Diversity Concerns in Advance Care Planning

To the Editor:

We salute recent efforts by Parischa and colleagues to improve communications in critical illness (1). This remains an area of healthcare disparity. Relative to non-Hispanic white individuals, end-of-life care of both Hispanic and African American individuals is significantly less likely to align with their preferences (2). Significant racial gaps in advance care planning persist even among populations with high healthcare literacy (3).

In this context, more extensive reporting on the identities of participating providers and decision makers would be enlightening. The authors correctly note the potential for implicit biases to have influenced serious illness conversation guide completion. However, it is also important to acknowledge a broader array of unresolved questions. Previous reports have noted that even where verbal content is similar, nonverbal communication can be markedly poorer with African American patients (4). Advance care directives may also paradoxically increase the emotional distress of African American caregivers, an effect opposite that observed in non-Hispanic white populations (5).

Discussions regarding end-of-life care invoke culture more strongly than most other domains of medicine. Ensuring that clinical tools are robust to use in diverse populations is an especially important task going forward.