Racial/Ethnic Disparities in Nursing Home End-of-Life Care: A Systematic Review

Elsevier, Journal of the American Medical Directors Association, Volume 22, Issue 2, 2021, Pages 279-290.e1, ISSN 1525-8610
Authors: 
Leah V. Estrada, Mansi Agarwal, and Patricia W. Stone

Objective
Health disparities are pervasive in nursing homes (NHs), but disparities in NH end-of-life (EOL) care (ie, hospital transfers, place of death, hospice use, palliative care, advance care planning) have not been comprehensively synthesized. We aim to identify differences in NH EOL care for racial/ethnic minority residents.

Design
A systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and registered in PROSPERO (CRD42020181792).

Setting and Participants
Older NH residents who were terminally ill or approaching the EOL, including racial/ethnic minority NH residents.

Methods
Three electronic databases were searched from 2010 to May 2020. Quality was assessed using the Newcastle-Ottawa Scale.

Results
Eighteen articles were included, most (n = 16) were good quality and most (n = 15) used data through 2010. Studies varied in definitions and grouping of racial/ethnic minority residents. Four outcomes were identified: advance care planning (n = 10), hospice (n = 8), EOL hospitalizations (n = 6), and pain management (n = 1). Differences in EOL care were most apparent among NHs with higher proportions of Black residents. Racial/ethnic minority residents were less likely to complete advance directives. Although hospice use was mixed, Black residents were consistently less likely to use hospice before death. Hispanic and Black residents were more likely to experience an EOL hospitalization compared with non-Hispanic White residents. Racial/ethnic minority residents experienced worse pain and symptom management at the EOL; however, no articles studied specifics of palliative care (eg, spiritual care).

Conclusions and Implications
This review identified NH health disparities in advance care planning, EOL hospitalizations, and pain management for racial/ethnic minority residents. Research is needed that uses recent data, reflective of current NH demographic trends. To help reduce EOL disparities, language services and cultural competency training for staff should be available in NHs with higher proportions of racial/ethnic minorities.