1. Cultural Competency in End-of-Life Communication Kamal Masaki, M.D. Department of Geriatric Medicine John A. Burns School of Medicine University of Hawaii

2. Acknowledgement Dr. Karen Lubimir and Dr. Aida Wen in the Department of Geriatric Medicine at JABSOM Manuscript in press in Hawaii Medical Journal

3. Demographics - Ethnicity 2010 U.S. Census: only 65% of U.S. population was non-Hispanic White 2050: expected to decrease to 46% Hawaii: over 70% of population is of Asian and/or Pacific Islander heritage API group is diverse, representing more than 30 ethno-cultural groups

4. Factors Affecting Health Behaviors Ethnic heritage Cultural norms Socioeconomic status Generation (cohort effects) Community Immigration status and timing

5. End-of-Life Discussions 1990 congressional enactment of the Patient Self Determination Act Encourage discussion of advanced directives and end-of-life decision making Patients and families may have different cultural beliefs about death and terminal illnesses

6. Possible Cultural Clashes? Western medicine assumes principles of autonomy and individualism Other cultures view collectivism or family centeredness as a core principle for decision making “Do no harm” may have different cultural interpretations (eg. giving a terminal diagnosis, use of morphine)

7. Patient-Centered Approach Culturally humble communication skills to respect individual variability More valuable than just knowing facts about a particular ethnic group More effective than just using cultural stereotypes

8. Communication Workshop Developed by Dr. Aida Wen Part of the required 4-week rotation in geriatrics and palliative care for fourth year medical students at JABSOM 3 interactive workshops, 1 hour each Faculty coach students with role playing and provide feedback on communication skills

9. Communication Workshop Overview of each topic by faculty Problem Based Learning (PBL) case Role playing in groups of 4 (patient, family member, physician, observer), with each person given a script Observer writes down observations Debriefing & feedback in large group

10. Session 1 – Breaking Bad News Overview of techniques for breaking bad news in a culturally sensitive manner PBL case: progression of cancer Teaching points: - appropriate use of interpreters - clarifying who makes decisions

11. Session 2 – Advanced Directives Overview of cultural factors that guide medical decision making PBL case: same as before, discussing goals of care and advanced directives Teaching points: - understand patient & family perspectives - avoid stereotypes, “patient-centered” - POLST form

12. Session 3 – Withdrawal of Rx Overview of assessing capacity, role of surrogates, and futility of care PBL case: withdrawal of artificial nutrition and ventilation in a terminal cancer patient with multisystem failure Teaching points: - sensitivity to minority populations - understanding “hope for cure” & “hope for peaceful and dignified death”

13. Evaluation Well received by students and faculty Helps fulfill training standards of: - JCAHO (hospitals) - LCME (medical schools) - ACGME (graduate med education) Core competencies of communication and professionalism

14. Future Directions Video vignettes to facilitate discussion Checklists for structured feedback Effect of training on outcomes such as palliative care OSCE scores GOAL: all graduating med students should be able to provide culturally competent care, particularly to those most vulnerable at the end of life

15. Aloha