OMEGA, Vol. 69(3) 271-282, 2014

END-OF-LIFE PREFERENCES IN AFRO-CARIBBEAN OLDER ADULTS: A SYSTEMATIC LITERATURE REVIEW

KAREN O. MOSS, MSN, RN, CNL ISHAN C. WILLIAMS, PH.D. University of Virginia, Charlottesville

ABSTRACT

Research suggests that older Blacks tend to prefer more aggressive treatment as they transition toward the end of life. African and Afro-Caribbean immigrants and their offspring are the fastest growing segments of the Black population in the United States. With the increasing population of Black older adults, the cost of end-of-life care is rising. This article presents a review of the literature on the end-of-life preferences of Afro-Caribbean older adults. Findings suggest that Afro-Caribbean older adults make end-of-life decisions with a significant emphasis on family structure, religion/spirituality, cultural identity, migration, and communication. Concerns regarding the meaning of end-of-life preparation and hospice are often viewed in ways that differ from that of healthcare providers. Future research is needed to investigate this process in the Afro-Caribbean older adult subset.

The proportion of the world’s population over the age of 60 will double from 11% to 22% between the years 2000 and 2050, with the number of people in this age group expected to increase from 605 million to 2 billion over the same period (WHO, 2012). The combination of ageing and modern medicine can inflict a more protracted death that can be more challenging than it was some years ago, prior to

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the evolution of today’s technology (Institute of Medicine, 1997). Passed in the United States in 1991, the Patient Self Determination Act specifies that patients should be informed of their right to make decisions concerning their medical care (The Library of Congress, 2012). According to this act, Medicare and Medicaidfunded healthcare organizations are to ensure that patient wishes with regards to the implementation of medical care decisions are carried out without discriminatory consequences determined by whether or not they possess an advanced directive (The National Library of Congress, n.d.). Such healthcare regulations assist in ensuring that individuals and families are reminded of the importance of addressing end-of-life (EOL) issues in a timely manner. Due to the rapid increase of in-patient hospital expenditures, healthcare spending during the last year of life is dramatically increased (Centers for Medicare & Medicaid Services, 2003). According to the federal government, 70% of healthcare expenditures are spent on older adults, 80% of which is done so in the last month of life (Mercury News Editorial, 2012). For racially and ethnically diverse individuals and families, specific barriers may arise related to religious or cultural differences, culturally appropriate healthcare practices, differing health beliefs, and access to services for care and support at the end of life (Carr, 2011; Siriwardena & Clark, 2004). A study conducted by Hanchate, Kronman, Young-Xu, Ash, and Emanuel (2009) found that, among Medicare decedents, spending in the last months of life was 32% more for Blacks in the United States than for Whites. The use of intensive care units and invasive procedures such as gastrostomies near the EOL contribute to higher costs even when consideration is made for a comparison of high hospice use in Whites (Hanchate et al., 2009). As Afro-Caribbean older adults are considered a part of the Black race, these data are likely to resemble the results of EOL spending observed in Afro-Caribbean older adults. In 2010 there were 40 million people (14%) in the United States that selfidentified as either Black alone or in combination with another race (United States Census Bureau, 2010). Persons who are considered Afro-Caribbean are of African descent or have migrated from the Caribbean region (Oxford Dictionaries, 2012). They are often from countries such as Jamaica, Haiti, and Barbados. Though not surrounded by the Caribbean Sea, the Bahamas and the Turks and Caicos Islands are also often considered to be part of the Caribbean due to their cultural and geographical similarities (Caribbean World Atlas, 2012). According to the Census 2000 Ethnographic Study (United States Census Bureau, 2003), African and AfroCaribbean immigrants and their offspring were the fastest growing segments of the Black population in the United States. Additionally, the Black population growth (alone or in combination), as reflected in the United States Census Reports (United States Census Bureau, 2010), exceeded that of the United States total population with a 15% increase. The Caribbean is also known as the West Indies (New World Encyclopedia, 2012). The number of descendants from the Caribbean residing in the United States was relatively small in the 19th century, but grew significantly after the

