To the Editors:—Shrank et al.1 have published interesting data about culture-based preferences for end-of-life care discussions. The data suggest that Euroamericans (EAs) and African Americans (AAs) alike value patient autonomy, advance directives, and input from various health professionals. Further, EAs want only “closest” family members in on decision making, seek technical guidance, base decisions on quality of life, and trust health professionals. In contrast, AAs want family and friends in on decision making, seek spiritual guidance, base decisions on possible miracles and protecting life, and distrust health professionals.
Yet one comment by the authors surprises us: “… this is the first study to explore patient preferences (about) end-of-life discussions, with a focus on … cultural differences …” Actually, we have already published such data, even in this journal.2,3,4
Many of our data are corroborated by those of Shrank and colleagues. Like them, we found that EAs and AAs believe in patient choice, advance directives, and family participation in decisions. Both groups believe that advance directives improve the chances that patient choices will be honored, and want a particular family member as a proxy. Euroamericans tend to trust that health professionals honor patients' wishes and to refuse life support based on quality-of-life considerations (including functional outcome and hospitalization requirements for aggressive care). In contrast, AAs tend not to trust that health professionals honor patients' wishes and to request life support for as long as possible.2
But our data differ from those of Shrank and colleagues in important ways. Unlike them, we found that EAs prefer to talk about death beforehand; AAs do not.4 Euroamericans also tend to believe that they can control treatment and, thus, want to express their wishes to physicians. In contrast, AAs tend to believe that the health care system—not patients—controls treatment and, thus, hesitate to express their wishes to physicians.2 We also found important gender differences. Specifically, more women than men in both ethnic groups trust the health care system to empower patients and respect their wishes.3
Taken together, all four articles1,2,3,4 reveal general (but not necessarily uniform) preferences within ethnic groups and genders. Knowing these preferences gives health professionals a place to start end-of-life care discussions. Yet the greatest challenge is recognizing variation within groups and avoiding harmful stereotyping. We welcome future contributions by Shrank and colleagues and others to this important field.
REFERENCES
- 1.Shrank WH, Kutner JS, Richardson T, et al. Focus group findings about the influence of culture on communication preferences in end-of-life care. J Gen Intern Med. 2005;20:703–9. doi: 10.1111/j.1525-1497.2005.0151.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
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