Evaluation of access to advance directives for seriously ill African Americans in urban communities served by safety net hospitals

Background: Hospitalized African Americans are known to often lack advance directives, particularly DNR orders, and to seek aggressive interventions during life-threatening illness and at end-of-life more often than whites and other ethnic minorities. The preference for aggressive care may be linked to poor access to a palliative medicine consultation (PMC). The authors hypothesized that access to the PMC process would increase use of DNR orders among this population. Methods: The PMC database (n=2831) was retrospectively reviewed to obtain a sample of African American patients who received services at a safety net hospital and were seen between September 2004 and June 2010. Data relating to demographics, diagnosis, DNR status on admission, PMC, and DNR status upon discharge were collected. The chi-square test was used to analyze the association between the consult, DNR discussion and DNR status on discharge. Results: Our sample of 1,123 African American patients had a mean age of 65 years. The primary diagnoses observed were: cancer; cardio/vascular disease; pulmonary disease; AIDS; and sepsis. There were 217 (20%) patients admitted without DNR status (Full Code) and 906 (80%) patients with unknown DNR status. The Consultation addressed DNR with 1,072 patients (95%). Among patients having a DNR discussion, 773 (68%) had a DNR order at the time of discharge (P<0.000). Conclusion: Patients who received a PMC elected DNR orders at rates higher than usual for African Americans. This finding indicates that DNR discussions with seriously ill African Americans may influence preferences related to intervening care and election of DNR orders.