palliative care across the continuum: how to improve...

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CAHSAH • CHAPCA Annual Conference & Expo May 22‐24, 2018, Monterey, CA

2018 California Association for Health Services at Home

Palliative Care Across the Continuum:

How to Improve Complex Care While

Reducing Costs

VJ Periyakoil, MD

Stanford University School of Medicine

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Learning objectives

• Identify the geriatric and palliative care workforce shortage in caring for medically complex aging patients

• Recognize the expanding role of out‐patient palliative care to improve care of chronically ill patients.

• Identify at least 2 strategies to improve access to outpatient palliative care.

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The ethno‐geriatrics imperative

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Health disparities are persistent and pervasive

• Racial disparities in life expectancy are a clear indicator for health inequity.

• Disparities in interhospital transfers

• Therapy denial for octogenarians and nonagenarians with stage II/III rectal adenocarcinomas

• Pain care disparities

Health indicators for ethnic patients

More likely to be poor

• Seventeen percent for older Black men, 16 percent for older Hispanic men, and 13 percent for older Asian men lived in poverty in 2014 compared to only 5% of Non Hispanic Whites.

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Health disparities impose a tremendous financial toll on the nation:

• Directs costs

• Indirect costs

• Medical Expenditure Panel Survey (MEPS) for the years 2002–2006

• Take a guess: How much will we save by eliminating health disparities?

Complexities of Culture

• Individual embedded in multiple layers of social systems, each with its own culture or subculture

• Different parts of culture are expressed at different times

• Some parts of culture or unrecognized

• Continuum of acculturation

• Health care has its own culture

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Culture in Action

• Provides a set of rules that govern life

• Basis of attitudes, beliefs and behaviors

• Influences what is considered “normal”

• Guides decision making process and the decisions

• Helps solve problems using implicit rules

• Influences how people react to outsiders

Key factors

• Acculturation

• Health literacy

• English proficiency

• Decision making

• Trust issues

• Cultural concepts of distress

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Explanatory Model of Illness

What do you call the illness?What do you think has caused the illness?Why do you think the illness started when it did?How does the illness work?How severe is the illness? What kind of treatment do you think the patient should

receive? What results do you expect?What are the chief problems the illness has caused?What do you fear most about the illness?

Kleinman, J Fam Pract. 1983;16(3):539‐545.

Culture of medicine

• Empirism

• Meliorism

• Evidence based medicine

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Biases

• Conscious biases

• Unconscious biases

Interdependence v. Independent Cultures

ASIAN VALUES

Interdependence

Group orientation

Age and experience

Soft‐spoken/Indirect

Collaboration

Group is more important than individual

AMERICAN VALUES

• Independence

• Self‐reliance

• Youth

• Out‐spoken/Direct

• Competition

Individual is more important than the group

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Confucianism: 5 Basic Human Relationships

1. Ruler to Ruled

2. Father to Son: Filial piety: “…Being good as a son and obedient as a young man is the root

of a man’s character.”

3. Elder Brother to Younger Brother

4. Husband to Wife dyad

5. Friend to Friend

Confucianism had no need of war, because if everyone is following their proper role then there was no need for war.

Chinese Character for Death

• A pictograph depicting 2 people, one living, next to one dead.

• The Chinese concept of death embodies those of grief, loss, and mourning.

• Death is not a personal experience limited to the one who dies.

• Death is absorbed into the interdependent relational framework.

• The role of the family is to protect the ill from bad news

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Protective Truthfulness

• Truth is important but not more important than hope.

• Truth Loss of hope Loss of will to live

• Truth can be withheld if it will increase needless suffering.

• It is the job of the family to protect the ill

Cross‐cultural Conflict:Negative spiral

• We are normal. Our way is the right way: Ethno‐centrism ( belief)

• Don’t know much about them ( fact)

• Cant understand their language ( fact)

• What they are doing does not seem normal (judgment)

• They are wrong/unreasonable (judgment)

• They are wasting my time and energy. (judgment)

• They are willful and malicious (judgment)

• They are trying to manipulate me (judgment)

• I will not take this from them anymore (decision)

• I will make them see reason. (decision)

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Staging a Productive Cross‐cultural Interaction

Before the interaction:

• Learn the bio‐psycho‐social‐spiritual facts.

• Learn their explanatory model

• Allow sufficient time

• Prepare the ambience ( quiet, private place)

• Get an interpreter (if needed)

• Take a learning stance

Staging a Productive Cross‐cultural Interaction

During the encounter:

• Transparency in agenda

• Language: Use their terms

• Mirroring/Reflecting

• Self‐disclosure:

– “Help me understand…”

– Tell me more….”

– “How can I help…”

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palliative care across the continuum: how to improve...

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