Cultural Considerations In Decision . - Stanford Medicine PDF

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1/5/2015Disclosure InformationCultural Considerations in Decision-Makingand Goals of Care DiscussionsHeather A. Harris, M.D.Continuing Medical Education committee membersand those involved in the planning of this CME Eventhave no financial relationships to disclose.Heather A. Harris, M.D.I have no financial relationships to disclose.I will not discuss off label use/or investigational use inmy presentation.Cultural Considerationsin Decision-Making andGoals of Care DiscussionsHeather A. Harris, M.D.Associate Medical DirectorSupportive and Palliative Care ServiceSan Francisco General Hospital & Trauma CenterAssociate Professor of Clinical MedicineUniversity of California, San FranciscoThis Can Be Intimidating What concerns do you have when thinkingabout cultural differences and medical decisionmaking?“I might offend patients and families .”“The medical care I provide may influenced by my own cultural biases .”“It’s so frustrating when families want to keep informationfrom the patient .”“My lack of knowledge about certain cultural issuesmay lead to suboptimal care ”“I don’t know how to make that patient/family understand .”1

1/5/2015Increasing Cultural Diversity Ethnic minoritiescurrently compose1/3 of USpopulationIn 2010, 1 out of 5adults over 65 wasof an ethnic minorityBy 2050 ethnicminorities areexpected to be themajorityUS Census Bureau, 2010; US Health and Human Services 2011Racial Diversity in San Mateo CountyOther RaceNative12%Hawaiian andOther PacificIslander1%Two or MoreRaces5%White53%Asian25%AmericanIndian andAlaskaNativeAfricanAmerican3%2010 U.S. Census DataDisparities in Care and Outcomesfor Chronic Kidney Disease Ethnic minorities suffer disproportionately fromCKD and ESRDESRD 3 times the incidence than for whitesGeographic disparities in CKD prevalence exist andvary by race CKD progression more rapid for ethnic minoritygroups than for whites Largely but not completely explained by genetic factorsStark socioeconomic disparities in outcomes fordialysis patients exist and vary by race, place ofresidence, and treatment facilityCrews, 20142

1/5/2015Renal Disease in the USDartmouth Atlas, 2014Our Hopes for the Next Hour Recognize racial, ethnic, and socioeconomic differencescontribute to disparities in treatment for patients withrenal diseaseDefine the concepts of cultural competency andcultural humility and learn to apply these concepts inconversations with patients and familiesDescribe eight common cultural factors that influencedecision-making and employ strategies to moreeffectively address these issuesLet’s Define Some Concepts What is Culture? Integrated patterns of human behavior that includelanguage, thoughts, communications, actions,customs, beliefs, values, and institutions of racial,ethnic, religious, social or work groups.Adapted from Cross, T., et al. (1989) and Yuen, E., et. al. 20103

1/5/2015Many Factors at Play Race/EthnicityAcculturationSex/Gender/Gender IdentitySocioeconomic StatusReligion/SpiritualityEducationAnd many more .Culture and Relation to Health Care “culture defines how health care information is received, howrights and protections are exercised, what is considered to be ahealth problem, how symptoms and concerns about the problemare expressed, who should provide treatment for the problem,and what type of treatment should be given.” “ In sum, because health care is a cultural construct, arising frombeliefs about the nature of disease and the human body, culturalissues are actually central in the delivery of health servicestreatment and preventative interventions”US Department of Health and Human Services. Office of Minority HealthCultural Competence “Cultural competence is a set of congruent behaviors, attitudes,and policies that come together in a system, agency or amongprofessionals and enable that system, agency or thoseprofessions to work effectively in cross-cultural situations.”-Cross et al, 1989 “Cultural competence is defined simply as the level ofknowledge-based skills required to provide effective clinicalcare to patients from a particular ethnic or racial group.”- U.S. Department of Health and Human Services, Health Resourcesand Services Administration, Bureau of Health ProfessionsReferenced from Georgetown University, National Center for Cultural Competence4

