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.”
