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/