We have made remarkable progress in reducing the use of feeding tubes for patients with advanced dementia.  This has been due to the leadership of people like Susan Mitchell and Joan Teno, among others.  One might hope that this reduction in use of feeding tubes has been in part due to advance care planning discussions that helped align care and treatment with patients goals.   How then, do we explain the concerning findings in a pair of recent papers demonstrating high rates of mechanical ventilation among patients with dementia?  In today’s podcast, we talk with Rashmi Sharma, who in JAGS found that rates of mechanical ventilation rose from 4% to 12% among whites with advanced dementia and 9% to 22% among blacks between 2001 and 2014.  One in five blacks with advanced dementia admitted from a nursing home received mechanical ventilation.  That’s startling.   And Zhi Jia found in a Medicare sample that Asians were more likely to receive mechanical ventilation than whites, and disparities were higher for older Asians with dementia compared to cancer.   We have made progress, due to the leadership of GeriPal superstars.  But even as we make progress in feeding tubes, it doesn’t seem to have translated across the board to mechanical ventilation, a burdensome and potentially non-beneficial treatment for patients with dementia.  The fact that rates are highest among older blacks and Asians is particularly concerning. Though the reasons behind this are complex, it’s likely that structural racism plays a major role in these growing inequalities.   We have more work to do. -@AlexSmithMD