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Barriers were drawn from the literature and from focus groups. Subjects who believed that a health care agent was irrelevant in the setting of involved family were significantly less likely to have completed a health care proxy.
Although there were significant differences in the baseline completion rates of health care proxies for the 3 ethnic groups, ethnicity did not predict prior appointment of a health care agent in multivariate analysis.Pearl V Puri and Asmita Sood, The Co-Star's Story
Enhanced educational efforts of both health care personnel and patients could increase the rate of formal health care proxy appointment. Advance directives have not been uniformly used by different segments of the US population and studies have consistently shown a lower baseline prevalence of advance directive completion for African Americans and Hispanics compared with non—Hispanic whites primarily with respect to living wills.
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Ethnic differences in knowledge about advance directives, 81012 differences in access to health care and associated opportunities to complete advance directives, 13 - 15 absence of appropriate surrogates, 16 and concerns about placing undue burdens on surrogates 17 have all been cited as potential explanations. It is also possible that members of disenfranchised ethnic groups perceive advance directives as a means of limiting their access to health care.
The objective of this study was to explore differences regarding knowledge and completion of health care proxies among 3 ethnic and racial groups. To this end, we sought to identify confounding variables that might explain observed differences in the prevalence of advance directives, particularly health care proxies, among different ethnic groups. Subjects and methods Subjects Subjects were recruited from the geriatrics and internal medicine outpatient clinics of a large New York City teaching hospital serving a multiethnic and socioeconomically diverse patient population.
Interviews were conducted with a consecutive series of patients older than 65 years without a diagnosis of dementia who identified themselves as either African American, Hispanic, or non—Hispanic white from September through March Prospective subjects were approached either before or immediately following their physician appointment for consent to participate.
Consenting patients were administered a item questionnaire by a single research assistant. The research assistant was white, fluent in Spanish, and had had extensive experience in interviewing and conducting research with different ethnic populations. Completion of the questionnaire typically required 25 minutes. Questionnaire development We designed a questionnaire to examine the relationship between a series of hypothesized barriers to completion of health care proxies and subjects' actual completion of these documents.
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Questionnaire development occurred in several steps. First, we reviewed the literature on advance directives, particularly those studies 7 - 1118 that included nonwhite subjects, to identify potential barriers. In the focus groups, we asked participants about their understanding of advance directives in general and health care proxies in particular, their reasons for noncompletion eg, personal or religious beliefs, family reasons, or logistical factors and their understanding of how decisions are made when patients lose decisional capacity.
At the conclusion of the focus group, barriers identified in previous studies that had not emerged spontaneously during the discussion were posed to the groups to elicit their reactions and comments a full description of the methodology and results of this qualitative study has been reported elsewhere Both barriers previously identified in the literature and those raised by the focus group participants were included in the questionnaire.