Factors Associated with Opinions about Hospice Among Older Adults: Race, Exposure to Hospice, and Attitudes Matter

BACKGROUND: Hospice is an interdisciplinary model of end-of-life care that focuses on quality of life, patient preferences, and dignity. Compared to alternate end-of-life care options, hospice is often considered the “gold standard’ of care for dying patients. It is associated with beneficial outcomes for patients and families. While nearly 1.6 million patients receive hospice care annually, it is estimated that 40% of people who are eligible for hospice services do not receive them; and disproportionately fewer minority patients enroll in hospice prior to death. The reasons for these disparities, however, are not well understood.

PURPOSE: To identify predictors of opinions about hospice (OAH) and evaluate the relationship between race and attitudes.

METHODS: Data were drawn from the American Association of Retired Persons (AARP) membership base in Florida. Among AARP Florida members, a random sample was selected. A mailed survey was administered from May-June 2008. The total respondent sample included 3,024 adults aged 50+ years (response rate=38%). Univariate, chi-square and multiple regression analyses were conducted to examine three research questions: 1) What factors are associated with OAH?; 2) Do racial/ethnic differences exist in terms of familiarity with hospice?; 3) How does race and ethnicity differ on OAH? For regression analyses, demographics and self-rated health were modeled with prior exposure to hospice, attitudes related to end-of-life care, and having engaged in advanced care planning entered as predictors. The main outcome, OAH, was measured using a single item inquiring about the overall OAH (5=extremely favorable; 1=not at all favorable). Familiarity with hospice was operationalized using an item identifying whether the respondent had heard of hospice services.

RESULTS: Race, prior exposure to hospice, the importance of pain control, and involvement of health care professionals were associated with OAH (p<.05). Whites, those who had been exposed to hospice, and individuals who reported a high importance of pain control and the involvement of healthcare professionals had more positive OAH than others. The relationship between race and OAH (p<.001) were significant. While OAH were generally very favorable across groups, Hispanics had less favorable opinions (M=4.11) than non-Hispanics (M=4.40) and Blacks had less favorable opinions (M=3.96) than Whites (M=4.42). There was an association between familiarity with hospice and race/ethnicity. Blacks had not heard of hospice (7.9%) compared to whites (4.2%; p<.001) and 27% of Hispanics had not heard of hospice compared to 4% of non-Hispanics (p<.001).

IMPLICATIONS: The results of this study indicate OAH differed by race and may contribute to disparities in hospice utilization. Minority groups may be less familiar with hospice, especially Hispanic individuals. In addition, exposure to hospice is linked to more favorable opinions. Findings help us to better understanding about racial and ethnic disparities in hospice care. Hospice providers may improve public attitudes by doing a better job of making their services more visible and familiar to communities of need. Future studies are needed to understand disparities in hospice.