Is Patient Right of Self-Determination Equitable? Ethnicity and Advance Directives

Paper

Thursday, July 22, 2004

This presentation is part of : Issues in Palliative Care

Robin Froman, RN, PhD, School of Nursing, Univ of Texas Health Science Center at San Antonio, San Antonio, TX, USA and Steven V. Owen, PhD, School of Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX, USA.

Learning Objective #1: Identify the relationships among ethnicity, presence of advanced end of life planning, and stability of advance directive decisions
Learning Objective #2: Discuss possible sources of inequity in patients' understanding of decision making processes related to advance directives

Objective. The Patient Self-Determination Act (1992) identified rights to express advanced directives (ADs). This NINR funded research (1 R15 NR05216-01) describes the stability of ADs across 3-day hospitalizations. English and Spanish speakers and those having expressed or not expressed ADs were included.

Design. This was a multiple-group comparison with an intervention.

Variables. Attitudes about AD, Stability of ADs, Ethnicity (Hispanic or Non-Hispanic).

Methods: Sample, Setting, Procedures. Subjects were hospitalized adults with minimum 3-day length of stay. Stratification created multiple comparison groups. First stratification by ethnicity created equal numbers of non-Hispanics and Hispanics. Half of each group had expressed ADs and half had no AD. Half of each group was randomly assigned to complete a self-report measure of attitudes about AD interventions (LSPQ, Froman & Owen, 2003) showing the complexity of ADs. Remaining participants completed a self-report of affect (PANAS, Watson, 1988). This created eight comparison groups. Participants were visited for three days to assess stability of ADs. Data were analyzed for ethnic group differences (non-Hispanic/Hispanic) in AD attitudes, stability of ADs, and change in AD related to questionnaire completed.

Findings: Six of the eight comparison groups were fully enrolled (N = 106). The two groups of Hispanics with ADs, were not filled at the end of 24 months of data collection. The incidence of Hispanics with ADs, even in the hospital setting, is notably low. Hispanics completing LSPQ show attitudes more in favor of ADs for life support than do the non-Hispanics (p < .01 on LSPQ). Chi square for change in AD was 17.31 (df = 7), significant at p < .025 showing non-Hispanics, regardless of existing AD statement or questionnaire completed, more likely to change AD during 3-day hospitalization. Completion of LSPQ also increased likelihood of changes in AD (chi square = 6.49, p < .025).

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