This essay focuses on one important aspect of racial disparities that has received comparatively little attention in the legal literature--the existence and causes of racial differences in end-of-life decision making and in the utilization of palliative and hospice care. African Americans and other racial minorities in the United States utilize palliative care and hospice less frequently than white Americans. These minority populations also tend to resist advance care planning and instead opt to receive more life-prolonging care at the end of life, even when quality of life and prognosis are poor. After a lifetime of limited access to health care compared with whites and, in some cases limited treatment options (because of lack of insurance coverage or biased clinical judgment by physicians), African Americans and other racial and ethnic minorities utilize strikingly higher levels of aggressive, life-prolonging care at the end of life. Much of the explanation for these disparities in end-of-life care appears to lie in problems with communication and trust between physician and patient, although broader influences of culture and religious belief also play a role. The complexities of communication between minority patients and their physicians run in two directions, creating a destructive synergy that can dampen empathy in the relationship and negatively impact care at the end of life. Although many cultural factors play a role in the decision making of African American patients regarding end-of-life care, this essay focuses primarily on issues of trust and communication because these impact African Americans most directly.
Barbara A. Noah, The Role of Race in End-of-Life Care, 15 J. HEALTH CARE L. & POL'Y 349 (2012).