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Physician perspectives on end-of-life care: Factors of race, specialty, and geography



Objectives: To describe physicians' end-of-life practices, perceptions regarding end-of-life care and characterize differences based upon physician specialty and demographic characteristics. To illuminate physicians' perceptions about differences among their African-American and Caucasian patients' preferences for end-of-life care.

Design and methods: Twenty-four African-American and 16 Caucasian physicians (N = 40) participated in an in-person interview including 23 primary care physicians, 7 cardiologists, and 10 oncologists. Twenty-four practices were in urban areas and 16 were in rural counties.

Results: Physicians perceived racial differences in preferences for end-of-life care between their Caucasian and African-American patients. Whereas oncologists and primary care physicians overwhelmingly reported having working relationships with hospice, only 57% of cardiologists reported having those contacts. African-American physicians were more likely than Caucasian physicians to perceive racial differences in their patients preferences for pain medication.

Significance of results: Demographic factors such as race of physician and patient may impact the provider's perspective on end-of-life care including processes of care and communication with patients.


Corresponding author

Corresponding author: Cindy L. Carter, Ph.D., Hollings Cancer Center, Medical University of South Carolina, 86 Jonathan Lucas Street, Charleston, SC 29425, USA. E-mail:


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American Medical Association (2004–2005). Physician Characteristics and Distribution in the U.S. Chicago: AMA Press, December 2004, 63, Table 3.1.
Ashton, C.M., Haidet, P., Paterniti, D.A., et al. (2003). Racial and ethnic disparities in the use of health services: Bias, preferences, or poor communication? Journal of General Internal Medicine, 18, 146152.
Auerbach, A.D., Hamel, M.B., Califf, R.M., et al. (2000). Patient characteristics associated with care by a cardiologist among adults hospitalized with severe congestive heart failure. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Journal of the American College of Cardiology, 36, 21192125.
Azoulay, E. & Pochard, F. (2003). Communication with family members of patients dying in the intensive care unit. Current Opinion in Critical Care, 9, 545550.
Bach, P.B., Cramer, L.D., Warren, J.L., et al. (1999). Racial differences in the treatment of early-stage lung cancer. New England Journal of Medicine, 341, 11981205.
Bach, P.B., Pham, H.H., Schrag, D., et al. (2004). Primary care physicians who treat blacks and whites. New England Journal of Medicine, 351, 575584.
Bach, P.B., Schrag, D., Brawley, O.W., et al. (2002). Survival of blacks and whites after a cancer diagnosis. Journal of the American Medical Association, 287, 21062113.
Basta, L.L. (2004). End-of-life medical treatment of older cardiac patients. American Journal of Geriatric Cardiology, 13, 313315.
Bertakis, K., Franks, P., & Azari, R. (2003). Effects of physician gender on patient satisfaction. Journal of the American Medical Women's Association, 58(2), 6975.
Blackhall, L.J., Murphy, S.T., Frank, G., et al. (1995). Ethnicity and attitudes toward patient autonomy. Journal of the American Medical Association, 274, 820825.
Borum, M.L., Lynn, J., & Zhong, Z. (2000). The effects of patient race on outcomes in seriously ill patients in SUPPORT: An overview of economic impact, medical intervention, and end-of-life decisions. Study to understand prognoses and preferences for outcomes and risks of treatments. Journal of the American Geriatrics Society, 48, S194198.
Burrs, F.A. (1995). The African American experience: Breaking the barriers to hospices. The Hospice Journal, 10, 1518.
Chan, B.T. & Austin, P.C. (2003). Patient, physician, and community factors affecting referrals to specialists in Ontario, Canada: A population-based, multi-level modeling approach. Medical Care, 41, 500511.