1/5/2015Cultural Competence Knowledge and skills Knowledge base of factors that can influencecultural beliefs, values, and health behaviors Skill in communication Reasonable to learn about populations frequentlyseen in your practiceVerbalNon-verbal communicationUse of professional interpretersCrawley, 2002Cultural Humility Coined by Melanie Tervalon and JannMurray-Garcia in 1998Lifelong commitment to self-evaluation andself-critique Recognize and work to fix power imbalancesthat exist between providers and patients Develop mutually beneficial clinical andadvocacy partnerships on behalf of individualsand populations Tervalon & Murray-Garcia, 1998Cultural Humility AttitudinalAwareness that culture shapes valuesAcknowledge differences exist Respect the differences Accept the patients’ world view and values as astarting point for the physician-patient relationship Crawley, 20025

1/5/2015ComparisonCultural CompetenceCultural HumilityGoalsBuild understanding of minoritycultures to better and moreappropriately provide servicesEncourage personal reflection andgrowth around culture in order toincrease awareness of arningStrengthsAllows for people to strive toobtain a goalEncourages lifelong learning with noend goal but rather an appreciation ofthe journey of growth andunderstandingPromotes skill buildingPuts clinicians and patients in a mutuallybeneficial relationship and attempts todiminish power dynamicsComparisonShortcomingsCultural CompetenceCultural HumilityEnforces the idea that there canbe 'competence' in a cultureother than one's ownChallenging for providers to graspthe idea of learning with and frompatientsSupports myth that cultures aremonolithicNo end result, which providers canstruggle withBased upon academic knowledgerather than lived experienceCompetency and Humility Components thatmay contribute tobuilding the road Unique pathDesire and processof going on thejourneyNever reach the end6

1/5/2015Practicing Humility:Clinician Know Thyself What cultural pieces do you as an individualbring to the table?Cultural identity pie chartPracticing Humility:Western Medical Culture Our own cultureLanguageValues Customs Norms Hierarchy Subspecialties – Sub cultures The Culture of Western MedicineFull disclosurePatient as soledecision-makerKey value of making choicesand exercising controlAvoiding unnecessary careindication of caringScience/technologyapproach to EOLAvoidance of painWithholding bad newsFamily plays key role indecision-makingUnfamiliarity with orreluctance to make “choices”Advocacy for greaterintervention indication of caringSpiritual/ faith-basedapproach to EOLCultural meaningattributed to painAdapted, Clark 20127

1/5/2015Theories of Disease Causation Natural Etiologies Germs, environmental factors, humors, heavenly bodiesFactors beyond human control, little personalBehavioral risk factors Ex. Diet, habits, sexual behaviorIndividual responsible for the disease Supernatural Social etiologies God punishing, kharma, lack of respect for ancestral spiritDisease arises due to conflict, social interactionJealousy, envy, “evil eye”Borkan, 2008Different Explanatory Models Mr. S. 65 y/o third generation GermanAmerican recently diagnosed with lung cancerand wonders why this happened to himPhysician – developed since he smoked for 50 yearsWife – God is punishing him for turning away fromthe Catholic church early in their marriage Daughter – admonishes him for not taking vitaminsupplements she had asked him to take for years Son – sue the Navy for the work at the shipyard thathe did during WWII Borkan, 2008Techniques to ElicitExplanatory Models What health problems or illnesses do you have and whatdo you think is causing them?What kinds of care have you sought to treat your illness?Tell me about you and how your illness fits into orchanges your life?Borkan, 20088

1/5/2015Interpretation ofBodily Signs and Symptoms Individuals – “sick” – abnormal signs orsymptomsSocial mileu - family members/health careproviders – must concur before patient canassume “sick role” Withdraw from work, family responsibilities, receiveassistance from othersBorkan, 2008Techniques to ElicitInterpretation of Symptoms How is this illness affecting your dailyfunctioning and the things that aremost important to you?What do you think will happen, orare concerned about, for the future?What changes have occurred for yourfamily since your illness began?How well do you feel your family iscoping?Borkan, 2008Types of Treatments Differing beliefs in types of treatments to relievesymptoms, cure illness, or prevent future harmProtective clothing, practicesRituals (prayer, offerings) Hygiene Non-Western medicine techniques (acupuncture,cupping, herbal remedies) Borkan, 20089

