title: End-of-life care in nursing home settings: do race or age matter?
abstract: OBJECTIVE
  One-quarter of all U.S. chronic-disease deaths occur in nursing homes, yet few studies examine palliative care quality in these settings. This study tests whether racial and/or age-based differences in end-of-life care exist in these institutional settings.
  
  
  METHODS
  We abstracted residents' charts (N = 1133) in 12 nursing homes. Researchers collected data on indicators of palliative care in two domains of care--advance care planning and pain management--and on residents' demographic and health status variables. Analyses tested for differences by race and age.
  
  
  RESULTS
  White residents were more likely than minorities to have DNR orders (69.5% vs. 37.3%), living wills (39% vs. 5%), and health care proxies (36.2% vs. 11.8%; p < .001 for each). Advance directives were highly and positively correlated with age. In-depth advance care planning discussions between residents, families, and health care providers were rare for all residents, irrespective of demographic characteristics. Nursing staff considered older residents to have milder and less frequent pain than younger residents. We found no disparities in pain management based on race.
  
  
  CONCLUSIONS
  To the extent that advance care planning improves care at the end of life, racial minorities in nursing homes are disadvantaged compared to their white fellow residents. Focusing on in-depth discussions of values and goals of care can improve palliative care for all residents and may help to ameliorate racial disparities in end-of-life care. Staff should consider residents of all ages as appropriate recipients of advance care planning efforts and should be cognizant of the fact that individuals of all ages can experience pain. Nursing homes may do a better job than other health care institutions in eliminating racial disparities in pain management.
authors.affiliation: UNC Project, Lilongwe, Malawi. kreynolds@unclilongwe.org.mw
authors.forename: Kimberly S
authors.initials: KS
authors.lastname: Reynolds
authors.forename: Laura C
authors.initials: LC
authors.lastname: Hanson
authors.forename: Martha
authors.initials: M
authors.lastname: Henderson
authors.forename: Karen E
authors.initials: KE
authors.lastname: Steinhauser
mesh_terms: D000328:Adult; D016223:Advance Directives / Q000208:ethnology; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002908:Chronic Disease; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008913:Minority Groups; D009657:North Carolina; D009735:Nursing Homes / Q000706:statistics & numerical data*; D059408:Pain Management; D010166:Palliative Care / Q000379:methods*; D044465:White People