Multicultural Issues in Geriatric Practice: A Palliative Care Approach Cynthia X. Pan MD, AGSF, FACP Psychosocial Consortium Plenary Weill Cornell Medical.

Multicultural Issues in Geriatric Multicultural Issues in Geriatric Practice:Practice:

A Palliative CareA Palliative CareApproachApproach

Cynthia X. Pan MD, AGSF, FACPCynthia X. Pan MD, AGSF, FACPPsychosocial Consortium PlenaryPsychosocial Consortium Plenary

Weill Cornell Medical College Division ofWeill Cornell Medical College Division ofGeriatrics and GerontologyGeriatrics and Gerontology

November 5, 2010November 5, 2010

Objectives

Teach effective communication skills in eliciting the values and health care practices of the older adult in order to enhance treatment options and outcomes

Present overview of multicultural issues for older adults in a palliative care setting.

Review screening tools on cultural and spiritual history.

Screen a video of an older adult, his family and treating physician and evaluate the interactions.

33

Culture Culture Culture is multidimensional and includes shared Culture is multidimensional and includes shared

knowledge, beliefs, values, attitudes, rules of knowledge, beliefs, values, attitudes, rules of behavior, world viewbehavior, world view

Context of culture dependent on social, Context of culture dependent on social, religious, linguistic, dietary, geographical and religious, linguistic, dietary, geographical and historical factors as well as personal history, historical factors as well as personal history, work experience, education, and economic work experience, education, and economic statusstatus

““Medicine” as a culture in itselfMedicine” as a culture in itself• Sub-cultures within it, by specialty or disciplineSub-cultures within it, by specialty or discipline (Adams, 1995)(Adams, 1995) (National Maternal and Child Health Center on Cultural Competency, 1997).(National Maternal and Child Health Center on Cultural Competency, 1997).

Cultural CompetenceCultural Competence Cultural competence comprises four Cultural competence comprises four

components:components: AwarenessAwareness of one's cultural worldview of one's cultural worldview AttitudeAttitude towards cultural differences towards cultural differences KnowledgeKnowledge of different cultural practices and of different cultural practices and

worldviewsworldviews Cross-cultural skillsCross-cultural skills Cultural competence results in an ability to Cultural competence results in an ability to

understand, communicate with, and effectively understand, communicate with, and effectively interact with people across cultures. interact with people across cultures.

(Cross, Bazron, Dennis, & Isaacs, 1989). (Cross, Bazron, Dennis, & Isaacs, 1989). (Davis, 1997). (Davis, 1997).

Ref: Office of Minority Health; http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15

Self AwarenessSelf Awareness

Be aware of our own cultural values and Be aware of our own cultural values and beliefs –beliefs –

Cultural assessment toolCultural assessment tool

Reaching out to Latino and Asian Elderly in Reaching out to Latino and Asian Elderly in Queens about Palliative Care & HospiceQueens about Palliative Care & Hospice

El Correo-Queens, April 2008

77

Palliative Care Planning Issues Palliative Care Planning Issues in Geriatric Carein Geriatric Care

Identify key participants for decision making, Identify key participants for decision making, with sensitivity to gender issueswith sensitivity to gender issues

Choose explanatory modelChoose explanatory model Determine language taboos including Determine language taboos including

disclosure/truth tellingdisclosure/truth telling Define filial responsibilitiesDefine filial responsibilities Understand the meaning of suffering and painUnderstand the meaning of suffering and pain Elicit meaning of death Elicit meaning of death

Communication in a Communication in a Multicultural Practice Multicultural Practice

Ask about preferred terms of addressAsk about preferred terms of address Offer respectful nonverbal communicationOffer respectful nonverbal communication Elicit decision making approach including: Elicit decision making approach including:

AAttitudes towards disclosure and consentttitudes towards disclosure and consent

Knowledge about advance directivesKnowledge about advance directives

End-of-life decision making and intensity of careEnd-of-life decision making and intensity of care

Ask about traditions/health beliefs and past Ask about traditions/health beliefs and past medical care, past medical decisionsmedical care, past medical decisions

Doorway Thoughts: Cross-Cultural Health Care for Older Adults. Vol 1/2. Jones and Bartlett Publishers. 2004. AGS.

Blackhall et al. Ethnicity and attitudes toward patient autonomy. JAMA

Cross Cultural Communication: Cross Cultural Communication: ETHNIC(S) TemplateETHNIC(S) Template

EExplanationxplanation TTreatmentreatment HHealersealers NNegotiateegotiate IInterventionntervention CCollaborateollaborate SSpirituality/Seniors/Support systempirituality/Seniors/Support system

Kobylarz. Kobylarz. J Am Geriatr Soc. 2002 Sep;50(9):1582-9.J Am Geriatr Soc. 2002 Sep;50(9):1582-9.

