Care Across Cultures: Communicating About Serious Illness
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Transcript of Care Across Cultures: Communicating About Serious Illness
Care Across Cultures: Communicating About Serious IllnessAndrea Chatburn, DO, MAMedical Director for Ethics, PHCMarch 29, 2016
Learning Objectives
• Explore when and how to disclose serious illness
• Enhance understanding of own culture• Expand understanding of diverse cultural
perspectives• Improve communication across cultures
and reduce conflict with patients and families
Nothing to disclose financially
Other disclosures:I am not a sociologist or an anthropologist
We are diverse
Vast amount of diversity
• What can caregivers be expected to know about individual cultures?
• How can we respond to cultural issues in an ethically appropriate manner?
Avoid stereotypes
• Do not make value assumptions based on patient’s cultural heritage
• Culture is not monolithic
Importance of Professional Translator
“The difference between the right word and the almost right word
is the difference between lightening and a lightening bug.”
-Mark Twain
OR:
Elements of a Culture Group
Influence of Values in Healthcare
• Expectations about health• Language used in describing symptoms• Expectations about medical care• Professional relationships• Decision making style
Providence Model for Ethics
Clinical Integrity Beneficence
AutonomyJustice &
Non-Maleficence
Worldview
• Collectivis– Interdependent with group– Good outcome includes group wellbeing– Lower need for individual privacy– Privacy need may be a group privacy
Worldview
• Individualis– Independent of group– Good outcome dependent on expression of
autonomy– High need for privacy
Worldview
• Teleology– Rules-based decision making
• Deontology– Consequences based decision making
Worldview
Individualist Collectivist
Rul
e-ba
sed
Style PreferencesC
onse
quen
ces
Individualist Collectivist
Rul
e-ba
sed
Style PreferencesC
onse
quen
ces
Values mostly independent, consequence-based decision making
Values mostly independent, rule- based decision making
Values mostly group consequence-based decision making
Values mostly group rule-based decision making
Layers within Culture
• National• Regional• Social & Employment• Gender• Generation• Function• Immigration & acculturation
Competing Cultural Influences
• African American cultural influences on End of Life Care– Experience of slavery, Tuskegee syphilis
experimentation, racial profilingDeath as obstacle to overcome
– Rich spiritual tradition Death as “Welcome friend”
Core Values & Virtues
• Identifying the values in conflict• Reflection on own personal values• Reflection on application of values to
the situation
Ring Theory of Personhood
SocietalRelationalIndividual
Innate
Krishna, 2014.
It’s all about relationships
• Related family vs. family of choice• Who does the patient trust?• Who does the family trust?• Calm vs. Storm
Resources for cultural knowledge
• Asking the patient• Literature- medical and narrative• Colleagues with culture knowledge• Cultural Interpreters & Religious leaders
Providence Model for Ethics
Clinical Integrity Beneficence
AutonomyJustice &
Non-Maleficence
What is a “good” outcome?
5 yo girl Lia Lee from Laos living in California with severe epilepsy
How do we ask about culture?
Case #1•Mr. Z – 70 year old•Spanish-speaking•Change in bowel habits, weight loss•Dx: Colon cancer•Son and daughter ask physician to not tell their father he has cancer
How do we ask about culture?
• Health Literacy:– 1 in 5 American Adults read at or below 5th
grade level– Most healthcare materials are written
above 10th grade level
Guess the Grade Level:
“Do you have a sharp shooting pain or
a dull aching pain?”
Answer: 3rd Grade
Guess the Grade Level:
“What are your information seeking preferences?”
Answer: 10th Grade
Guess the Grade Level:
“If your heart were to stop would you want us
to restart it?”
Answer: 2nd Grade
Guess the Grade Level:
“Are you worried about suffocating?”
Answer: 10th Grade
Case #2
• Ms. P is a 25 yo woman• Russian-speaking only• In ER with fever, confusion• Family refuses LP but requests we
“do everything”
Fear or Love?
Fear as motivator for behavior•I am AFRAID that I will lose what I have•I am AFRAID I will NOT get what I want
Difficulty is about unmet needs
• Difficult patient and family behaviors may be a surrogate for communicating unmet needs
• Failure to meet needs may be real or percieved
Responding to difficult encounters
Layering exercise
What does it mean to “reveal God’s love?”
• Routinely ask patients how they would like to receive information, test results
• Work to understand the concerns and values of the patient and family
• Open ended questions• Seek to understand what is a good outcome,
what do they fear?
• Find common ground
Bibliography• Crawley, L., et. al. Palliative and End of Life Care in the African American Community. JAMA 2000;
284:2518-2521.• Crawley, L., et al. Strategies for Culturally Effective End of Life Care. Annals of Internal Medicine.
2002;136:673-679.• Duxbury, J. Difficult Patients. Oxford: Butterworth-Heinemann. 2000.• Gurmankin AD, et al. The effect of numerical statements of risk on trust and comfort with
hypothetical physician risk communication. Medical Decision Making 2004; 24:265-271.• Health Literacy: A Prescription to End Confusion Lynn Nielsen Bohlman,et al., eds. Committee on
Health Literacy, Institute of Medicine, National Academy of Sciences• Krishna, LKR. Accounting for Personhood in Palliative Sedation: the Ring Theory of Personhood.
Medical Humanities. 2014. 40:.17-21 • Lo, Bernard. Resolving Ethical Dilemmas: A Guide for Clinicians, 5 th ed. 2013. Philadelphia. LWW.
Ch. 44, p. 323-331.• Periyakoil, VJ. Hear today Gone Tomorrow: Health Literacy. AAHPM 2014. • Wessler, R. et al. Succeeding with difficult clients: Application of cognitive appraisal therapy.
Academic Press.• https://www.tamu.edu/faculty/choudhury/culture.html• https://readability-score.com/