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Blacks, Hispanics have steeper end-of-life costs

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March 9, 2009

Striking new research shows dying blacks and Hispanics have much steeper treatment costs than whites, sobering evidence that racial health-care differences continue right up until death.

It’s not that minorities are being charged more than whites. It’s that they tend to get more costly, intensive treatments including feeding tubes and other invasive medical procedures near death. That’s in sharp contrast with what often happens throughout their lives, when minorities are less likely than whites to get aggressive medical care.

The results raise a troubling question about whether medical resources for nonwhite patients are “misallocated over a lifetime,” with minorities receiving more treatment at the end, when there is little chance of improving or extending life, the study authors said.

The study appears in Monday’s Archives of Internal Medicine. It involved nearly 160,000 Medicare patients and records on their treatment in the last six months of life. It is the most comprehensive on the topic and confirms results suggested in smaller studies on disparities in end-of-life care, said co-author Dr. Ezekiel Emanuel, a researcher in the bioethics department at the National Institutes of Health.

Medicare costs in those final months averaged $20,166 for whites. Among blacks, they were $26,704, about 30 percent higher; and among Hispanics, $31,702 or almost 60 percent higher. Those individual cost differences can add up to billions of dollars on a national scale, Emanuel said.

Reasons why minorities receive more costly end-of-life care are unclear; the study had no data to explain that. But Emanuel and other doctors offered several theories.

“Some of it may be preference. Some of it may be fear-based,” Emanuel said.

Distrust of doctors and suspicions about getting less attentive treatment than whites likely is another factor, the study authors said.

Also, because of cultural or spiritual beliefs, some minorities are more likely to hold out hope for a miraculous recovery, or to oppose letting doctors play God and hasten death by abandoning treatment, said Dr. Elbert Huang, a Chinese-American physician with the University of Chicago Medical Center.

Letting doctors withdraw aggressive end-of-life treatment is mostly a western European approach, Huang said.

In a smaller, earlier study of healthy elderly patients in Rochester, N.Y., Dr. William Bayer said he found blacks were more likely than whites to say they would favor aggressive treatment even after brain death.

Blacks in that study tended to believe that “if God wants to take our lives, he will decide when and where that will happen,” said Bayer, of the University of Rochester Medical Center.

Dr. Otis Brawley, a black physician in Atlanta and chief medical officer for the American Cancer Society, said the new findings “make sense.”

“They play into all of my prejudices and they play into all of my personal experiences,” Brawley said.

He said other reasons contribute to the phenomenon.

Because low-income minority patients often get less preventive medical care, they’re less likely than whites to have long-term relationships with doctors, Brawley said. So physicians who treat them late in life may be strangers unwilling to “pull the plug” without knowing their wishes.

Also, Brawley said, black patients often have splintered families, and estranged relatives are in charge of making end-of-life decisions.

“They feel guilt about saying, ‘let this patient die,’” he said.

“The breakdown of the family in certain cultures contributes somewhat to this phenomenon,” he said. “I’ve seen it so many times.”



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Professor Vernellia R. Randall
Institute on Race, Health Care and the Law
The University of Dayton School of Law
300 College Park 
Dayton, OH 45469-2772
Email: randall@udayton.edu


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