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Civil War (James, 2002). In 2005 there were between 2.6 and 3 million Caribbean individuals (of all races) in the United States with 1.5 million being Afro-Caribbean, representing 1% of the total population (The Schomburg Center for Research in Black Culture, 2005). More than 72% of Afro-Caribbean individuals were foreign-born, representing 4.6% of the Black population of the United States (The Schomburg Center for Research in Black Culture, 2005). The growth of this demographic segment provides an indication of the growing numbers of Afro-Caribbean individuals that reside in the United States. As migration to the United States from the Caribbean continues, subsequent generations may not continue to identify themselves with or even be aware of the existence of their Caribbean ancestry. Hence, this number may be under-reported. End-of-life preferences may be culturally based in Afro-Caribbean origins, despite the country of residence. As a result, there is a need to further understand EOL preferences in this group of African descendants. End-of-life care represents a significant part of healthcare provision. Researchers found that ethnic minorities, in general, are less likely to make formal EOL preparations (Carr, 2011). Such disparities in healthcare occur when the determination exists that a health outcome is seen between populations to a greater or lesser extent (Healthy People 2020, 2010). The impact of ageing in the AfroCaribbean community results in an increased number of Afro-Caribbean older adults seeking health services for advanced disease (Koffman & Higginson, 2001). Very little information is known about EOL preferences specifically in Afro-Caribbean older adults. The purpose of this systematic review is to provide an appraisal of the evidence as it relates to Afro-Caribbean older adult preferences at the end of life. METHOD The Cochrane Handbook of Systematic Reviews and Interventions (The Cochrane Collaboration, 2011) was used for the collection and presentation of this analysis. Searches of the following databases were conducted: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochran Review, Google, Google Scholar, Ovid MEDLINE, University of the West Indies Medical Journal, Web of Science, and Virgo. Amalgamations of the following search terms were used: African Caribbean, Afro-Caribbean, Caribbean, death, end-of-life, older African Caribbean, older Afro-Caribbean, Black Caribbean, West Indies, and United Kingdom. While conducting the initial search it was noted that much of the literature focused on Afro-Caribbean individuals residing in the United Kingdom. For this reason, it was decided to include the term United Kingdom in the search as well. This aided in yielding additional articles on the subject of Afro-Caribbean older adult EOL preferences. The articles reviewed were required to have a focus that specifically referenced older adults (aged 65 years and older) of AfroCaribbean or Black heritage in a major portion if not all of its sampling or

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discussion. Due to the paucity of literature with this focus, the time frame for the search was not restricted to yield the most evidence available. RESULTS Initial literature searches yielded 26 potential articles. Once further analyzed to ensure the inclusion criteria were met, 18 articles were excluded. Reasons for these exclusions centered on them focusing on minorities in general without a specific reference to Afro-Caribbean older adults. The lack of focus on older adults was the second most common exclusion criteria that resulted in the final review that consisted of eight articles that spanned from 1992 to 2012. Of these, there was one systematic review, three case analyses, one report, and three expert opinions. Table 1 presents a summary of the findings from this review. Several themes emerged: the significance of family structure, the unique facets that cultural identity and migration offers, religion/spirituality, the meaning of hospice and EOL care, and the importance of communication. Family Structure Blacks place a greater focus on family interdependence than on individual autonomy (Carr, 2011). Within the Afro-Caribbean older adult community there is a significant focus on the extended family structure, especially during times of death (Green, 1992). During illness, it is not uncommon for Afro-Caribbean older adults to be cared for in their own homes by family, friends, and/or church members (Goldstein, Anapolsky, Park, Immordino, & Ukoha, 2004; The Shap Working Party on World Religions in Education, n.d.). Grandparents are considered central to family relationships, thus a very high premium is placed on age as both wisdom and death are closely associated with the aging process (Green, 1992; Shap Working Party on World Religions in Education, n.d.). This presents a unique opportunity for Afro-Caribbean older adults to share wisdom regarding EOL with younger generations. It is often the rulings of the Afro-Caribbean older adult leaders within the family that predict the outcomes of many major family decisions. Carr (2011) proposed that individuals who witness the prolonged or painful death of a loved one may be motivated to avoid the same for themselves and other loved ones. The large gatherings present during the death of such respected individuals present unique opportunities to help others within the family to better understand and prepare for EOL themselves and thus can greatly improve this outcome for many others in the community as well. Cultural Identity and Migration In 2010, Healthy People 2020 identified cultural sensitivity as one of the influences on health behaviors across populations. This finding can be due to the fact that across all settings, cultural issues will remain a significant part of older

