A Twist on Cultural Diversity

In the Bay Area, where diversity is the norm, caregivers often represent cultures from all over the world, while the residents they care for may be mostly white, Anglo-Americans whose only language is English.  Perhaps a look at Anglo-American culture will reveal ways to improve interactions between caregivers and residents.

In an ideal world, two people trying to communicate would each reach out to understand the other’s culture.  Realistically, residents may not be capable of learning about the caregiver’s culture to meet the caregiver halfway.  It defaults to the caregiver to bridge the gap.

Generalizations

Although no statement about someone in a particular culture holds true for all members of that culture, we can make useful generalizations that steer us in the right direction.  For example, Anglo-Americans tend to be:

• Time oriented and more rigid about times: 10:45 means exactly 10:45.
• Direct, with less socializing before getting down to business.
• Less formal, speaking and acting casually.
• In general, Anglo-Americans want to be pain-free and may not be as stoic as some other cultures.  They may ask for pain medication where a person from another culture might “tough it out.” 

Comfort zones

Anglo-Americans may be more open about discussing personal matters, illness, and dying than others. 

If a resident wants to talk about a subject that makes you uncomfortable, you may want to find someone else who might be able to interact with him more directly—perhaps someone from social services, a chaplain, or another caregiver.

Researchers have demonstrated that Anglo-Americans generally require a larger personal space around them—in other words, they don’t stand as close when talking as people of other cultures do.*  For instance, they may become uncomfortable and step back if they feel another person is standing too close.

Independence

Anglo-Americans as a whole tend to be more individually oriented and like control. They leave less to fate and want to direct their own lives. American law requiring informed consent is based on the principle of autonomy—freedom of choice for the individual.  In other cultures the family or physician may make decisions for a patient, whereas in the US the individual is considered more important to decision-making than the family. 

Many Anglo-Americans see themselves as having a pioneer spirit and prefer not to be dependent on their children for care or support, while in other cultures it is expected that older people will live with their adult children. 

Best practices

Whenever cultures differ there is plenty of room for misunderstandings.  Usually neither is right or wrong—just different.  The best practice for communicating smoothly is to ASK.  Ask family members or the resident about how things are done in their family.   People are usually grateful that you are asking and appreciate that you are trying to learn about how they like to do things.

*The New York Times, “In Certain Circles, Two Is a Crowd,” Nov. 16, 2006.

This article was originally published in Pathways & Partners Newsletter - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Breaking Bad News to Asian Patients

Cultural Differences

Only 30% of Asian patients want to discuss life expectancy, whereas 60% of Western patients do.  Of Japanese patients, 78% want a family member present when learning news about a bad prognosis, starkly contrasting with US patients, 81% of whom prefer to be alone.

These are examples of the widely varying cultural preferences highlighted in “Breaking Bad News to Asian Patients,” an article subtitled “A Primer on Asian Bioethics,” by Desiree Lie at Medscape (http://www.medscape.com/viewarticle/744651_2).  She cites several studies about communicating bad news to patients, noting the contrast in preferences of Asian patients.

The author notes that although both Asian and Western bioethics stress truth-telling and autonomy, the Asian conception of autonomy considers the family as the autonomous unit whereas the Western application of the ethical principle in medicine generally refers to the individual.  Lie states that in Asian culture, the first person to be told about a diagnosis of cancer is the head of the household—not the patient.  Lie acknowledges that traditions vary within cultures and within the same cultural group in different geographic regions.

Lie suggests 1) asking the patient what he or she prefers when having a diagnosis presented, 2) finding out who is the center of decision-making in the family, and 3) inviting the patient to share “ancestral values” about illness, the role of family members and spiritual beliefs.  These kinds of conversations may furnish you with clues to the best routes of communication.

Author Lie says, “Allowing [the patient] to make the initial decision of how to be given news about her diagnosis gives her and her family ‘face’ and is likely to improve follow-up, communication, satisfaction, adherence, and future management of her disease.”

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 23.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Hospice Facts & Figures: 2010 Snapshot

The National Hospice and Palliative Care Organization (NHPCO) has released facts and figures for 2010. Key statistics in the report, which mainly compares data from 2009 to 2010, include:

• 1.58 million hospice patients served
• Average length of service was 67.4 days
• Median length of service 19.7 days
• 66.7 % patients died at home
• 21.9% died in hospice inpatient facilities
• 11.4% died in acute care hospitals
• 87.2% of hospice patients were 65 or older: 38% were 85 or older
• 35.6% deaths with diagnosis cancer; 13% deaths with diagnosis dementia

The percentage of non-white Caucasian patients increased in every category: 11% multiracial or other race in 2010, compared to 8.7% in 2009; 8.9% v. 8.7% Black/African American; 2.5% v. 1.9% Asian, Hawaiian, other Pacific Islander; and 0.3% v. 0.2% American Indian or Alaskan native. 
 

