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Carmen H.M. Houben, MSc; Martijn A. Spruit, PhD; Jos M.G.A. Schols, MD, PhD; Emiel F.M. Wouters, MD, PhD; Daisy J.A. Janssen, MD, PhD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: See earlier cited article for author conflicts of interest.

aDepartment of Research and Education, CIRO, Horn, the Netherlands

bDepartment of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, the Netherlands

cDepartment of Family Medicine and Department of Health Services Research, Faculty of Health, Medicine and Life Sciences/CAPHRI, Maastricht University, Maastricht, the Netherlands

dDepartment of Respiratory Medicine and the Centre of Expertise for Palliative Care, Maastricht UMC+, Maastricht, the Netherlands

CORRESPONDENCE TO: Carmen H. M. Houben, MSc, Department of Research and Education, CIRO, Hornerheide 1, 6085 NM Horn, the Netherlands


Copyright 2017, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(5):1182-1183. doi:10.1016/j.chest.2017.01.014
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We thank Dr Chertoff for his letter to the editor in response to our manuscript entitled “Instability of Willingness to Accept Life-Sustaining Treatments of Patients with Advanced Chronic Organ Failure During 1 Year.” Chertoff’s main worry is about the racial breakdown of our study. More specifically, he wants to know how this racial breakdown affected our results and whether our findings are applicable to larger countries with significant racial diversity.

As already mentioned as a methodological consideration in our manuscript, almost all participants of our study were white. We therefore agree with Dr Chertoff that this may limit the generalizability of our findings. Indeed, previous studies show differences regarding preferences for end-of-life care between white and non-white populations. A systematic review shows, for example, that African-American populations prefer more aggressive care, participate less in advance care planning, and are more likely to informally discuss end-of-life care, in comparison with white populations.

However, it can be questioned whether differences regarding end-of-life care between white and non-white populations can be fully explained by racial diversity. In our opinion, international differences should also be taken into account. In fact, the consistency of willingness to accept life-sustaining treatment was higher in our Dutch study in comparison with American studies,, which also used the Willingness to Accept Life-sustaining Treatment questionnaire and which also were performed in a predominantly white population. As already mentioned in the manuscript, the most important explanation for the different results in Europe and the United States should be sought in international differences. Previous research in patients with COPD has shown that a higher proportion of US patients than Dutch patients reported that their ideas about the kind of medical care they want change at different times. In fact, the majority of advance care planning studies are performed in the United States, and important differences exist in the communication about and the provision of end-of-life care between Europe and the United States. Indeed, communication about end-of-life care is less common in Dutch patients in comparison with US patients, and Dutch patients are more often involved in decision-making than are US patients.

In conclusion, we agree with Dr Chertoff that the racial breakdown has affected our results and that our findings probably would be different if our study was performed in larger countries with significant racial diversity. In our opinion, both racial and international differences seem to affect preferences for end-of-life care and should be taken into account when interpreting study results. Further international research in racial diverse populations is needed to identify the specific influence on preferences for end-of-life care.

References

Houben C.H.M. .Spruit M.A. .Schols J.M.G.A. .Wouters E.F.M. .Janssen D.J.A. . Instability of willingness to accept life-sustaining treatments in patients with advanced chronic organ failure during 1 year. Chest. 2017;151:1081-1087 [PubMed]journal
 
Sanders J.J. .Robinson M.T. .Block S.D. . Factors impacting advance care planning among African Americans: results of a systematic integrated review. J Palliat Med. 2016;19:202-227 [PubMed]journal. [CrossRef] [PubMed]
 
Fried T.R. .Van Ness P.H. .Byers A.L. .Towle V.R. .O'Leary J.R. .Dubin J.A. . Changes in preferences for life-sustaining treatment among older persons with advanced illness. J Gen Intern Med. 2007;22:495-501 [PubMed]journal. [CrossRef] [PubMed]
 
Fried T.R. .O'Leary J. .Van Ness P. .Fraenkel L. . Inconsistency over time in the preferences of older persons with advanced illness for life-sustaining treatment. J Am Geriatr Soc. 2007;55:1007-1014 [PubMed]journal. [CrossRef] [PubMed]
 
Janssen D.J. .Curtis J.R. .Au D.H. .et al Patient-clinician communication about end-of-life care for Dutch and US patients with COPD. Eur Respir J. 2011;38:268-276 [PubMed]journal. [CrossRef] [PubMed]
 

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Tables

References

Houben C.H.M. .Spruit M.A. .Schols J.M.G.A. .Wouters E.F.M. .Janssen D.J.A. . Instability of willingness to accept life-sustaining treatments in patients with advanced chronic organ failure during 1 year. Chest. 2017;151:1081-1087 [PubMed]journal
 
Sanders J.J. .Robinson M.T. .Block S.D. . Factors impacting advance care planning among African Americans: results of a systematic integrated review. J Palliat Med. 2016;19:202-227 [PubMed]journal. [CrossRef] [PubMed]
 
Fried T.R. .Van Ness P.H. .Byers A.L. .Towle V.R. .O'Leary J.R. .Dubin J.A. . Changes in preferences for life-sustaining treatment among older persons with advanced illness. J Gen Intern Med. 2007;22:495-501 [PubMed]journal. [CrossRef] [PubMed]
 
Fried T.R. .O'Leary J. .Van Ness P. .Fraenkel L. . Inconsistency over time in the preferences of older persons with advanced illness for life-sustaining treatment. J Am Geriatr Soc. 2007;55:1007-1014 [PubMed]journal. [CrossRef] [PubMed]
 
Janssen D.J. .Curtis J.R. .Au D.H. .et al Patient-clinician communication about end-of-life care for Dutch and US patients with COPD. Eur Respir J. 2011;38:268-276 [PubMed]journal. [CrossRef] [PubMed]
 
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