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adult care (Goldstein et al., 2004). According to Evans et al. (2012), AfroCaribbean older adults demonstrate an affinity for cultural identity when faced with particularly vulnerable circumstances such as at the end of life. Cultural origins influence the manner in which these individuals think about treatment and care at the end of life (Evans et al., 2012; Goldstein et al., 2004). The many effects of migration are often evident when Afro-Caribbean older adults relocate to another country. The shift that is made from traditional Caribbean, rural settings, to a society that is more technological, alters their attitude towards death (The Shap Working Party on World Religions in Education, n.d.). Some Afro-Caribbean older adults expressed the desire to die in the comfort of their own homes, located in the Caribbean (African Caribbean Consultation, 2010; Goldstein et al., 2004). The Shap Working Party on World Religions in Education (n.d.) found that Afro-Caribbean older adults expressed that death is viewed by other cultures as being mechanically distant, is soon forgotten, and has no role in the wider culture. This was said to have a notable difference in the perception of death in the Caribbean versus the United Kingdom. The same adjustment could also present a comparable challenge for Afro-Caribbean older adults adjusting to life in the United States. Religion/Spirituality The importance of religion and spirituality for Afro-Caribbean older adults at the EOL cannot be overstated. The availability of a facility and opportunity for prayer, a bible, and regular contact with a preferred minister and church were listed as potential barriers to desired care at the end of life (Green, 1992; African Caribbean Consultation, 2010). This significance presents another opportunity for Afro-Caribbean older adults to be formally educated about advanced directives and hospice in community-based settings using trusted church leaders. As AfroCaribbean older adults often identify themselves as churchgoers (Green, 1992), this can provide a unique opportunity to include family members in conversations about EOL preferences in the safety of the church environment. Meaning of End-of-Life Preparation and Hospice Participants in the African Caribbean Consultation (2010) conducted with residents of an Afro-Caribbean older adult housing community in the United Kingdom were reluctant to speak about death. Emphasized here was the lack of understanding of support needs and its impact on EOL care (African Caribbean Consultation, 2010). When asked about EOL plans, one participant expressed that she had already planned, made known, and paid for her funeral expenses (African Caribbean Consultation, 2010). This tendency to focus on funeral preparation when alluding to EOL as opposed to the care they receive prior to death can be a potential area for further education within this population.

Purpose

Design

Evans, N., Menaca, A., Andrew, E., Koffman, J., Harding, R., Higginson, I., Pool, R., & Gysels, M. (2012)

To systematically review all original studies related to minority ethnic groups and EOL care in the United Kingdom.

Systematic Review

African Caribbean To create a report Report on the consultaConsultation tion with an elderly (2010) African Caribbean community on the EOL care strategy

Author (year)

45 studies

N/A

Sample & Instrument

· Participants preferred to be cared for with honesty and openness about the dying process. · Respondents wanted professionals to communicate with families and keep them involved and informed. · Wanted opportunities to express wishes to family. · Concerns around use of hospice meant death imminent. · Hospital death was desired because of the experienced staff and support available. · Opportunities to practice religion/spiritual activities were sought. · Care desired at the EOL prevented because families fear discussing death. · Lack of understanding of support needs impacting EOL care. · Request frequent links with preferred minister and church. · Desired death with dignity and respect. · Ongoing access to family/friends/relatives was important. · Need for more culturally-tailored, individualized support. · Need to connect with relatives from overseas to care for them during dying process. · Lack of recognition or respect for their ethnicity cultural identity was highlighted. · Past experiences or mistrust of perceived or actual racism negatively impacts communication. · Cultural competency training can be based on minority ethnic needs in cultural terms. · Place of care, age structure, and death, communication and awareness of services contribute to substandard quality services and low service use.

Major Findings

Table 1. Description of Review Articles on End of Life in Afro-Caribbean Older Adults

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Koffman, J., & Higginson, I. (2001)

Green, J. (1992)

Goldstein, C., Anapolsky, E., Park, J., Immordino, M., & Ukoha, N. (2004)

