Yvonne M. Davila, MSN, RN

Cultural Competence

at the End of Life

Death is not a medical event. It is a personal and family story of profound choices, of momentous words, and telling sciences.

Dr. Steve Miles

Why do HCPs Need to be Trained in Cultural

Competency?

www.omhrc.gov/claswww.nap.edu

www.hhs.gov/ocr/lep/guide.htmlwww.jointcommission.org

Cultural Competency as a strategy Allows HCP to understand,

appreciate, & work with individuals from cultures other than their own

Responding to current & projected demographic changes in the U.S.

Eliminating long-standing disparities in the health status of people

Improving quality of services Meeting legislative, regulatory, and

accreditation mandates Gaining a competitive edge in the

marketplace Decreasing the likelihood of

liability/malpractice claims

Better quality of life-trajectory of serious illness

Reduced non-beneficial care near death

Adaptation to medical to illness realities

Enhanced goal-consistent care

Positive family outcomesReduced costs

EVIDENCE that Early Discussions about

Serious IllnessGoals of Care & EOL

Preferences Improves Care

Indications for Communication

Solid tumor with metastases, hypercalcemia, or spinal cord compression

CHF, class III or IV with 2/hospitalizations

CKD, on dialysis, age 75 years/older COPD, on home oxygen w/FEV1 <

35% predicted All patients whose physicians

answer “no” to the follow question: “Would you be surprised if this patient died in the next year?”

Communication for Patient with Serious and Life-

Threatening Illness

American College of Physicians High Value Care Advice

Systematic integration of structured discussions in the EHR

Training & Education Use of qualified interpreters

Dedicated & Structured sections in the EHR

Quality & Timing of conversations about serious illness care goals

Offer practical advice for clinicians about quality communication (serious illness care plan)

Promising Practices

Language Barriers Availability & effective use of

written translated materials & appropriate use of interpreters

Conflicts regarding death & dying beliefs and values

Conflicts about revealing diagnosis or whom information is shared with

McNamra (1997)

Patients want the truth about prognosis

You will not harm your patient by talking about EOL issues

Anxiety is normal for both patient and clinician during these discussions

Patients have goals and priorities besides living longer

Learning about patient’s goals and priorities empowers you to provide better care

Basic Principles of EOL

Communication

Culturally Competent Skills Self-awareness**Treating each encounter

as a cross cultural experience

Recognize & challenge personal beliefs and assumptions

Respect values & beliefs which differ from one‘s own

Cultural diversity in relation to

dying, death, and grief will manifest itself on the basis

of family/social background, gender, age,

race/ethnicity, and religion or

spirituality

Perspective Death & Dying Health & Suffering Hospice & Palliative Care Perception of Pain (Pain Relief) Acceptance of Western health

care practices and their use of alternative traditional practices

Role of Spiritual & Religious beliefs and practices

Role of the family* Communication * Role of the patient in problem-

solving and in the process of decision-making

(Lopez, 2007)

Cultural Factors to

Consider in End of Life

Care

Cultural Factors to Consider in EOL

Death as a Taboo Subject

Death AcceptingDeath DenyingDeath Defying

Cultural Factors to Consider in EOL Care

Collective Decision Making

Cultural Factors to Consider in EOL Care

Perception of the Physician’s Status and health care experience in the country of origin

Cultural Factors to Consider in EOL Care

Perception of Pain and Request for Pain Relief

“Pain”“Hurt”“Ache”

Cultural Factors to Consider in EOL Care

Role of Religion and Faith

What do you think caused your illness?

Why do you think your illness started when it did?

What do you think this illness does to you?

How severe is your illness? What are the main problems your

illness has caused you? What do you fear most about your

illness? What kind of treatment would you

like to have? What are the most important

results that you would like to get from your treatment?

Arthur Kleinmann’s 8 questions

Explanatory Model

Questions to clarify cultural

generalizations and provide insight into

the patient’s personal meaning of the illness

ETHNICSFramework

E-ExplanationT-TreatmentH-HealersN-NegotiateI-InterventionC-CollaborateS-Spirituality

Kobylarz FA, Heath JM, Like RC, The ETHNICS Mnemonic; A Clinical Tool for Ethnogeriatric Education,” Journal of the American Geriatrics Society 2002, Sep: 50(9):1582-9

Concept of the illness explanatory model developed by Dr. Kleinman

Domains cultural aspect of health & illness

Does not replace the standard medical history taking process

Framework to facilitate communication during the clinical encounter

Designed to be integrated into the routine 15-minute visit

Each letter represents a cross cultural domain to explore

Used in any setting

ETHNICSFramework for

Culturally Appropriate Care

Determines how patients perceive their illness, condition, or symptoms

Facilitates communication

Direct question to be asked:Why do you think you have this?

Probe questions to be asked:-What do others say about these symptoms?-Do you know anyone else who has had this kind of problem?

Inquires about interventions (medical and alternative)

Used before and during the clinical encounter

Direct question:What have you tried for this…?

Probe questions:What kind of medicines, home remedies, or treatments have you tried for this illness?Is there anything you eat, drink, or do on a regular basis to stay healthy?What kind of treatment are you seeking from me?

Treatment

TREATMENT

Asks about ALL the HCPs (medical & alternative)

Before and in the clinical encounter

Direct question:Who else l have you sought help from for this?

Probe question: Have you sought help from

alternative or folk healers, friends, or other people who are not doctors for help with your problems?

HEALERS

Resuscitation

Feeding & Hydration

Inquiry to establish whether patients are willing to work actively with the HCP to see outcomes in a jointly acceptable manner

Builds on previously identified beliefs

Seek outcomes in a jointly acceptable manner that incorporate your patient’s beliefs

Direct question:How best do you think I can help you?

Negotiate

Discussion between patients and the HCP about a mutually proposed course of action

Direct statement:“This is what I think needs to be done now.”

Intervention

Allows patients and HCP to mutually discuss how the therapeutic

Direct question:“How can we work together on this?”

Provides the HCP with an understanding of how a patient’s faith or religion can affect their symptoms

Direct question:How can faith/religion/spirituality help you with this…..?

Tell me about your spiritual life. How can your spiritual beliefs help you with this? Spirituality

Systemic, institutional, interpersonal barriers

Disability related issues Communication impairments

Focuses on the acute and chronic visit

Awareness of cultural issues on 1. Establishing treatment priorities2. Influencing adherence3. Addressing EOL care

Translating Into Practice

Challenges

Bureau of Primary Health Care Resources and Services Administration, Department of Health and

Human Services, Cultural Competence: a Journey.

Developing cultural competence is an ongoing, life-

long journey for individuals, families, organizations, and

communities

“Maintaining cultural humility,

avoiding stereotyping,

engaging in mutually

respectful communication,

and fostering empowerment in relationships are

critical.”