Goals of Care: A G O O D Goals of Care: A G O O D ConversationConversation

GG oals of care (given context of serious oals of care (given context of serious illness)illness)

OO ptions ptions OO pinion/medical recommendation pinion/medical recommendation DD ocumentation ocumentation

“VALUE” GuidelinesFor Family Meetings

Value and appreciate family commentsAcknowledge / address emotions Listen activelyUnderstand the patient as personElicit family questions

Lautrette A, et al. N Engl J Med 2007; 356:469-478. http://depts.washington.edu/eolcare/instruments/index.html

Cultural PreferencesCultural Preferences

Caveat: Avoid stereotypesCaveat: Avoid stereotypes Use cultural preference as background Use cultural preference as background

Ask each older adult:Ask each older adult:• ““This is what I understand about beliefs in your This is what I understand about beliefs in your

culture. Does this apply to you?”culture. Does this apply to you?”

Consider potential roles multidisciplinary Consider potential roles multidisciplinary team members might play.team members might play.

• What are the disciplines’ strengths?What are the disciplines’ strengths?

1313

African-American CulturesAfrican-American Cultures Slavery: poverty, persecutionSlavery: poverty, persecution Belief in God: healing power, prayer, miraclesBelief in God: healing power, prayer, miracles Trust in health care services: limitedTrust in health care services: limited Tuskegee Syphilis Experiment (Alabama)Tuskegee Syphilis Experiment (Alabama) Decision-making locus: mixedDecision-making locus: mixed Longevity - may trump quality of life yearsLongevity - may trump quality of life years AD - legalized genocide, denial of care, AD - legalized genocide, denial of care,

premature deathpremature death

Gamble. Am J Public Health. 1997

Green et al. Ethn Dis. 2000

Corbie-Smith, et al. J Gen Intern Med. 1999

Mr. J.Mr. J. Mr. L. J. is an 86 yo African American male with Mr. L. J. is an 86 yo African American male with

advanced CAD, heart failure, diabetes, and advanced CAD, heart failure, diabetes, and chronic kidney disease. He was admitted for chronic kidney disease. He was admitted for exacerbation of heart failure and pneumonia, exacerbation of heart failure and pneumonia, which are controlled at this point. The medical which are controlled at this point. The medical team plans to discharge him to SNF, with a plan team plans to discharge him to SNF, with a plan not to re-hospitalize. A palliative care consult not to re-hospitalize. A palliative care consult was called. was called.

Mr. J. is upset because the medical resident Mr. J. is upset because the medical resident repeatedly referred to him as “Larry” and repeatedly referred to him as “Larry” and addressed him in a loud voice as though he addressed him in a loud voice as though he were hard of hearing. were hard of hearing.

When Mrs. J. arrived, the medical team was in When Mrs. J. arrived, the medical team was in conference and not available to answer her conference and not available to answer her questions.questions.

Mr. JMr. J

Mr. and Mrs. J. had been asked to complete a DNR Mr. and Mrs. J. had been asked to complete a DNR document ASAP. Mrs. J. was afraid that if she completed document ASAP. Mrs. J. was afraid that if she completed the DNR, doctors would no longer provide care to her the DNR, doctors would no longer provide care to her

husband.husband. Mrs. J. was upset that the resident told Mr. J. that he should Mrs. J. was upset that the resident told Mr. J. that he should

not be admitted to the hospital again as “nothing else could not be admitted to the hospital again as “nothing else could be done”. She feels Mr. J is in a great deal of pain that has be done”. She feels Mr. J is in a great deal of pain that has not been adequately treated. not been adequately treated.

Mrs. J. does not want her husband in an SNF. The closest Mrs. J. does not want her husband in an SNF. The closest facility is miles away from home, inconvenient for visits. It facility is miles away from home, inconvenient for visits. It is a Jewish facility and Mrs. J was worried Mr. J would not is a Jewish facility and Mrs. J was worried Mr. J would not like the food. like the food.

Mr. J.Mr. J. Intervention:Intervention: Mr. & Mrs. J. met with the palliative care and Mr. & Mrs. J. met with the palliative care and

medical team and their questions were medical team and their questions were answered. They have no children but did have answered. They have no children but did have strong community church support, and two strong community church support, and two very involved nephews. very involved nephews.