Expert Opinion

N/A

· Cultural origins influence the way advanced practice nurses and older adults think about treatment and care at the end of life. · Cultural issues are and will remain a significant part of older adult care. · Respecting and learning older adult’s unique values and belief system is important in making care more culturally sensitive. · In the Caribbean, dying patients are often taken care of in the comfort of their own homes by friends, families and church members. · Individuals should die with comfort, dignity, and respect. · A high percentage of Afro-Caribbean older adults are church attenders. Expert N/A To examine the · Religious and cultural differences are likely to be minimized while island Opinion needs of the identity predominates at death. Afro-Caribbean · Grandparents are central in family relationships and play a significant role community in the in the rearing of grandchildren. United Kingdom. · Good family relations are maintained as they come together at the death of a loved one. · Extended family may wish to make prolonged and frequent visits and close family members will want to be present at the time of death. · Prayers are said together and the clergy visits. · Believe that the body must be intact for the after-life. · Are deeply offended by bodily disfigurement thus are not likely to agree to organ donation. · Are not likely to give consent for a post mortem—except in coroner’s case. · Feel that doctors are unapproachable and remote. · Feel unable to ask questions and communicate with doctors. · Deceased Black Caribbean participants were more likely to have fewer Retrospective N = 100 To provide a deaths in hospice and to have died in hospital, as compared to White Case Analysis (50 nativereport on EOL patients. born Whites experiences of & 50 Black · Hospital nurses were criticized for reluctance to devote time to patients Black Caribbean and their caregivers and their insensitivity to caregivers and family who Caribbeans individuals as wished to remain with them and the lack of empathy for dying patients. reported by · Examples of best preferences in palliative and culturally sensitive care caregivers should be extended to more health professionals via training and focused on satiseducation. faction with health services. To provide suggestions to Advanced Nurse Practitioners on how to address EOL care in patients’ cultures.

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· Migration from traditional West Indian rural communities to technological society has affected the attitude toward death. · Traditional Afro-Caribbean communities place a high regard on the extended family and age. · Wisdom and death are closely associated with aging. · Death is treated with dignity that is reserved for the aged. · Older adults have a place of reverence and respect in African and subsequently Afro-Caribbean cultures.

Expert Opinion

The Shap Working Party on World Religions in Education (n.d.)

N/A

· Social care and health processionals performing assessment interviews N = 45 with different cultural backgrounds than their own should allow (26 Black opportunities for interviewees to express information about their illness Caribbean that may include spiritual and religious beliefs as these may alter percep& 19 White tions of symptoms, illness, and treatment decisions. British

Case Analysis

Koffman, J., Morgan, M., Edmonds, P., Speck, P., & Higginson, I. (2008)

· Twice as many Black Caribbean patients preferred to die at home than N = 100 native-born Whites. (50 native· Family members of Black Caribbean patients believe more could have born been done to involve both them and the patient regarding location of Whites & death decision-making. 50 Black Caribbean)

Retrospective Case Analysis

To compare preferred location of death among deceased first generation Black Caribbean and native-born White patients. To examine the meanings of religion, spirituality and perceptions among Black and minorities in the United Kingdom living with cancer. To examine death as cultural phenomenon within the West Indian communities in Britain and relate these to the cultural changes in the West Indian community.

Koffman, J., & Higginson, I. (2004)

Major Findings

Design

Purpose

Author (year)

Sample & Instrument

Table 1. (Cont’d).

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Due to the extra care that can be provided in the event a loved one is terminally ill, the willingness to consider hospice services was also expressed (African Caribbean Consultation, 2010; Goldstein et al., 2004). However, the conflicting view that if one was to go to hospice it meant that death was eminent also emerged (African Caribbean Consultation, 2010). Some other participants preferred to die in the hospital where experienced staff would be present to provide needed support (African Caribbean Consultation, 2010). Many AfroCaribbean older adults prefer to be cared for at home by their children at the EOL (African Caribbean Consultation, 2010) with twice as many more than native-born Whites in a United Kingdom preferring to die at home (Koffman & Higginson, 2004). However, similar to the statistics seen in the general population, Koffman and Higginson (2004) found that Afro-Caribbean older adults tended to be more likely to die in hospital, citing reasons such as availability of needed treatment, the emotionally protective effect of an institutional death, or it being God’s will. Communication Communication between healthcare professionals and Afro-Caribbean older adult patients and families is considered a challenge. The preference exists among Afro-Caribbean older adults for professionals to liaise openly and honestly with family members about dying and the timelines associated, while keeping them informed and involved in EOL care (African Caribbean Consultation, 2010). With regards to the location of death, family members of Afro-Caribbean older adults feel as though more can be done to involve both them and the patient in this decision (Koffman & Higginson, 2004). Past experiences of mistrust, perceived or actual racism severely alters this communication process (Evans et al., 2012).

