1. Yvonne M. Davila, MSN, RN

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

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

4.  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

5.  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

6. 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?”

7.  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

8.  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)

9.  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

10. 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

11.  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)

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

13. Cultural Factors to Consider in EOL Care  Collective Decision Making

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

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

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

17.  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

18. 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

19.  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

20.  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?

21.  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

22.  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?

23.  Resuscitation  Feeding & Hydration

24.  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?

25.  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.”

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

27.  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?

28.  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

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