Project Summary/Abstract Candidate: This K23 award will provide an opportunity for Dr. Brown to transition to an independently funded physician scientist with a focus on reducing and eliminating inequities in serious illness. This project builds on her previous work investigating disparities in communication and palliative care, and examining associations between socioeconomic status, race/ethnicity, and healthcare utilization at the end of life. Dr. Brown will attain expertise in research methods in health disparities and social determinants of health, creating and maintaining a cohort, advanced qualitative research methods, and refinement and implementation of a pilot randomized trial. This will occur through an integrated career development plan consisting of coursework, mentorship from highly accomplished and skilled independent researchers, and protected time to gain practical research experience. Environment: The University of Washington (UW) provides a rich academic environment and a broad range of educational and research resources including: the UW Division of Pulmonary, Critical Care, and Sleep Medicine Clinical Research Training Track, which provides a collegial and collaborative environment; the Cambia Palliative Care Center of Excellence; the School of Public Health; and the Institute of Translational Health Sciences. Dr. Brown has assembled a mentoring team with expertise in outcomes and social epidemiology, strong records of funding and publication, and success in training early-investigators. Research: This proposal outlines a mixed methods study with the following goals: 1) understand the associations between perceived discrimination, mistrust, communication, and healthcare intensity at the end of life; 2) elicit perspectives of marginalized patients who endorse experiencing healthcare discrimination and how this affects patient-clinician communication and healthcare decision-making during serious illness; and 3) perform a pilot randomized trial of an intervention to improve resilience and facilitate communication skills in patients who endorse experiencing discrimination from healthcare professionals. Dr. Brown will create and maintain a prospective cohort of patients with serious illness to investigate the relationships between perceived discrimination, mistrust, communication, and healthcare outcomes. Next, she will conduct semi-structured interviews with a sub-group of patients from this cohort and use modified grounded theory methods to understand patients' perspectives of the role of discrimination on communication and decision-making. Lastly, she will perform a pilot randomized trial of an established intervention (Promoting Resilience in Stress Management) to improve resilience and help facilitate goal-making and communication skills in patients who have experienced healthcare discrimination. Understanding how perceived discrimination affects communication and decision- making in serious illness will help contribute toward reducing inequities in the care of minorities with serious illness and other vulnerable patient populations.

Project Narrative Racial and ethnic minorities are more likely to experience high intensity, non-beneficial, burdensome and expensive care at end-of-life despite the fact that the majority of these patients prefer to die at home. The roles of perceived discrimination and lack of trust and how these factors affect communication and decision- making around the care one receives at the end of life are not understood. Understanding these associations will contribute important knowledge toward the development of interventions to improve communication, patient-reported outcomes, and goal-concordant care in patients who endorse experiencing perceived healthcare discrimination.