By Stacey Kusterbeck
When ethicists consult on a case involving end-of-life decision-making, discussions center around the patient’s goals and values, prognosis, and preferences. Yet, income and insurance status are two other factors that affect the likelihood of patients withdrawing life-sustaining treatments, a recent study suggests.1
A previous retrospective study of patients with spontaneous intracerebral hemorrhage showed that higher neighborhood socioeconomic status was associated with higher likelihood of withdrawal from life-sustaining treatments.2 “I was curious to see if the same pattern exists in patients with aneurysmal subarachnoid hemorrhage, who are typically younger than patients with spontaneous intracerebral hemorrhage,” says Ali Mahta, MD, associate professor of neurosciences and director of the neurocritical care fellowship program at the University of California, San Diego. Mahta and colleagues analyzed 410 patients admitted to an academic medical center from 2016 to 2023. The researchers defined high economic-insurance status as not using Medicaid, having any other insurance, and living in a ZIP code within the top two quintiles of household income. They defined low economic-insurance status as having no insurance or having Medicaid, and living in a ZIP code in the bottom two quintiles of household income.
The study findings were consistent with the previous findings on intracerebral hemorrhage patients. Patients residing in areas with higher neighborhood income were more likely to have life-sustaining treatments withdrawn compared to those in areas with lower neighborhood income. “Educational background and cultural differences might have affected decision-making processes, and how much their family trusted healthcare providers during goals of care discussions,” offers Mahta. Another possible explanation is that patients who live in areas with higher household incomes have higher expectations for complete or near-complete recovery with higher quality of life, compared to patients from lower income neighborhoods who may not have the same expectations. "This could explain the higher rates of withdrawal from life-sustaining treatments among patients from higher household incomes," suggests Mehta.
Clinicians have an ethical obligation to ensure that families and healthcare proxies receive accurate, unbiased information regarding prognostication. This should include best- and worst-case scenarios and available treatment options. “It’s important to consider cultural values and healthcare literacy, and the educational background of family members, when having goals of care discussions,” adds Mahta.
Many patients and family members make end-of-life decisions based on concerns about financial hardship brought on by medical costs, reports Holland Kaplan, MD, assistant professor of clinical ethics and general internal medicine at the Center for Medical Ethics and Health Policy at Ben Taub General Hospital, a safety net hospital. Patients with limited financial resources may not have access to hospice or palliative care resources at the end of life that could improve their comfort. Additionally, patients with low socioeconomic status may be less likely to have family members or others to act as surrogate decision-makers when they lack decision-making capacity because of housing insecurity, incarceration, or other factors. “Patients with no support system or who lack capacity are referred to as ‘unrepresented,’ since they have no one to make decisions on their behalf,” notes Kaplan. In those cases, depending on the state in which the patient is receiving care, decision-making might default to physicians, chaplains, ethics committees, or other parties. “Even if a patient does have capacity, making decisions near the end of life is very difficult without any support,” says Kaplan. If patients have limited health literacy, this can make it particularly difficult for them to engage in informed medical decision-making, especially if they have minimal support from family or friends.
“Clinicians may subconsciously make recommendations based on quality of life for all patients. But this can particularly happen with patients with low socioeconomic status,” says Kaplan.
Patients with low socioeconomic status may also be more likely to distrust hospitals and clinicians. This is more likely if patients perceive that a clinical team is pushing them to limit treatment, or if the patients are aware of historical injustices against particular groups of people, says Kaplan. Ethicists can address these concerns in these ways, offers Kaplan:
- Encouraging clinicians to recognize and mitigate biases that could be affecting treatment recommendations for patients with low socioeconomic status.
- For patients with low socioeconomic status who are thought to be unrepresented, ensuring that a complete search has been conducted for next of kin. “If there is someone who can assist with decision-making for patients with limited decision-making capacity, that individual should be involved in the patient’s care. Different states have different approaches to decision-making for patients without capacity, so the decision-maker may differ depending on the state the patient is in,” says Kaplan.
- Helping to ensure that a clinician’s level of communication is appropriate for the patient’s level of health literacy.
“In cases where patients or families distrust the healthcare system, ethicists might be able to act as neutral mediators and try to help rebuild trust,” suggests Kaplan.
References
1. Haripottawekul A, Stipanovich A, Uriarte SA, et al. The impact of socioeconomic status on decision on withdrawal of life-sustaining treatments in aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2025; Jan 7. doi: 10.1007/s12028-024-02197-7. [Online ahead of print].
2. Melmed KR, Lewis A, Kuohn L, et al. Association of neighborhood socioeconomic status with withdrawal of life-sustaining therapies after intracerebral hemorrhage. Neurology. 2024;102(3):e208039.
When ethicists consult on a case involving end-of-life decision-making, discussions center around the patient’s goals and values, prognosis, and preferences. Yet, income and insurance status are two other factors that affect the likelihood of patients withdrawing life-sustaining treatments, a recent study suggests.
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