St. Paul hospice physician explains why there are racial disparities in end-of-life care

After a long career, Dr. Dennis Cross is now doing what he calls "my most meaningful work."

The Woodbury doctor, 72, cares for hospice patients through Our Lady of Peace in St. Paul; he considers their families to be his patients as well.

Hospice has become a welcome option that millions of families seek for end-of-life care. But significantly fewer people of color choose hospice for themselves or their loved ones. According to the Minnesota Network of Hospice and Palliative care, 53% of Minnesota white patients used Medicare hospice benefits at the end of life compared to 38% of patients of color. That Minnesota gap is slightly larger than on the national level.

Dr. Cross talked about racial disparities in this aspect of medicine and the efforts to share the value and comfort of hospice with communities of color.

Q: Why do you think a disproportionate number of people of color have not embraced hospice care?

A: There are many reasons for the reluctance. One of the big ones is the idea that taking care of a loved one at the end of life is the family's job and responsibility, they should do it all. I tell people, you can participate in the plan we tailor for your mom or granddad, you can be very involved with their personal needs, but let us help.

Q: A recent study by geriatric researchers at Duke University concluded that Black Americans are more likely to experience untreated pain at the end of life because of the disparity in using hospice. What explains that?

A: There's a different philosophy and approach in hospice than in a hospital setting where curing the patient is the goal. In hospice, comfort is the goal.

Hospice care includes medication to relieve pain for the patients. They are not in distress and so their families are not as troubled with seeing them suffer.

These are patients with heart failure, cancer, liver disease who have a projected lifespan of six months. It's a sensitive topic but I show them their MRIs, talk frankly about how we've exhausted their treatment. My role is to help people understand dying is part of living and hospice is a special way to care for them. We emphasize living the last days as fully as possible.

Q: What else contributes to this hesitancy?

A: Among African Americans, there's a legacy of distrust with health care. Older folks who are now the age to enter hospice know about the Tuskegee experiments and other such mistreatment. They've experienced discrimination and have a lifetime of interacting with white doctors who didn't listen and take time with them. They've been talked down to and they missed having compassionate experiences with American medicine.

No one they trust has visited with them about the benefits of hospice and what to expect with this choice.

I try to open the lines of communication with these patients and set the tone for respectful conversations.

Q: Do some of your patients think hospice services will be too expensive?

A: Many of my African American patients have told me, "We can't afford all this." When they meet with me, we explain that Medicare will cover the visits of the nurses and aides and also equipment, supplies, even things like respite care in the last six months of life.

We formulate a plan of care; if the patient is alert, they help determine what we're doing.

Hospice can also offer emotional counseling [and] spiritual support for the patient and families.

Q: What are some of the myths and misunderstandings that keep underserved communities from considering hospice?

A: They are comfortable talking about the funeral they want, but not how they want to die.

A lot of people think hospice is a place they have to go to. We know that being in a familiar setting is what's important, and for most people that's in their own home, where it's comfortable to have visitors, their music, prayer. We say we can bring all the services to the home or bring a caring environment in whatever place the person calls home — that could be a skilled nursing facility, assisted living or in a dedicated hospice facility.

Q: What's your advice for individuals and their families who are considering hospice?

A: For people of any race or circumstance, ask questions, don't be afraid.

My grandfather and my old uncles in Mississippi used to say they were "ready to move on up the hill." They were not afraid of death. Now people have false notions from the media and drug commercials that everything can be fixed. They might say, "My dad or granddad is dying, why aren't you treating him?"

So often there's a gap in understanding when a diagnosis is terminal. It's frightening when doctors say they can do no more.

When people don't want to accept that the time comes to pass away, they miss out on a peaceful experience.

Q: What have your experiences and your patients taught you about dying?

A: Although the thought of dying can overwhelm patients, a lot of times I've seen it where the patient is ready but their family is not. Then the dying person becomes the one providing comfort to family rather than the other way around.

Everything comes up when a loved one is dying, the beautiful connections and also the family discord. I've learned that people pass away and die how they lived. If they were an angry or distrustful person or they were estranged from family, they likely won't make a huge transformation.

Grief is expressed in many ways; some people are quiet and some are hysterical. At the end of life, Black and white, they want the same. Respect, empathy, honesty. I have learned the power of silence and the power of being present to just sit with a family in their grief.

Q: Do you think working with an African American doctor makes a difference for communities of color?

A: I do. When I make home visits sometimes they are shocked to see a Black doctor, but they instinctively know the stress and rigor it took me to get where I am. I am respectful in the tone of my voice and the way I make eye contact.

I understand their experience. I'm served in Vietnam and I was just out of the bush and back in my hometown of Milwaukee when I wanted to buy a car. I had my honorable discharge papers in my pocket, but 15 lending institutions turned me down before I got a loan from a man in an office over a restaurant. He charged 18% interest and I had to make weekly payments on my Buick.

I think I was only accepted into medical school because they didn't require a picture with my application.

Q: How did your background prepare you to work with hospice patients?

A: I started working in internal medicine and family practice and later I did a fellowship in nephrology and became a kidney specialist. I worked with those patients who, after many years of care, reached the decision to withdraw from dialysis. At the time we doctors didn't have much literature to help us. This taught me to be honest with patients and their families. I went on to work with Our Lady of Peace in 2008. I was medical director for 10 years; now I'm a staff physician.

The No. 1 tool for a hospice doctor is not in their bag. It's listening and communicating. People know when you are empathetic.

Q: Moving forward, what do you think might make a difference in closing this racial gap?

A: We need more African American hospice providers — doctor, nurses, chaplains. I'd like to get more medical students of color interested. Two of my children are now training to be physicians; one is a resident and the other is just graduating from medical school. In my training, I learned nothing about helping people at the end of life. This will be part of their education.

Kevyn Burger is a Minneapolis writer and broadcaster.