Cherny, N.I. & Catane, R. (2003). Attitudes of medical oncologists toward palliative care for patients with advanced and incurable cancer: Report on a survey by the European Society of Medical Oncology Taskforce on Palliative and Supportive Care. Cancer, 98, 25022510.
Christakis, N.A. & Iwashyna, T.J. (1998). Attitude and self-reported practice regarding prognostication in a national sample of internists. Archives of Internal Medicine, 158, 23892395.
Coppola, K.M., Ditto, P.H., Danks, J.H., et al. (2001). Accuracy of primary care and hospital-based physicians' predictions of elderly outpatients' treatment preferences with and without advance directives. Archives of Internal Medicine, 161, 431440.
Crawley, L., Payne, R., Bolden, J., et al. (2000). Palliative and end-of-life care in the African American community. JAMA, 284, 25182521.
Daaleman, T.P. & VandeCreek, L. (2000). Placing religion and spirituality in end-of-life care. JAMA, 284, 25142517.
David, A.S., Mary, R., Neil, S., et al. (2002). Deaths from heart failure in general practice: Implications for palliative care. Palliative Medicine, 16, 495498.
Degenholtz, H.B., Thomas, S.B., & Miller, M.J. (2003). Race and the intensive care unit: Disparities and preferences for end-of-life care. Critical Care Medicine, 31, S373378.
DesHarnais, S., Kurent, J., & Carter, R. (2005). Physician and patient concordance regarding discussions of preferences for end-of-life care: A pilot program in South Carolina. The Gerontologist, 45, 283.
Detmar, S.B., Muller, M.J., Wever, L.D., et al. (2001). The patient–physician relationship. Patient-physician communication during outpatient palliative treatment visits: An observational study. JAMA, 285, 13511357.
Diringer, M., Edwards, D., Aiyagari, V., et al. (2001). Factors associated with withdrawal of mechanical ventilation in a neurology/neurosurgery intensive care unit. Critical Care Medicine, 29, 17921797.
Ditto, P.H., Danks, J.H., Smucker, W.D., et al. (2001). Advance directives as acts of communication: A randomized controlled trial. Archives of Internal Medicine, 161, 421430.
Dowsett, S.M., Saul, J.L., Butow, P.N., et al. (2000). Communication styles in the cancer consultation: Preferences for a patient-centered approach. Psycho-oncology, 9, 147156.
Evans, R., Stone, D., & Elwyn, G. (2003). Organizing palliative care for rural populations: A systematic review of the evidence. Family Practice, 20, 304310.
Exley, C., Field, D., Jones, L., et al. (2005). Palliative care in the community for cancer and end-stage cardiorespiratory disease: The views of patients, caretakers and health care professionals. Palliative Medicine, 19, 7683.
Fallowfield, L., Jenkins, V., Farewell, V., et al. (2002). Efficacy of a Cancer Research UK communication skills training model for oncologists: A randomised controlled trial. Lancet, 359, 650656.
Ferrell, B.R., Virani, R., Grant, M., et al. (2005). Evaluation of the End-of-Life Nursing Education Consortium undergraduate faculty training program. Journal of Palliative Medicine, 8, 107114.
Fetters, M.D., Churchill, L., & Danis, M. (2001). Conflict resolution at the end of life. Critical Care Medicine, 29, 921925.
Flory, J., Xu-Young, Y., Gurol, I., et al. (2004). Place of death: U. S. trends since 1980. Health Affairs, 23, 194200.
Foley, K. & Gelband, H. (2001). The Institute of Medicine Report: Improving Palliative Care for Cancer. Washington, DC: National Academy Press.
Goldstein, N.E., Concato, J., Bradley, E.H., et al. (2005). Doctor-patient communication about prognosis: The influence of race and financial status. Journal of Palliative Medicine, 8, 9981004.
Goodlin, S.J., Hauptman, P.J., Arnold, R., et al. (2004). Consensus statement: Palliative and supportive care in advanced heart failure. Journal of Cardiac Failure, 10, 200209.
Gordon, A.K. (1996). Hospice and minorities: A national study of organizational access and practice. The Hospice Journal, 11, 4970.
