Doctors less likely to engage Black caregivers in shared decision-making

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Shared decision-making is widely considered a cornerstone of health care delivery in the U.S., especially when making care decisions for critically ill patients. But a recent study finds that doctors engage in far less shared decision-making with Black caregivers for such patients than they do with Whites.

The study’s authors recorded 39 conversations between doctors and caregivers to patients who were undergoing prolonged mechanical ventilation in intensive care units between 2012 and 2017. They coded transcriptions of the conversations across 17 categories such as caregiver health literacy, physician empathy (defined as “statements by the medical team that acknowledge caregivers’ emotions”); power differentials (defined as “deferral to expertise or position; dismissal or condescension); and missed opportunities for empathic responses (defined as “instances where the medical team failed to respond to the caregiver’s emotional statements.”)

The results showed areas where the shared decision-making behaviors of the clinicians differed according to the race of the caregiver. The first was in demonstrations of emotional support for the caregivers. Statements made to Black caregivers tended to be shorter and more generic, or less personalized, than those to White caregivers.

“Opportunities for empathic responses were missed when Black caregivers expressed negative emotions, while White caregivers received acknowledgement and validation of their emotions,” the authors wrote.

Second, the clinicians rarely acknowledged expressions of trust and gratitude from Black caregivers but confirmed their personal commitment to the patient when similar expressions came from White caregivers.

The third area of difference was willingness to share medical information, even with caregivers demonstrating similar levels of health literacy and knowledge of the health care system. Black caregivers often got less information and acknowledgement of their expertise than did Whites.

Finally, unlike any of the Black caregivers, many of the White caregivers preferred a palliative approach to care based on earlier advance care planning conversations. But since the doctors were more willing to endorse palliative care for all patients, the effect was less validation for Black caregivers’ preferences. Moreover, “even when compared with White caregivers who preferred restorative care, Black caregivers faced more resistance from clinicians regarding their treatment preferences,” the authors wrote.

Their findings, they say, lend credence to testimony from seriously ill Black patients that “silencing and dismissal are the most commonly experienced forms of interpersonal racism, which then contribute to their perceptions of clinician and health system untrustworthiness.”

The study, “Racial Differences in Shared Decision-Making About Critical Illness” was published online February 26, 2024 on JAMA Internal Medicine.