Source: www.nhpco.org/files/public/Statistics_research/2011_Facts_Figures.pdf

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 23.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Hindus & Hospice

Many Hindu beliefs align with hospice and palliative care goals.  A senior research specialist at the City of Hope in Duarte explored the Hindu concepts of suffering, karma and reincarnation in a recent article in the Journal of Hospice and Palliative Nursing.

Susan Thrane, MSN, RN, OCN, explained that among other similarities, Hindus often believe that death should neither be sought or prolonged, values that reflect the hospice philosophy.  However, they do sometimes believe that physical suffering is beneficial in that it can lead to spiritual growth, perhaps resulting in a better birth in a future life.

Although palliative and hospice care usually seeks to relieve pain and suffering, it also seeks to help individuals meet their personal goals, and sensitive to cultural beliefs.

Thrane found that Hindus tend to be family oriented, and may often defer health care decisions to the oldest son. 

There are an estimated 2.3 million Hindus in the US.

Cultural Sensitivity in Caregiving

One definition of culture:  "The constellation of values, norms and behavior guidelines that are shared by a group of individuals."  -Reflections on Nursing Leadership, 1st Qtr 2001

American medicine applies certain bio-ethical principles, such as autonomy and truth-telling, that can be at odds with the values of some of the many cultures found in the Bay Area.
 
These Western bio-ethical principles are based on Anglo-European values, which are also reflected in American law.  People from other cultures, whether caregivers, patients or families, may bristle when healthcare providers attempt to adhere to these values.

Withholding from patients information needed to make informed treatment decisions is illegal. Yet in many cultures telling patients negative information about their health condition is harmful to the patient.  Talking to the patient instead of the oldest child may also be seen as an infringement on the proper role of the family.
 
Distrust of the system

Significant distrust of the healthcare system exists.  In a group of culturally mixed elders in New York City researchers found: 

• Many equated less aggressive treatment with abandonment.
• Many thought having an advance directive was harmful, especially if it burdened one person.
• Most were reluctant to name anyone but a family member as a proxy or agent. 

Another example would be the African-American history of slavery and exploitation as test subjects.   African-Americans are half as likely as Anglos to opt for treatment to improve quality of life at the expense of length of life, even if pain will be constant. 

People that are poorer or socially disadvantaged expect to be denied care and often regard advance directives as legal devices of the health care system to deny care.  Some close-knit families feel that advance directives are destructive, and are incredulous on learning about laws that conflict with family decision-making.

One pattern seems to transcend almost all cultures: the elderly tend to have and prefer a passive voice in decision-making (e.g. “Doctors do the best they can”). 

Cultural multiplicity

In one culture illness may be seen as a test of faith and withdrawing treatment may be construed as interfering with God’s will, while in another using extraordinary treatments may be considered interfering with God’s will.

Pacific Island cultures may feel dying outside the home will leave the departed wandering without a place to rest while in another Asian culture, Chinese, death may be seen as a harbinger of more bad luck for the family of the deceased, so the patient may want to avoid dying at home. 

In many cultures, language and thought shape reality.  Talking about death must be avoided in places as diverse as Greece, China, Italy, Mexico, Korea, and countries in the Horn of Africa.

Can’t Know All Cultures

Clearly, we cannot know all cultures.  So how do we go about being culturally sensitive?  Proceed with caution.  Here are some things to bear in mind when working with a culturally diverse population:

• Not all members of a particular culture share the same beliefs.
• Find out how much the resident wants to know.
• Ask who the patient would like to be informed about health issues.
• Ask who to discuss treatments and outcomes with.

Above all, leave your cultural beliefs at the door when you go to work.  Deciding what the patient should or should not know is a form of paternalism.  It is also a distortion of the healthcare provider’s role as a patient advocate.

Consider taking a “values history.”  Find out:

• The patient’s perception of roles of caregivers and physician.
• The importance of self-sufficiency to patient.
• His or her attitude toward life (what brings enjoyment).
• What the patient fears most.
• What would be important to the person when dying?
• What is their religious background and belief system?

Although we want to avoid stereotyping, generalities can be useful: “I know that in some families of your culture we see [                   ].  Is this true in your family also?”

In a nutshell

Cultural sensitivity can be reduced to a few simple concepts:

• Leave your own cultural beliefs and biases at the door.
• Ask questions, then listen.  

Bio-Ethical Principles

• Autonomy: individual rights trump all
• Truth-telling: patients have a right to full disclosure
• Justice: resources should be equitably allocated.
• Confidentiality: Patients have a right to privacy
• Beneficence: act in the best interest of the patient
• Non-malfeasance: do no harm
• Responsibility: agree and adhere to regimen

At Pathways...

Early during the admission visit, the nurse asks the patient how much information about their health condition they would like to know, and whether they want to make their own healthcare decisions.

If they do not want to be the decision maker or know about their condition, we ask who they would like us to speak to.

If the patient does not speak and understand English very clearly, the nurse calls the AT&T language line and asks these questions via a translator. At subsequent visits a family member may translate.

Documenting this exchange meets the ethical principles of autonomy and truth-telling while respecting the patient’s cultural beliefs.