Minority groups focusing on end-of-life care

NAACP joins the cause

Minorities are significantly less likely to receive appropriate analgesia for a number of painful conditions, although patient-physician strategies to overcome barriers to appropriate analgesia exist, says Stacie Pinderhughes, MD, assistant professor of geriatrics at the Mount Sinai School of Medicine in New York City.

"Literature suggests that physicians evaluate pain equally, whether you’re African-American, Hispanic, or white, but for some reason there appears to be differences in prescribing practices," Pinderhughes said during an address at an American Medical Association briefing on Feb. 21. "In a study examining undertreatment of pain in cancer patients, 65% of minority patients did not receive guideline-recommended analgesic prescriptions, compared with 50% of non-minority patients,"

Pinderhughes cited one study that examined African-American patients and non-Hispanic white patients who presented to the emergency room with fractures. African-American patients were 66% more likely to receive no pain medication for their fractures as compared to their white counterparts.

In another study of Hispanic and non-Hispanic white patients who presented to the emergency room with fractures, Hispanic patients were twice as likely to receive no analgesia as compared to their white counterparts, Pinderhughes said.

Pinderhughes says three types of factors can affect access to opioids for minority patients:

  • patient factors;
  • provider factors;
  • system factors.

Two examples of patient factors are fears of addiction and fears of judgment. "Will I become a drug addict?" or "Will my sister or daughter think I’m a drug addict?" are questions that patients have. There are also fears of not wanting to distract a physician from the primary problem. "If I’m an elderly African-American woman with cancer, I may not want to tell my doctor about my pain, because I may be fearful that my doctor will not focus on treating my cancer," Pinderhughes said.

Limited access to opioids in neighborhood pharmacies is yet another major patient factor for minorities, said Pinderhughes. In 2000, a study group led by Sean Morrison, MD, at the Mount Sinai School of Medicine in New York City, examined the percentage of pharmacies in that city’s neighborhoods that stocked adequate opioid pain medications. The group found that minorities living in predominantly minority neighborhoods were much less likely to have access to pain medications because the neighborhood pharmacies did not stock them.

While such pharmacy variability is considered a patient factor, Pinderhughes said it also can be considered a system factor. A negative personal experience with addiction in family members is another example of a patient factor that may affect willingness to request pain treatment.

Pinderhughes characterizes the medical community’s lack of education and discomfort associated with prescribing pain medications as "provider factors." Physicians have just recently started mandatory training in the principles of pain management, she said. "I graduated from medical school in 1994 and I didn’t get one class on the benefits of pain management," she said.

Today, medical schools teach physicians clinical competencies in pain management and palliative care. Still, Pinderhughes says some physicians may be reluctant to prescribe pain medications because they may not know how to prescribe them, or they may be uncomfortable with managing potential side effects.

"When a patient resists treatment for pain, the physician needs to understand and ask, What are your concerns about taking these pain medications? Are you fearful of addiction? Are you fearful that this means you’re giving up? Does this have something to do with valuing suffering or a valuation of stoicism?’" Pinderhughes said.

"It’s also important that we educate care providers that it’s beneficial and ethically correct to treat people’s pain. The harms associated with not treating pain include decreased function, poor quality of life, and increased morbidity. We also need more education about the effectiveness of good side effect management, and the extremely, extremely, extremely low risk of addiction."

The National Association for the Advancement of Colored People also has joined forces with end-of-life care advocates to improve care. Along with Last Acts, the nation’s largest campaign to improve care near the end of life, the NAACP hopes to reverse disturbing trends such as poor pain management. The move marks the first time the NAACP has put care for the dying on its agenda. It is also the most recent sign that end-of-life issues are of growing importance in minority health circles.

The NAACP’s decision to embrace end-of-life issues was approved under the leadership of chairman Julian Bond and president and CEO Kweisi Mfume, on the recommendation of the organization’s health committee. The chair of that committee, Rupert Richardson, said the NAACP will bring to end-of life issues its knowledge of advocacy on a range of health care issues spanning the life cycle from prenatal care through aging.

"Because of past experience in all facets of health care by people of color, we feel strongly that we can educate African-Americans not just to utilize services for end-of-life care, but also to know what to look for, what to demand, and how to access care at the end of life," Richardson said.

In addition to recognizing the need to improve end-of-life care among minority groups, Last Acts says the new standard of care for the dying is palliative care, an approach providing relief of pain and symptoms as well as emotional and spiritual support for the patient and family. While knowledge of palliative care is on the rise, research has shown that minorities and the poor receive less pain management, less hospice care, and fewer opportunities to die at home surrounded by loved ones.

"One of our campaign’s major goals is to bring more diverse groups in as partners," says Karen Kaplan, Last Acts national program director. "NAACP, with its long, successful history and wide recognition among African-Americans, can certainly help us communicate to minorities that good care is not only available, but that by definition it must respect patients’ ethnic, cultural, and spiritual backgrounds."

Among Last Acts’ other diverse partners are the Association of Black Cardiologists, the Intercultural Cancer Council, the National Black Women’s Health Project, the National Hispanic Council on Aging, and the National Indian Council on Aging. The campaign’s more than 860 partner organizations also include health professional groups such as the American Medical Association and the American Nurses Association, health advocacy groups such as the American Cancer Society and the Alzheimer’s Association, and many local hospitals, hospices, and grass-roots coalitions.