I once suggested "palliative care" to a patient of mine--a black man who was dying of cancer. "Dr. Payne," he replied to my offer of what I considered a painless and dignified death, "do you talk to all of your patients about this?"

Among African Americans, my patient is not alone in resisting efforts to free himself from the sort of fate many white Americans say they fear: a painful death while tied to machines that sustain life at great human and financial cost. African Americans are significantly less likely to prepare a living will, talk to their doctors about end-of-life care or to participate in a hospice program. When death is inevitable and imminent, blacks are twice as likely as whites to request life-sustaining treatments that can make dying a miserable experience for both patients and their families.

As an African American physician trained in pain management and palliative and end-of-life care, I have been asking myself what can be done to address these attitudes among black Americans. The answer is important because doctors who treat African American patients should understand that there may be differences in the way patient and doctor would choose to die. In addressing this resistance, we may succeed in giving many African Americans the gift of "a good death" when death is the only possible outcome.

Few people--patients or doctors--understand or request palliative care, an increasingly common approach to care at the end of life. With palliative care, both the patient and doctor recognize that though the disease cannot be cured, some quality of life can remain. This form of care focuses far less on life-saving measures than on relief of pain and other physical symptoms while it addresses the patient's emotional, social and spiritual needs. It does not treat the person as if he or she is on the brink of death. Indeed, it neither hastens nor postpones death. It simply recognizes that life can be meaningful and rewarding even if one is diagnosed with a terminal illness.

In my experience many patients, especially African Americans and members of other medically under-served minority groups, tend to think of "palliative care" as "giving up hope." I suspect this is so because many African Americans fear their cultural and personal values will not be respected when they are dying. They sometimes worry that their race and socioeconomic status make them more "disposable" and that treatment decisions will reflect that attitude. They do not see palliative and hospice care as offering better care at the end of life. Many worry, as my patient did, that palliative care is really a code word for "no care" or "less care."

Statistics indicate that many African Americans do not have access to good health care. For example, a report published in October in the New England Journal of Medicine showed that African Americans with lung cancer are less likely to undergo surgery--and therefore less likely to survive the disease--than white patients.

Physicians, nurses and other health care providers in hospital settings should be better educated in pain management and palliative care. This training should include a greater understanding of differences in the way blacks and whites may perceive end-of-life care. African Americans would be more likely to respond positively to providers who are specifically trained to discuss alternatives to life-sustaining treatments with minority-group patients.

Because studies indicate that most minority communities are served predominantly by minority physicians, affirmative action programs at medical schools should be maintained and perhaps expanded. This would improve minority community's access both to health care, in general, and to physicians who are sensitive to minority attitudes toward end-of-life care.

Pharmacies in minority neighborhoods should be encouraged to carry the  controlled substances necessary to provide adequate pain relief to area residents for whom such medication has been prescribed. Medications essential for treatment of pain, infections and other conditions must be affordable and accessible.

As we try to implement these ideas, we will encounter a skeptical audience. A few years ago in Houston, I invited a group of African American clergymen to hear about alternatives for end-of-life care, hoping they would pass on the message to their flocks. They listened politely and then said, in essence: "How can you ask us to trust an institution that one generation ago would not let us in the door? And given our goal of gaining greater access to cancer care, why are we talking about limiting access to treatment at the end of life?"

The medical community's long, sorry history of racism and unethical behavior toward African Americans must be acknowledged and corrected. And then we must move beyond this to help African Americans improve access to all medical services, including palliative and hospice care--which will allow us to die "the good death" to which we are all entitled.

Reprinted from The Washington Post, February 15, 2000