DISCUSSION Based on the evidence presented, the challenge to better understand the preferences and improve the quality of the EOL care provided to Afro-Caribbean older adults requires further research. There is a need for further education in a more culturally appropriate manner that can lead to a better quality of life for patients and families as they transition towards the end of life. This then begs the question: How is cultural competency really defined? Each person knows his/her culture best. As there are more diverse cultures and variances of those in existence today than ever before, it is challenging for healthcare providers to be well versed on the intricacies that accompany them all. The obligation is for each individual to share their personal wishes with their providers (Koffman, Morgan, Edmonds, Speck, & Higginson, 2008). This practice can play a very significant role in ensuring that care provided is both culturally sensitive and individually tailored to the unique needs of the patient and family (Koffman et al., 2008). This can promote the

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receipt of the best possible care at the EOL, especially when the cultural background of patients and providers differ (Koffman et al., 2008). Language barriers as a result of the existence of the various Caribbean dialects and the terms used in the healthcare setting could contribute to the communication obstacles that exist (Venters & Gany, 2011). Afro-Caribbean nursing staff could assist in bridging the communication gap between Afro-Caribbean patients/ families and other healthcare providers (Green, 1992). As researchers conceptualize the reasons why Afro-Caribbean older adults prepare for EOL in the manner in which they do, it can also lead to numerous changes within the approach of decreasing unnecessary suffering at the EOL in this population. There is a common desire to die with respect and dignity (African Caribbean Consultation, 2010; Goldstein et al., 2004; The Shap Working Party on World Religions in Education, n.d.). The significance of religion and spirituality presents another potential opportunity for Afro-Caribbean older adults to be formally educated in a community-based setting while using a trusted entity such as the church and its leaders. As Afro-Caribbean older adults often identify themselves as churchgoers (Green, 1992), this presents a prospect for them to learn more about their desire to experience death with dignity that is inclusive of family members becoming involved in such preparatory conversations as well. Limitations of the Literature From the evidence presented there is a need for further research to be conducted on this topic. In order to increase the understanding of clinical, cultural, organizational, and other perspectives or preferences that improve care for those approaching death, additional research with improved quality is needed (Institute of Medicine, 1997). The literature regarding EOL in Afro-Caribbean older adults is marginal and sparse. There is also little empirical evidence available. Additionally, much of the literature reported information from the United Kingdom or the United States. As the Caribbean is comprised of various independent countries which themselves possess diverse ethnic cultures, this presents additional challenges for data extrapolation. Further studies are needed to examine the EOL experiences of Afro-Caribbean older adults (Koffman & Higginson, 2004). Afro-Caribbean older adults possess a distinctive set of preferences linked to those that are culturally affixed, which undergird their decisions surrounding EOL preferences. The focus on family ties and respect for older adults provide an opportunity to improve attitudes towards the preparation for end of life. The importance of religion and spirituality cannot be overemphasized. Communication among healthcare professionals is identified as a key factor in improving EOL care of Afro-Caribbean older adults. The lack of hospice use and the desire to die at home are inconsistent. The potential implications of further qualitative or mixed methods research conducted in this area can assist with understanding this unique group of individuals while delivering optimal healthcare to patients and families. With a clearer understanding, society in general will be less apt to judge the preferences of

