286:

37 Attention to Spirituality Impacts Care

38 Assessing Cultural Influence Context General Awareness about groups Context specific to the patient Country of birth Language Previous experience with medical care Address issues of mistrust directly I wonder if it is hard for you to trust me because of XXX Kagawa-Singer et al. JAMA 2001;286:

39 Assessing Cultural Influence Communication Introduce Advance Care Planning Document beliefs and preferences even if no formal document completed Emphasize benefits to family Ask permission Would it be OK if we talked about Avoid medical or complex jargon Attention to health literacy Kagawa-Singer et al. JAMA 2001;286:

40 Desire for Comfort Care in Advanced Dementia Before Video After Video 100% 80% 81% 100% 87% 90% 90% 96% Desire for comfort care 60% 56% 40% 33% 20% 0% Race no longer a predictor of preferences when controlling for health literacy. Whites African Americans Low Health Literacy Adequate Health Literacy Volandes et al. J Palliat Med 2008;11:

41 Assessing Cultural Influence Communication Introduce Hospice and Palliative Care Emphasis on how the services may help patients meet their goals (staying at home, not suffering) Emphasis on quality of life (rather than death) Discuss how the services can help family too Acknowledge uncertainty (hospice graduates) Palliative care as a bridge ongoing life-prolonging care

42 Assessing Cultural Influence Decision-making style Is there anyone else I should talk to about your care? Who helps you to make decisions? Who will make decisions for you if you are unable to make decisions for yourself? Consider importance of family consensus in decisionmaking Consider importance of fictive kin Kagawa-Singer et al. JAMA 2001;286:

43 Assessing Cultural Influence Work to Create Diverse Teams URM clinicians more likely to care for medically underserved populations. Minority patients report better interpersonal care from clinicians of their own race/ethnicity. Non-English speaking patients report better interpersonal care, comprehension, adherence with a language-concordant practitioner Greater workforce diversity may lead to greater trust in healthcare or advocacy for underserved

44 African Americans in Healthcare % of Total Workforce U.S. Health Workforce Chartbook 2013

45 Assessing Cultural Influence Environment Where do you live? Who cares for you? Available resources to provide care Community-based organizations for support Attention to medical and nonmedical needs Kagawa-Singer et al. JAMA 2001;286:

46 Nonmedical Needs are Substantial National Study of Hospices (N=164) Boucher et al. J Palliat Med 2071;20:

47 Conclusions Culture may significantly impact decision-making at the end-of-life and the experience of care Some racial and ethnic minorities receive lower quality care throughout the life span, including at the end of life Attention to the diverse beliefs, preferences, needs, and experiences of older adults may increase quality of end-of-life care for patients and their families

48 Continuing Education Credits 1 hour of CE credit is being offered for this webinar. For the live webinar, to obtain the credit you must: Add your name to the chat box (to verify attendance) Complete the survey. The survey will open automatically at the end of the webinar and the link will be sent in a follow-up . If you did not register for this webinar and would like CE credit, contact gero@duke.edu