Implicit Bias Yields Health Inequities for Dementia Patients

According to a JAMA Internal Medicine study, staff members’ implicit bias about minority groups was linked to variability in end-of-life care delivered to Black patients with dementia, limiting health equity for nursing home residents.

Between June 2018 and July 2021, researchers interviewed 169 staffers at 14 nursing homes that provided high-intensity and low-intensity care in four states. 

The study looked to explore the association between staffing perceptions at nursing homes and the variability in the type of care provided by nursing home residents with advanced dementia, specifically in cases when staff utilized aggressive interventions such as tube-feeding or hospitalizations.

These aggressive interventions have limited clinical benefit, are extremely costly, and do not usually yield a good patient experience, most experts agree.

In comparison to highest-intensity care facilities, researchers suggested that the lowest-intensity care facilities provided:

• More pleasant physical environment
• Standardized advance care planning
• Better staff engagement regarding shared decision-making 

In addition, staff at low-intensity care facilities held unfavorable attitudes towards tube-feeding.

Study findings showed that staff in all nursing homes expressed implicit biases. For example, some indicated they thought Black residents’ families were unwilling to engage in advanced care planning and supported more aggressive care techniques. 

However, staff in nursing homes providing the lowest-intensity care believed feeding tubes lengthened life expectancy for dementia patients.

“The study identified several factors that nursing homes could target to improve delivery of goal-directed care to all residents,” Ruth Palan Lopez, PhD, GNP-BC, FAAN, professor and associate dean of research, said in the press release. “One is to improve provider knowledge and communication skills that less aggressive interventions may be more in line with the residents’ wishes and best evidence.”

“For example, many nurses may believe that feeding tubes prolong the life of advanced dementia patients, but this is not borne out by existing studies,” continued Lopez, who is also the Jacques Mohr Chair at MGH Institute of Health Professions School of Nursing. “Nursing homes need to make sure their staff is aware that hand feeding is better for residents. Based on prior research, aggressive interventions can be less effective compared to less-intensive interventions, like feeding residents manually, while requiring more time of the nursing staff provides better care to their patients.”

Nursing homes could reduce health inequities by boosting support for low-resource facilities, regulating advanced care planning, and informing staff about evidence-based care. 

“Staff preconceptions that Blacks are less willing to engage in advance care planning and want more aggressive care speaks to the need to address systemic racial biases in nursing homes,” Susan L. Mitchell, MD, MPH, lead author of the study, said in a public statement. “Achieving health equity for all nursing home residents with advanced dementia must be the driving force behind all efforts aimed at reducing disparities in their care.”