The Ways Inequality Affects Black Americans at the End of Life
Contributing factors: health inequity, discrimination and lack of cultural competency
Jodi Savage was her grandmother's caretaker in her last days. Like many Black Americans, her grandmother's cultural beliefs and religious background led to very little discussion around the end of life. Culturally speaking, Black Americans on the whole tend to avoid discussing end-of-life topics for fear of speaking things into existence. Focus is placed on making the best of the time you're given. A lack of cultural competency from physicians led to a misunderstanding of Savage's grandmother's needs and minimal support through the death-planning process. Savage endured all of this while trying to remain strong as her grandmother battled Alzheimer's.
Savage wasn't prepared for the process of making such impactful decisions on her grandmother's behalf. No one assisted her with end-of-life planning during the process of caretaking, and she didn't discuss end-of-life care until the night before her grandmother died.
Savage's experience isn't rare. Dr. Ramona Rhodes, an associate professor who works in internal medicine at UT Southwestern Medical Center and specializes in racial and ethnic disparities in older adults' care, says Black Americans have a few key differences with end-of-life experiences compared to white Americans.
"Members of underrepresented groups have been found to opt for more aggressive treatments at the end of life, [are] less likely to participate in advance care planning and [are] less likely to enroll in hospice at the end of life," Rhodes said. "The reasons for these disparities are often multifactorial. The research suggests that mistrust in health care systems may be one of those reasons."
Inequality Affects End of Life
It's no secret that wage gaps, discrimination and institutional racism limit Black Americans' access to health equity. However, what's discussed a lot less frequently is that these factors impact the way this group experiences death, too.
Nearly one in four Black Americans live in poverty as compared to one in 10 white Americans, and for older Black Americans, that number is even larger. Nearly 64 percent of older Black Americans are on the cusp of poverty. Because of financial insecurity, preoccupation with daily survival can take priority over death-related planning like writing advance directives and funeral planning for Black Americans. Studies suggest around 24 percent of older Black Americans have advance directives as compared to 44 percent of older white Americans. Savage's grandmother had life insurance, but no will.
Black Americans predominantly live in states that refused the Medicaid expansion. Those who face financial obstacles are disproportionately impacted by a lack of coverage. The Black community has an uninsured rate of 12 percent, which can make health conditions more difficult to manage.
Black Americans report higher rates of dissatisfaction with medical and end-of-life care options like hospice than white Americans. The medical system's historical mistreatment of Black Americans impacts trust in end-of-life providers.
Only 38.3 percent of Black American Medicare patients enrolled in hospice care prior to their deaths, compared to 51 percent of white patients.
"The research suggests that mistrust in health care systems may be one of those reasons," Rhodes said. "This mistrust may stem from historical occurrences, such as the Tuskegee Syphilis Study [where the U.S. Public Health Service researched syphilis by letting it go untreated in 622 Black men in Alabama] or from patients' and/or family members' own personal experiences with the health care systems that were not positive."
Lack of Cultural Competency Affects End of Life
It's rare that end-of-life care providers educate employees on the importance of cultural competency, and even fewer of the providers are Black themselves. Naturally important unique cultural qualities that are held dear to Black individuals end up overlooked.
Black Americans are more likely to manage both every day and critical health experiences with their religious faith. That faith leaves them less likely to see a chronic illness or terminal diagnosis as a predictor of life expectancy. Medical professionals who aren't familiar with this commonality might interpret this custom as delusion and be unsure how to engage with the patient.
Despite health challenges, Savage's grandmother's spirituality remained but was misunderstood on her path to an Alzheimer's diagnosis.
"During the hospital stay that led to her being diagnosed with Alzheimer's disease with psychotic symptoms, one doctor said my grandmother had religious ideations because she was very religious, called herself a prophet and said God spoke to her," Savage said. "Had he taken the time to learn about her background, he would have known that my grandmother had always been very religious."
In addition to a lack of knowledge about options, Rhodes said lack of culturally-competent care is commonly experienced by Black Americans.
"Other causes that have been cited in the literature include a lack of knowledge about advance care planning, palliative and hospice care and a perceived conflict [between] spiritual or religious beliefs and the hospice and palliative medicine philosophy of care," she noted.
Alone at the End of Life
Savage's grandmother was lucky to have her. Data suggests that in the near future, Black Americans might be exceptionally vulnerable to having their wishes ignored due to a rising lack of family members. By 2020, a projected 1.2 million older Black men and 1.6 million older Black women will not have kin. The consequences of this go much further than loneliness.
As the rates of aging Black Americans without relatives increases, they will be left without caretakers or anyone advocate on their behalf.
End-of-life issues and disparities that impact Black Americans are a cumulation of the challenges and systemic issues that plague Black Americans through their entire lifespan.
Savage's experience made her aware of the importance of having these conversations ahead of time so they don't have to be done in the moment.
"We often make end-of-life care decisions based on our inability to let go of our loved ones, but our loved ones are entitled to a good death — one that is humane and with as little suffering as possible," Savage said. "Sometimes, letting go is the most compassionate and loving thing we can do."
In the future, Rhodes would like to see providers designing and implementing culturally-sensitive interventions that address these disparities. She added: "Ultimately, for me, it is important that patients be informed not only about their condition, but their options for care at the end of life. I want them to be able to make a well-informed decision — whatever that decision may be."
The John A. Hartford Foundation is a private, nonpartisan, national philanthropy dedicated to improving the care of older adults. The leader in the field of aging and health, the Foundation has three priority areas: creating age-friendly health systems, supporting family caregivers, and improving serious illness and end-of-life care.