Americans are also underrepresented in the use of hospice care. In recent years, only 5–7 percent of hospice patients have been African Americans, even though they make up about 14 percent of the total population. Payne (Chapter 5) describes the historical, cultural, and economic determinants of this pattern of underutilization of palliative and end-of-life care in the African-American population, which can be taken as a model for other medically underserved and vulnerable populations that are less well studied. Bias (conscious and unconscious) of health care providers, lack of economic access for many African-American and other minority group members, and a wide range of cultural factors place minority groups at a disadvantage in getting adequate palliative care.

Unequal treatment in the U.S. health care system has deep roots in the African-American community. The health care system, along with many other societal institutions, lacks credibility with many African Americans because of past abuses, which are commonly known: slavery, medical experimentation, Jim Crow laws, and so forth. Denial of death (even in the face of terminal illness) is seen—if unconsciously—as fighting back against past injustice; whereas accepting palliative care is viewed as giving up on care that the majority might receive.

Even when palliative care is wanted and needed, however, it may not be available. Hospice care may not be available in poor, inner-city areas, which are generally underserved for health care. A stark example comes from a recent study demonstrating that pharmacies in predominantly non-white communities do not stock opioids at all or have inadequate stocks (Morrison et al., 2000). In an accompanying editorial, the story is recounted of an elderly woman with unrelieved bone pain from metastatic cancer, whose daughter was unable to buy a prescribed morphine-based drug in any local pharmacy (Freeman and Payne, 2000). This is just an example of inequities that pervade the provision of palliative care for minority populations.

There is an urgent need for palliative care units in inner-city hospitals, which involves not only providing facilities, but training teams of providers to staff these units. Even more fundamental, research is required to understand the needs and preferences of African Americans and other minorities for end-of-life care and to elucidate the health policy and financial barriers that leave these groups with inadequate care during the dying process.

Lack of Information Resources for the Public on Palliative and End-of-Life Care

Faced with a diagnosis of cancer, people often respond by gathering information about the cause of their ailment, treatment options, and advances in medical research. Patients find information from any number of



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