Post Hoc Analysis of Automated Early Warning System Alert Linked to End-of-Life Discussions—Is There a Racial Disparity in Effectiveness?

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I read with great interest the article published in a recent issue of Critical Care Medicine by Picker et al (1). Indeed, it was pleasing to learn about the effectiveness of automated early warning system alerts in identifying patients that might benefit from palliative care discussions and reduce the number of ICU transfers. In addition to these encouraging findings, I was also struck by the racial breakdown of the study groups, in that half of the participants were African-American (Table 2) (1). As I am confident the authors are aware, prior research has shown that compared to whites, blacks at the end of their lives (EOLs) are more likely to use intensive care, life-sustaining treatments, (i.e., invasive mechanical ventilation, hemodialysis, and feeding tubes) die in the hospital, and less likely to receive comfort-directed care (2–4). Additionally, numerous studies have shown blacks to prefer life-sustaining treatments, even in the context of terminal illness or persistent vegetative state, more than whites (2, 3). Finally, hospitalized blacks are less likely to have do-not-resuscitate orders, have fewer advance directives and living wills, and receive cardiopulmonary resuscitation more frequently than whites (5).
Knowing that racial disparities pervade numerous aspects and disciplines of EOL care, combined with these findings presented by Picker et al (1), has lead me to wonder whether automated early warning system alerts are equally effective at stimulating palliative care discussions in African-Americans and Caucasians (1–5). If possible, I implore the authors to conduct a post hoc analysis to compare the effectiveness of their intervention between these two races. I believe that the findings of this investigation, whether significant or not, would add invaluable knowledge to the ever-evolving field of racial disparities in EOL care research.
For decades, racial disparities in EOL care have been a core topic of research (2–5). Unfortunately, most investigators repeatedly report significant African-American disparities in EOL care, with African-Americans being less likely to prefer hospice or palliative care (2–5). I want to commend Picker et al (1) for their well-written, clearly presented, and uplifting report of a promising intervention that could increase palliative care discussions in patients at the EOLs (1). My hope is that the researchers heed my suggestion and use their unique dataset to illuminate any potential racial disparities that may be present. By doing this, the authors can cast additional light on potential racial disparities in palliative care discussions so that all patients, regardless of race, can be equally informed.
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