Gornick, M.E. (2003). A decade of research on disparities in Medicare utilization: Lessons for the health and health care of vulnerable men. American Journal of Public Health, 93, 753759.
Gottlieb, S.H. (2003). Palliative care in heart failure. Advance Studies in Medicine, 3, 456463.
Greiner, K.A., Perera, S., & Ahluwalia, J.S. (2003). Hospice usage by minorities in the last year of life: Results from the National Mortality Followback Survey. Journal of the American Geriatrics Society, 51, 970978.
Gross, C.P., Vogel, E.W., Dhond, A.J., et al. (2003). Factors influencing physicians' reported use of anticoagulation therapy in nonvalvular atrial fibrillation: A cross-sectional survey. Clinical Therapeutics, 25, 17501764.
Haidet, P., Hamel, M.B., Davis, R.B., et al. (1998). Outcomes, preferences for resuscitation, and physician-patient communication among patients with metastatic colorectal cancer. SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatments. American Journal of Medicine, 105, 222229.
Hanratty, B., Hibbert, D., Mair, F., et al. (2002). Doctors' perceptions of palliative care for heart failure: Focus group study. British Medical Journal, 325, 581585.
Happ, M.B., Capezuti, E., Strumpf, N.E., et al. (2002). Advance care planning and end-of-life care for hospitalized nursing home residents. Journal of the American Geriatrics Society, 50, 829835.
Hart, A., Jr., Kohlwes, R.J., Deyo, R., et al. (2003). Hospice patients' attitudes regarding spiritual discussions with their doctors. The American Journal of Hospice & Palliative Care, 20, 135139.
Hauser, J., Kleefield, S., Brennan, T., et al. (1997). Minority populations and advance directives: Insights from a focus group methodology. Cambridge Quarterly of Healthcare Ethics, 6, 5871.
Hogan, C., Lunney, J., Gabel, J., et al. (2001). Medicare beneficiaries' costs of care in the last year of life. Health Affairs, 20, 188195.
Horne, G. & Payne, S. (2004). Removing the boundaries: Palliative care for patients with heart failure. Palliative Medicine, 18, 291296.
Hunt, R. & McCaul, K. (1998). Coverage of cancer patients by hospice services, South Australia, 1990 to 1993. Australian and New Zealand Journal of Public Health, 22, 4548.
Jenkins, C., LaPelle, N., Zapka, J., et al. (2005). End-of-life care and African Americans: Voices from the community. Journal of Palliative Medicine, 8(3), 585592.
Karim, K., Bailey, M., & Tunna, K. (2000). Nonwhite ethnicity and the provision of specialist palliative care services: Factors affecting doctors' referral patterns. Palliative Medicine, 14, 471478.
Kass-Bartelmes, B.L. & Hughes, R. (2004). Advance care planning: Preferences for care at the end of life. Journal of Pain & Palliative Care Pharmacotherapy, 18, 87109.
Levenson, J.W., McCarthy, E.P., Lynn, J., et al. (2000). The last six months of life for patients with congestive heart failure. Journal of the American Geriatrics Society, 48, S101109.
Lofmark, R., Nilstun, T., & Bolmsjo, I.A. (2005). From cure to palliation: Staff communication, documentation, and transfer of patient. Journal of Palliative Medicine, 8, 11051109.
Lunney, J.R., Foley, K.M., Smith, T.J., & Gelband, H. (eds.). (2003). Institute of Medicine: Describing death in America: What we need to know. National Research Council of the National Academies, Washington, DC: The National Academies Press.
Mebane, E.W., Oman, R.F., Kroonen, L.T., et al. (1999). The influence of physician race, age, and gender on physician attitudes toward advance care directives and preferences for end-of-life decision-making. Journal of the American Geriatrics Society, 47, 579591.
Mehta, N.J., Khan, I.A., Mehta, R.N., et al. (2001). End-of-life care-related publications in cardiology journals. American Journal of Cardiology, 88, 1460–1463, A1469.
National Center for Health Statistics (2003). Deaths and percentage of total deaths for the 10 leading causes of death by race. National Vital Statistics Report, 52, 9.
National Comprehensive Cancer Network (2004). Clinical practice guidelines in oncology.
