Send to

Choose Destination
Am J Hosp Palliat Care. 2019 Dec;36(12):1057-1062. doi: 10.1177/1049909119843276. Epub 2019 Apr 21.

Understanding Underuse of Advance Care Planning Among a Cohort of African American Patients With Advanced Cancer: Formative Research That Examines Gaps in Intent to Discuss Options for Care.

Author information

1 Division of Geriatric Medicine, UT Southwestern Medical Center, Dallas, TX, USA.
2 Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA.
3 City University of New York School of Medicine, New York, NY, USA.
4 Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX, USA.
5 Division of General Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.
6 VA Portland Health Care System, Portland, OR, USA.
7 Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA.



Advance care planning (ACP), palliative care (PC), and hospice are often underutilized by African Americans (AAs). This study assessed the impact of stage of intent to discuss ACP options as key potential barriers.


We examined intent to discuss completion of ACP, PC, and hospice among 22 AA patients with cancer admitted to a local safety net hospital. Participants were asked about intent to discuss an advanced directive or living will (AD/LW), medical power of attorney (MPOA), PC, and hospice with their doctors. Intent to discuss these ACP components was based on the transtheoretical model. Electronic health records were reviewed at various intervals to assess completion of ACP behaviors and survival.


Participants had colorectal (33%), breast (44%), and lung (23%) cancer, and 82% had stage III/IV disease. Low percentages of patients were in the precontemplation stage for AD/LW completion (4.6%), MPOA completion (13.6%), and PC discussions (27.2%), but 77.2% were in the precontemplation stage for hospice discussions. At 1 year, only 5% completed an AD/LW, 36.4% appointed an MPOA, 42.9% were referred to PC, and 12.5% were referred to hospice. More than half (54.6%) were deceased by the study's conclusion. Most (81%) of these died within 6 months of their baseline study assessment.


Despite being hospitalized with advanced cancer and having poor prognosis, intent to discuss ACP options, PC, and hospice in this population was variable, and completion of these activities was low. This formative research is needed to develop education and counseling interventions for this high-risk, vulnerable population.


African Americans; advance care planning; advanced cancer; hospice; palliative care; safety net


Supplemental Content

Full text links

Icon for Atypon
Loading ...
Support Center