Yvonne M. Davila, MSN, RN

Death is not a medical event. It is a personal and family story of profound choices, of momentous words, and telling sciences.

 Cultural Competency as a strategy  Allows HCP to understand, appreciate, & work with individuals from cultures other than their own

 Responding to current & projected demographic changes in the U.S.  Eliminating long-standing disparities in the health status of people  Improving quality of services  Meeting legislative, regulatory, and accreditation mandates  Gaining a competitive edge in the marketplace  Decreasing the likelihood of liability/malpractice claims

 Better quality of life- trajectory of serious illness  Reduced non-beneficial care near death  Adaptation to medical to illness realities  Enhanced goal-consistent care  Positive family outcomes  Reduced costs

Indications for Communication  Solid tumor with metastases, hypercalcemia, or spinal cord compression  CHF, class III or IV with 2/hospitalizations  CKD, on dialysis, age 75 years/older  COPD, on home oxygen w/FEV1 < 35% predicted  All patients whose physicians answer “no” to the follow question: “Would you be surprised if this patient died in the next year?”

 Systematic integration of structured discussions in the EHR  Training & Education  Use of qualified interpreters  Dedicated & Structured sections in the EHR  Quality & Timing of conversations about serious illness care goals  Offer practical advice for clinicians about quality communication (serious illness care plan ) Promising Practices

 Language Barriers  Availability & effective use of written translated materials & appropriate use of interpreters  Conflicts regarding death & dying beliefs and values  Conflicts about revealing diagnosis or whom information is shared with McNamra (1997)

 Patients want the truth about prognosis  You will not harm your patient by talking about EOL issues  Anxiety is normal for both patient and clinician during these discussions  Patients have goals and priorities besides living longer  Learning about patient’s goals and priorities empowers you to provide better care

Culturally Competent Skills  Self-awareness**  Treating each encounter as a cross cultural experience  Recognize & challenge personal beliefs and assumptions  Respect values & beliefs which differ from one‘s own

 Perspective Death & Dying  Health & Suffering  Hospice & Palliative Care  Perception of Pain (Pain Relief)  Acceptance of Western health care practices and their use of alternative traditional practices  Role of Spiritual & Religious beliefs and practices  Role of the family*  Communication *  Role of the patient in problem- solving and in the process of decision-making (Lopez, 2007)

Cultural Factors to Consider in EOL Death as a Taboo Subject Death Accepting Death Denying Death Defying

Cultural Factors to Consider in EOL Care  Collective Decision Making

Cultural Factors to Consider in EOL Care  Perception of the Physician’s Status and health care experience in the country of origin

Cultural Factors to Consider in EOL Care  Perception of Pain and Request for Pain Relief “Pain” “Hurt” “Ache”

Cultural Factors to Consider in EOL Care  Role of Religion and Faith

 What do you think caused your illness?  Why do you think your illness started when it did?  What do you think this illness does to you?  How severe is your illness?  What are the main problems your illness has caused you?  What do you fear most about your illness?  What kind of treatment would you like to have?  What are the most important results that you would like to get from your treatment? Arthur Kleinmann’s 8 questions Explanatory Model Questions to clarify cultural generalizations and provide insight into the patient’s personal meaning of the illness

ETHNICS Framework E-Explanation T-Treatment H-Healers N-Negotiate I-Intervention C-Collaborate S-Spirituality Kobylarz FA, Heath JM, Like RC, The ETHNICS Mnemonic; A Clinical Tool for Ethnogeriatric Education,” Journal of the American Geriatrics Society 2002, Sep: 50(9):1582-9

 Concept of the illness explanatory model developed by Dr. Kleinman  Domains cultural aspect of health & illness  Does not replace the standard medical history taking process  Framework to facilitate communication during the clinical encounter  Designed to be integrated into the routine 15-minute visit  Each letter represents a cross cultural domain to explore  Used in any setting Framework for Culturally Appropriate Care

 Determines how patients perceive their illness, condition, or symptoms  Facilitates communication  Direct question to be asked: Why do you think you have this?  Probe questions to be asked: -What do others say about these symptoms? -Do you know anyone else who has had this kind of problem?

 Inquires about interventions (medical and alternative)  Used before and during the clinical encounter  Direct question: What have you tried for this…?  Probe questions: What kind of medicines, home remedies, or treatments have you tried for this illness? Is there anything you eat, drink, or do on a regular basis to stay healthy? What kind of treatment are you seeking from me? TreatmentTreatment TREATMENT

 Asks about ALL the HCPs (medical & alternative)  Before and in the clinical encounter  Direct question: Who else l have you sought help from for this?  Probe question:  Have you sought help from alternative or folk healers, friends, or other people who are not doctors for help with your problems?

 Resuscitation  Feeding & Hydration

 Inquiry to establish whether patients are willing to work actively with the HCP to see outcomes in a jointly acceptable manner  Builds on previously identified beliefs  Seek outcomes in a jointly acceptable manner that incorporate your patient’s beliefs  Direct question: How best do you think I can help you?

 Discussion between patients and the HCP about a mutually proposed course of action  Direct statement: “This is what I think needs to be done now.”

 Allows patients and HCP to mutually discuss how the therapeutic  Direct question: “How can we work together on this?”

 Provides the HCP with an understanding of how a patient’s faith or religion can affect their symptoms  Direct question: How can faith/religion/spirituality help you with this…..? Tell me about your spiritual life. How can your spiritual beliefs help you with this?

 Systemic, institutional, interpersonal barriers  Disability related issues  Communication impairments  Focuses on the acute and chronic visit  Awareness of cultural issues on 1.Establishing treatment priorities 2.Influencing adherence 3.Addressing EOL care

Bureau of Primary Health Care Resources and Services Administration, Department of Health and Human Services, Cultural Competence: a Journey.