Race in the Advance Directives Conversation

 

Much of my work as a Palliative Care physician involves conversations with patients and their families for whom the medical outlook is bleak: to help them receive the treatment they want, not more and not less. Such discussions are best held in tandem with the primary medical team and with the nurse. Many times, both attending doctors and housestaff have said, “But it’s so much harder to get a DNR (Do Not Resuscitate Order) with African-American families.”

My experience differs.  

If we perform this procedure of serious illness conversation with skill and human engagement, two separate domains predict lower likelihood of a family’s sticking irrationally to Full Code. One is lack of trust in those who are treating. That occurs more commonly among persons who have had reason to distrust the big Us even when the little We have behaved perfectly: those from poverty; those who have been incarcerated; and, those who have been mocked or hated for their religion, their sexual orientation, the language they speak or the color of their skin. And among all these groups, there are many families of such strength and courage that they see beyond their trouble with Us, to what is best for the loved one, and make the brave and difficult decision to ally with Us.

The exceptionally privileged and wealthy trust Us less and are more likely to believe that only someone like them–“best man in America for osteosarcoma of the left ear”–is the only doc to be believed. This group also falls into the trap of thinking that primary care is a default career choice of those who weren’t bright enough to become specialists.

The other group that clings irrationally to Full Code–and which has a similar distribution among all races and all economic backgrounds–consists of those with unfinished emotional business. They cling because they are trying to catch up at two seconds to midnight.

All of which merely is an exegesis on the (misattributed) Physician’s Prayer of Maimonides, which implores the practitioner to see in the patient only a fellow creature that is suffering and in difficulty. One of the great glories of Our profession is its relegation of race to a physical finding. Dr. Gross’s analysis mirrors the advice I give to residents and Fellows: don’t tell me the patient’s race. Instead tell me something that makes a difference to me as his healer.