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those who are dissimilar. Understanding these differences in preferences could potentially bring about significant healthcare policy changes geared toward improving the efficiency and quality of the healthcare delivery system. An improved healthcare outcome in the wider Afro-Caribbean community could improve EOL care for Blacks in general and expectantly the population at large. ACKNOWLEDGMENTS The authors wish to acknowledge Dr. Karen Rose for her dedication to the professional and scholarly development of her doctoral student Karen Moss. REFERENCES African Caribbean Consultation. (2010, November 1). African Caribbean end of life care consultation, pp. 1-5. Caribbean World Atlas. (2012). Description. Retrieved from http://www.worldatlas.com/ webimage/countrys/carib.htm Carr, D. (2011). Racial differences in end-of-life planning: Why don’t Blacks and Latinos prepare for the inevitable? Omega: Journal of Death and Dying, 63(1), 1-20. Centers for Medicare and Medicaid. (2003). Last year of life expenditures. Retrieved from http://www.cms.gov/site-search/search-results.html?q=end%20of%20life Evans, N., Menaca, A., Andrew, E., Koffman, J., Harding, R., Higginson, I., et al. (2012). Systematic review of the primary research on minority ethnic groups and end-of-life care from the United Kingdom. Journal of Pain and Symptom Management, 43(2), 261-286. doi: 10.1016/j.jpainstmman.2011.04.012 Goldstein, C., Anapolsky, E., Park, J., Immordino, M., & Ukoha, N. (2004). Research guiding practice related to cultural issues at end of life care. Geriatric Nursing, 25(1), 58-59. doi: 10.1016/j.gerinurse.2003.12.007 Green, J. (1992). Death with dignity: The Afro-Caribbean community. Nursing Times, 88(8), 50-51. Hanchate, A., Kronman, A. C., Young-Xu, Y., Ash, A. S., & Emanuel, E. (2009). Racial and ethnic differences in end-of-life costs: Why do minorities cost more than Whites? Archives of Internal Medicine, 169(5), 493-501. doi: 10.1001/archinternmed.2008.616 Healthy People 2020. (2010). Disparities. Retrieved from http://healthypeople.gov/ 2020/about/DisparitiesAbout.aspx Institute of Medicine. (1997). Approaching death improving care at the end of life. Retrieved from http://www.nap.edu/catalog/5801.html James, W. (2002). Explaining Afro-Caribbean social mobility in the United States: Beyond the Sowell thesis. Society for Comparative Study of Society and History, 40(2), 218-262. doi: 10.017/S0010-4175/02/218-262 Koffman, J., & Higginson, I. J. (2001). Accounts of careers’ satisfaction with healthcare at the end of life: A comparison of first generation Black Caribbeans and White patients with advanced disease. Palliative Medicine, 15(4), 337-345. UI: 12054151. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=4762822&site =ehost-live Koffman, J., & Higginson, I. (2004). Dying to be home? Preferred location of death of first-generation Black Caribbean and native-born White patients in the United Kingdom. Journal of Palliative Medicine, 7(5), 628-636.

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Koffman, J., Morgan, M., Edmonds, P., Speck, P., & Higginson, I. (2008). “I know he controls cancer”: The meanings of religion among Black Caribbean and White British patients with advanced cancer. Social Science & Medicine, 67(5), 780-789. doi: 10.1016/j.socscimed.2008.05.004 Mercury News Editorial. (2012). Mercury News editorial: Healthcare spending on end-of-life treatment is irrational. Retrieved from http://www.mercurynews.com/ opinion/ci_19905093 New World Encyclopedia. (2012). Caribbean. Retrieved from http://www.newworldencyclopedia.org/entry/caribbean Oxford Dictionaries. (2012). Afro-Caribbean. Retrieved from http://oxforddictionaries. com/definition/english/Afro-Caribbean Siriwardena, A. N., & Clark, D. H. (2004). End-of-life care for ethnic minority groups. Clinical Cornerstone, 6(1), 43-48. The Cochrane Collaboration. (2011). Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0), J. Higgins & S. Green (Eds.). Retrieved from www. cochrane-handbook.org The National Library of Congress. (n.d.). Bill summary & status 101st Congress (18981990) H.R. 4449 CRS Summary. Retrieved from http://thomas.loc.gov/cgibin/ bdquery/z?d101:HR04449:@@@D&summ2=m& The Shap Working Party on World Religions. (n.d.). Death and the Afro-Caribbean peoples. Retrieved from http://www.shapworkingparty.org.uk/specialedition/2_ lashley.html The Schomburg Center for Research in Black Culture. (2005). Caribbean immigration. Retrieved from http://www.inmotionaame.org/home.cfm United States Census Bureau. (2003). Generation X speaks out on civic engagement and the decennial census: An ethnographic approach. Census 2000 Ethnographic Study. Retrieved from https://www.google.com/search?q=Generation+X+speaks+out+on+ civic+engagement+and+the+decennial+census%3A+an+ethnographic+approach&ie =utf-8&oe=utf-8&aq=t&rls=org.mozilla:en-US:official&client=firefox-a United States Census Bureau. (2010).The Black population: 2010. Retrieved from www.census.gov/prod/cen2010/briefs/c2010br-06.pdf Venters H., & Gany, F. (2011). African immigrant health. Journal of Immigrant & Minority Health, 13(2), 333-344. doi: 10.1007/s10903-009-9243-x World Health Organization (WHO). (2012). Interesting facts about aging. Retrieved from http://www.who.int/ageing/about/facts/en/index.html

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End-of-life preferences in Afro-Caribbean older adults: a systematic literature review.

Research suggests that older Blacks tend to prefer more aggressive treatment as they transition toward the end of life. African and Afro-Caribbean imm...
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