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Impact of Immigrant Status on Aggressive Medical Care Counter to Patients' Values Near Death among Advanced Cancer Patients
Abstract
Background: Little is known about disparities in end-of-life (EoL) care between U.S. immigrants and nonimmigrants.
Objective: To determine immigrant/nonimmigrant advanced cancer patient differences in receipt of values-inconsistent aggressive medical care near the EoL.
Design: Analysis of data from Coping with Cancer, a federally funded, prospective, multi-institutional cohort study of advanced cancer patients with limited life expectancies recruited from 2002 to 2008.
Setting/Subjects: U.S. academic medical center and community-based clinics. Self-reported immigrant ( n = 41) and nonimmigrant ( n = 261) advanced cancer patients with poor prognoses who died within the study observation period.
Measurements: The primary independent/predictor variable was patient immigrant status. Primary outcome variables: (1) aggressive medical care near death, operationalized as the use of mechanical ventilation, resuscitation, feeding tube, and/or antibiotics in the last week of life and (2) receipt of values inconsistent aggressive care, operationalized as receiving aggressive care inconsistent with stated preferences for comfort-focused EoL care.
Results: In a propensity-weighted sample ( N = 302), in which immigrant and nonimmigrant groups were weighted to be demographically similar, immigrants were significantly more likely than nonimmigrants to receive aggressive medical care [OR 1.9; 95% CI (1.0–3.6); p = 0.042] and values-inconsistent aggressive medical care [OR 2.1; 95% CI (1.1–4.2); p = 0.032] near death.
Conclusions: Immigrant, as compared with nonimmigrant, advanced cancer patients are not only more likely to receive aggressive EoL care, but also more likely to receive care counter to their wishes. These findings indicate potential disparities in, rather than differences in preference for, aggressive care and a need for further investigation into potential causes of these disparities.