National Hospice and Palliative Care Organization. (2000). NHPCO facts and figures 2000. Alexandria, VA.
Payne, R., Medina, E., & Hampton, J.W. (2003). Quality of life concerns in patients with breast cancer: Evidence for disparity of outcomes and experiences in pain management and palliative care among African-American women. Cancer, 97, 311317.
Preisser, J.S., Cohen, S.J., Wofford, J.L., et al. (1998). Physician and patient predictors of health maintenance visits. Archives of Family Medicine, 7, 346351.
Ramondetta, L.M. & Sills, D. (2004). Spirituality in gynecological oncology: A review. International Journal of Gynecological Cancer, 14, 183201.
Reese, D.J., Ahern, R.E., Nair, S., et al. (1999). Hospice access and use by African Americans: Addressing cultural and institutional barriers through participatory action research. Social Work, 44, 549559.
Roter, D., Hall, J., & Yutaka, A. (2003). Physician gender effects in medical communication. A meta-analytic review. JAMA, 288, 756764.
Selecky, P.A., Eliasson, C.A., Hall, R.I., et al. (2005). Palliative and end-of-life care for patients with cardiopulmonary diseases: American College of Chest Physicians position statement. Chest, 128, 35993610.
Smedley, B.D., Stith, A.Y., & Nelson, A.R. (eds.) (2002). Unequal Treatment—Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press.
Steinmetz, D., Walsh, M., Gabel, L.L., et al. (1993). Family physicians' involvement with dying patients and their families. Attitudes, difficulties, and strategies. Archives of Family Medicine, 2, 753760; discussion 761.
Stewart, M. (1996). Effective physician–patient communication and health outcomes: A review. Canadian Medical Association Journal, 152, 14231433.
Stjernsward, J., Colleau, S.M., & Ventafridda, V. (1996). The World Health Organization Cancer Pain and Palliative Care Program. Past, present, and future. Journal of Pain and Symptom Management, 12, 6572.
Teno, J.M., Weitzen, S., Fennell, M.L., et al. (2001). Dying trajectory in the last year of life: Does cancer trajectory fit other diseases? Journal of Palliative Medicine, 4, 457464.
Tucker, R. (1994). Patient self-determination act: An African American perspective. Cambridge Quarterly of Healthcare Ethics, 3 (3), 417419.
Tulsky, J. (2005). Interventions to enhance communication among patients, providers, and families. Journal of Palliative Medicine, 8, S95S102.
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Promotion, & National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health (2004). The health consequences of smoking: A report of the surgeon general.
van Ryn, M. & Burke, J. (2000). The effect of patient race and socio-economic status on physicians' perceptions of patients. Social Science & Medicine, 50, 813828.
von Gunten, C.F., Ferris, F.D., & Emanuel, L.L. (2000). The patient–physician relationship. Ensuring competency in end-of-life care: Communication and relational skills. JAMA, 284, 30513057.
von Gunten, C.F., Mullan, P.B., Harrity, S., et al. (2003). Residents from five training programs report improvements in knowledge, attitudes and skills after a rotation with a hospice program. Journal of Cancer Education, 18, 6872.
Wilson, I.B., Green, M.L., Goldman, L., et al. (1997). Is experience a good teacher? How interns and attending physicians understand patients' choices for end-of-life care. SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatments. Medical Decision Making, 17, 217227.
Wotton, K., Borbasi, S., & Redden, M. (2005). When all else has failed: Nurses' perception of factors influencing palliative care for patients with end-stage heart failure. Journal of Cardiovascular Nursing, 20, 1825.
Zapka, J., Hennessy, W., Carter, R., et al. (in press). End-of-life communication and hospital nurses: An educational pilot. Aging and Minority Health.


Physician perspectives on end-of-life care: Factors of race, specialty, and geography



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