Why Black, Hispanic, and Asian Patients Hesitate to Opt for Palliative Care: Deep Metaphors from Patients, Community Leaders, and Clinicians with Shared Cultural Identities to Shape More Effective Outreach.

Background: In the United States, national data show that Black, Hispanic, and Asian patients are less likely than White patients to receive palliative care (PC) despite comparable or greater symptom burden. Multiple factors contribute to this inequity, but one familiar to clinicians is that a significant proportion of Black, Hispanic, and Asian patients and families hesitate to choose PC when it is offered. Objectives: As part of a larger project to develop public messaging for advance care planning, PC, and hospice, we conducted a qualitative study aimed at identifying the "deep metaphors" evoked when Black, Hispanic, and Asian patients consider PC. Methods: We sampled Black, Asian, and Hispanic patients receiving PC, community leaders, and PC clinicians, and interviewed them using a qualitative method designed to elicit emotional meanings and unconscious mental orientations, the Zaltman Metaphor Elicitation Technique. The interviews were video-recorded, transcribed, and analyzed using a variation of the constant comparative method. Results: We enrolled 15 patients (5 Black, 5 Hispanic, 5 Asian), 8 community leaders (5 Black, 3 Hispanic, 1 Asian), and 6 palliative care clinicians (2 Black, 2 Hispanic, 2 Asian). Patients' images about their experiences of being offered PC revealed the metaphor of "inside/outside"-a sense of simultaneous inclusion and exclusion with regard to their community and also the medical system. The patients' sense of belonging and protection felt from their communities was demonstrated in images that evoked the metaphor of "home," as a physical and emotional place with a sense of belonging. The metaphor of home as a place of belonging was mirrored in community leader and PC clinician interviews. Conclusion: Designing public messaging and outreach for PC that invokes the deep metaphor of "home," especially in the sense of belonging, is a strategy supported by qualitative evidence that should be tested further.