Care plan: Mr. J. to be d/c’d with home Care plan: Mr. J. to be d/c’d with home hospice, church support, and medical f/u with hospice, church support, and medical f/u with hospice medical director. hospice medical director.

When pain was better controlled and his When pain was better controlled and his concerns were addressed, he agreed to DNR. concerns were addressed, he agreed to DNR.

1717

Hispanic CulturesHispanic Cultures Death: natural part of the life cycleDeath: natural part of the life cycle Familismo: welfare of the familyFamilismo: welfare of the family Jerarquismo: respect for hierarchyJerarquismo: respect for hierarchy Personalismo: trust borne of mutual respectPersonalismo: trust borne of mutual respect Espiritismo: effect of good & evil spiritsEspiritismo: effect of good & evil spirits Presentismo: present orientationPresentismo: present orientation Sympatia: the meaning of nodding?Sympatia: the meaning of nodding?

Marshall et al. Health Care Ethics for the 21st C. 1998

Koenig & Gates-Williams. West J Med. 1995. Understanding cultural difference in caring for dying patients.

Triandis et al. Simpatia as a cultural script of Hispanics. J of Personality & Soc Psychology. 1984

1818

Asian & Pacific Island culturesAsian & Pacific Island cultures Filial piety and family responsibilityFilial piety and family responsibility Treatment termination = ancestor murderTreatment termination = ancestor murder

• Fear of being judged by communityFear of being judged by community

Language taboos: “death/dying”Language taboos: “death/dying”• Associations with numbers, colorsAssociations with numbers, colors

Avoidance of undue sufferingAvoidance of undue suffering Illness as a family eventIllness as a family event Good death: dying with a full stomachGood death: dying with a full stomach

• Importance of feeding; history of disasters/starvationImportance of feeding; history of disasters/starvation Death outside the home: wandering soulsDeath outside the home: wandering souls

Death in the home: ? Omen, young children, crowdingDeath in the home: ? Omen, young children, crowding

Candib. Truth telling and advance planning at the end-of-life. Fam Syst Health 2002

Yeo & Hikuyeda. Cultural issues in end-of-life decision making. Sage 2000

Blackhall et al. Ethnicity and attitudes toward patient autonomy. JAMA 1995.

1919

……Asian & Pacific Island Asian & Pacific Island culturescultures

生 老 病 死生 老 病 死 一 切 尽 在 不 言 中一 切 尽 在 不 言 中

2020

Islamic CulturesIslamic Cultures

Medication: “do something good”, hospitals are Medication: “do something good”, hospitals are where people diewhere people die

Demanding behavior => the family caresDemanding behavior => the family cares Planning for death => brings on evil eyePlanning for death => brings on evil eye Privacy: resistance to stating wishesPrivacy: resistance to stating wishes Truth telling: an unforgivable actTruth telling: an unforgivable act

Cultural CompetenceCultural Competence

Caveat: Avoid stereotypesCaveat: Avoid stereotypes Ask, don’t judgeAsk, don’t judge People are more alike than differentPeople are more alike than different Take advantage of strengths and expertise Take advantage of strengths and expertise

multidisciplinary team members might multidisciplinary team members might have.have.

VideoVideo

Mr. KochiMr. Kochi

End of Life/CondolencesAs Teaching Moments

With the older adult ask questions i.e.: "What's the most important thing you did?“ Offer to do an ethical will

With the mourners reach out, ask for stories, describe your relationship with

older person, include memories, express sympathy, offer non-judgmental view whatever end of life decisions were made

Conclusion Cultural beliefs impact all aspects of life, but come into Cultural beliefs impact all aspects of life, but come into

sharp relief during serious illness and end of life caresharp relief during serious illness and end of life care Culturally sensitive & competent care includes an Culturally sensitive & competent care includes an

awareness of one’s own cultural identity and value awareness of one’s own cultural identity and value preferences preferences

Simple tools are available to introduce and help Simple tools are available to introduce and help guide the conversationguide the conversation

General information on cultural diversity is critical General information on cultural diversity is critical but we are always working with individualsbut we are always working with individuals

Cultural competence combines self-reflection and an Cultural competence combines self-reflection and an ability to see other perspectives in order to create patient-ability to see other perspectives in order to create patient-centered treatment plans for those with serious illnesses centered treatment plans for those with serious illnesses or at the end of lifeor at the end of life

““Every person is Every person is

Like all others,Like all others,

Like some others, Like some others,

Like no other.”Like no other.”

- Buddhist proverb- Buddhist proverb

ReferencesReferences

See handoutSee handout