care across cultures: communicating about serious illness

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  • Care Across Cultures: Communicating About Serious IllnessAndrea Chatburn, DO, MAMedical Director for Ethics, PHCMarch 29, 2016

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  • Learning ObjectivesExplore when and how to disclose serious illnessEnhance understanding of own cultureExpand understanding of diverse cultural perspectivesImprove communication across cultures and reduce conflict with patients and families

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  • Nothing to disclose financiallyOther disclosures:I am not a sociologist or an anthropologist

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  • We are diverse

    Profound worldwide demographic change. It is inevitable that each of us will car for patients with cultural backgrounds different from our own. I would add that each of us will work alongside a colleague, team member, co-worker or consultant who has a cultural background and world view different from our own.*

  • Vast amount of diversityWhat can caregivers be expected to know about individual cultures?

    How can we respond to cultural issues in an ethically appropriate manner?

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  • Avoid stereotypesDo not make value assumptions based on patients cultural heritage

    Culture is not monolithic

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  • Importance of Professional TranslatorThe difference between the right word and the almost right word is the difference between lightening and a lightening bug.-Mark Twain

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  • OR:

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  • What is culture?https://www.polleverywhere.com/free_text_polls/PyQIdkayg30VJ4K*

  • What would you personally consider "bad news"?https://www.polleverywhere.com/free_text_polls/yQY0xXjoenopIHa*

  • Elements of a Culture Group

    How does culture influence patients in healthcare decision making?*

  • Influence of Values in HealthcareExpectations about healthLanguage used in describing symptomsExpectations about medical careProfessional relationshipsDecision making style

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  • What are the essential parts of your own cultural background?https://www.polleverywhere.com/free_text_polls/WW1Pm5tT9Z2I13i*

  • Providence Model for Ethics

    In many cultures, individual patient autonomy is less important than protecting patients from distress and fulfilling obligations to family members*

  • WorldviewCollectivisInterdependent with groupGood outcome includes group wellbeingLower need for individual privacyPrivacy need may be a group privacy

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  • WorldviewIndividualisIndependent of groupGood outcome dependent on expression of autonomyHigh need for privacy

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  • WorldviewTeleologyRules-based decision makingDeontologyConsequences based decision making

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  • Worldview

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  • IndividualistCollectivistRule-basedStyle PreferencesConsequences

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  • IndividualistCollectivistRule-basedStyle PreferencesConsequencesValues mostly independent, consequence-based decision makingValues mostly independent, rule- based decision makingValues mostly group consequence-based decision makingValues mostly group rule-based decision making

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  • Layers within CultureNationalRegionalSocial & EmploymentGenderGenerationFunctionImmigration & acculturation

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  • Competing Cultural InfluencesAfrican American cultural influences on End of Life CareExperience of slavery, Tuskegee syphilis experimentation, racial profiling

    Death as obstacle to overcomeRich spiritual tradition

    Death as Welcome friend

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  • Core Values & VirtuesIdentifying the values in conflictReflection on own personal valuesReflection on application of values to the situation

    How does culture influence paitents?*

  • Ring Theory of Personhood

    SocietalRelationalIndividualInnateKrishna, 2014.

    Singapore. *

  • Its all about relationshipsRelated family vs. family of choiceWho does the patient trust?Who does the family trust?Calm vs. Storm

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  • Resources for cultural knowledgeAsking the patientLiterature- medical and narrativeColleagues with culture knowledgeCultural Interpreters & Religious leaders

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  • Providence Model for Ethics

    In many cultures, individual patient autonomy is less important than protecting patients from distress and fulfilling obligations to family members*

  • What is a good outcome?5 yo girl Lia Lee from Laos living in California with severe epilepsy

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  • How do we ask about culture?Case #1Mr. Z 70 year oldSpanish-speakingChange in bowel habits, weight lossDx: Colon cancerSon and daughter ask physician to not tell their father he has cancer

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  • How do we ask about culture?Health Literacy:1 in 5 American Adults read at or below 5th grade levelMost healthcare materials are written above 10th grade level

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  • Guess the Grade Level:Do you have a sharp shooting pain or a dull aching pain?

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  • Answer: 3rd Grade

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  • Guess the Grade Level:What are your information seeking preferences?

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  • What are your information seeking preferences?https://www.polleverywhere.com/multiple_choice_polls/LuYqBOlFNdjJBK5*

  • Answer: 10th Grade

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  • Guess the Grade Level:If your heart were to stop would you want us to restart it?

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  • If your heart were to stop, would you want us to restart it?https://www.polleverywhere.com/multiple_choice_polls/lNTI0m9xtmuqmFZ*

  • Answer: 2nd Grade

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  • Guess the Grade Level:Are you worried about suffocating?

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  • Are you worried about suffocating?https://www.polleverywhere.com/multiple_choice_polls/K3ASGExrkDogjws*

  • Answer: 10th Grade

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  • Case #2Ms. P is a 25 yo womanRussian-speaking onlyIn ER with fever, confusionFamily refuses LP but requests we

    do everything

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  • Fear or Love?Fear as motivator for behaviorI am AFRAID that I will lose what I haveI am AFRAID I will NOT get what I want

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  • Difficulty is about unmet needsDifficult patient and family behaviors may be a surrogate for communicating unmet needsFailure to meet needs may be real or percieved

    When we call a family difficult what we really mean is that we the clinicians, are experiencing a difficult encounter (Wessler)*

  • Responding to difficult encountersLayering exercise

    Difficult encounters make us fees frustrated, uncomfortable, or ineffective, defeated (Duxbury)*

  • What does it mean to reveal Gods love?Routinely ask patients how they would like to receive information, test resultsWork to understand the concerns and values of the patient and familyOpen ended questionsSeek to understand what is a good outcome, what do they fear?Find common ground

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  • BibliographyCrawley, 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 SciencesKrishna, 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, 5th 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.htmlhttps://readability-score.com/

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    *Profound worldwide demographic change. It is inevitable that each of us will car for patients with cultural backgrounds different from our own. I would add that each of us will work alongside a colleague, team member, co-worker or consultant who has a cultural background and world view different from our own.*

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    *What is culture?https://www.polleverywhere.com/free_text_polls/PyQIdkayg30VJ4K*What would you personally consider "bad news"?https://www.polleverywhere.com/free_text_polls/yQY0xXjoenopIHa*How does culture influence patients in healthcare decision making?*

    *What are the essential parts of your own cultural background?https://www.polleverywhere.com/free_text_polls/WW1Pm5tT9Z2I13i*In many cultures, individual patient autonomy is less important than protecting patients from distress and fulfilling obligations to family members*

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    *How does culture influence paitents?*Singapore. *

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    *In many cultures, individual patient autonomy is less important than protecting patients from distress and fulfilling obligations to family members*

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    *What are your information seeking preferences?https://www.polleverywhere.com/multiple_choice_polls/LuYqBOlFNdjJBK5*

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    *If your heart were to stop, would you want us to restart it?https://www.polleverywhere.com/multiple_choice_polls/lNTI0m9xtmuqmFZ*

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    *Are you worried about suffocating?https://www.polleverywhere.com/multiple_choice_polls/K3ASGExrkDogjws*

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    *When we call a family difficult what we really mean is that we the clinicians, are experiencing a difficult encounter (Wessler)*Difficult encounters make us fees frustrated, uncomfortable, or ineffec

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