Cognitive Authority Theory: Reframing health inequity, disadvantage and privilege in palliative and end-of-life care.

Background: There persist disparities in access to quality palliative and end-of-life care, often based on avoidable injustice. Research and theory to explain this health inequity focuses on structural or individual-based factors, overlooking important relational factors between health professionals, patients and families.

Aim: To apply Cognitive Authority Theory in palliative and end-of-life care to explain neglected relational drivers of inequity in access and experience.

Methods: Cognitive Authority Theory, a middle-range theory of power relations between individuals and authority over knowledge, was developed from empirical and review data. This paper demonstrates its utility in explaining an overlooked component of inequity in palliative care: interactions between health professionals and patients/caregivers.

Results: Using examples from the palliative care literature, we characterise how people who are socially disadvantaged have fewer resources to exploit during consultations with health professionals which makes it difficult for them to have their voices heard, their choices prioritised by others, and to express their expertise. We examine the implications of health professionals' judgements of expertise for care access, experience, involvement and appropriateness. We offer a fresh perspective on the mechanisms by which stereotypes, bias and power imbalances between health professionals and patients reinforce existing health inequities, drawing on the role of social privilege in shaping inequity in palliative care.

Conclusion: This paper provides a new language to articulate relational drivers of inequity in palliative care. It explains how to use Cognitive Authority Theory to design and interpret research to determine how healthcare interactions reinforce both social privilege and social disadvantage at end-of-life.