1/5/2015Techniques to ElicitPerspective on Treatments What treatments have you sought to treat your illnessand which have been the most effective?What things help you the most in coping with yourillness?Borkan, 2008Truth Telling Western biomedical framework (recent) Value patient autonomy, informed consent, anddiscussion of prognosisNot the norm in much of the world Many countries southeastern Europe, muchof Asia, Central and South America, MiddleEast physicians, patients, families feelwithholding medical information is moreethical and humaneKagawa-Singer, 2001Truth Telling: Consequences Possible ConsequencesAnger, mistrust, removal of patient fromongoing medical care if clinician proceeds withinforming patient against their (or family)wishes Blame for contributing, causing or worseningthe situation Introducing hopelessness, misunderstandingas to why the patient is being informed Kagawa-Singer, 200110

1/5/2015Truth Telling: Strategies Informed Refusal Some patients want to know everything about their conditionand others prefer that the doctors talk with their families.How would you like to get this information?Use a hypothetical case Many patients in a similar condition to yours have found ithelpful to consider treatment options such as .Acknowledges fearsRespects need for indirect discussion Implicitly invites additional questions Kagawa-Singer, 2001; Carrese & Rhodes, 1995Family Involvementin Decision-Making Western biomedical frameworkValue patient autonomyRight to be informed of condition, treatment options Ability to choose or refuse life-prolonging medical care Advance Directives, POLST – written methods toensure patients wishes are followed Advance care discussions and written documentation notconsidered standard of care in many countriesKagawa-Singer, 2001Family Involvementin Decision-Making For many cultures decision-making is the dutyof the family Responsibility to protect a (dying) patientRemove burden of decision-making11

1/5/2015Family Involvement inDecision-Making: ConsequencesPossible Consequences Conflict if clinician insists patient must be theone to make decisions Alienate patient and family Kagawa-Singer, 2001Family Involvement inDecision-Making: Strategies Talk with the patient to determine their desiredlevel of involvement in receiving informationand decision-makingAscertain key members of the patientsfamily/friends who the patient deems importantto include in conversation and ensure they areincluded Is there anyone else that I should talk with about your illness?Kagawa-Singer, 2001Response to Inequities in Care Recognize several groups have historical past ofmistreatment, abuse with medical research, ongoingcurrent inequities other realms of life African-Americans – slavery, Tuskeegee SyphilisExperiment Native American – reservations, 300-mile LongWalk, past mistreatments regarding education andmedical treatment Japanese-Americans – Internment camps WWII Current studies reveal physicians perception ofpatients are influenced by patient ethnicityVan Ryn & Burke, 200012

1/5/2015Inequities in Care: Consequences Lack of trustIncreased desire for futile aggressiveinterventionsLack of ability to collaborate with patient andfamilyDissatisfaction with care for all involvedInequities in Care: Strategies Explicit references to work towards achievingthe best care possibleAddress directly I wonder whether it is hard for you to trust a physician who isnot of your same background?Understand and accommodate desires for moreaggressive care Respectfully negotiate in instances of medical futilityCommunication andLanguage Barriers Medical language is a foreign languageImpacted by health literacyLanguage other than English as primarylanguageLack of appreciation for non-verbalcommunication Looking in the eyeNodding13

1/5/2015Communication andLanguage Barriers: Consequences Bidirectional misunderstandingUnnecessary or undesired treatmentUnnecessary physical, emotional, spiritualsufferingCommunication andLanguage Barriers: Strategies Avoid complex or medical jargonCheck in frequently to assess understandingUse professional interpreters Seek advice from cultural insider Avoid use of family or “by-stander” medical staffInterpreter, colleagueKagawa-Singer, 2001; Crawley 2002Religion and Spirituality Western biomedical framework discountsimportant religion and spiritualityMany believeGod has ultimate say in issues of life and death, notthe physician Suffering may be redemptive and should be endured 14

1/5/2015Religion and Spirituality:Consequences Lack of faith in physician, medical treatmentLack of adherence to treatment regimensReligion and Spirituality: Strategies Assess the importance religion/spirituality hasin your patients life Where do you find strength to make sense of this experience?Spiritual or religious strength sustains many people in timesof distress. What is important for us to know about yourfaith or spiritual needs?Kagawa-Singer, 2001This Can Be Less Intimidating Concepts of cultural competencyand cultural humility help inthinking about conversations withpatients and familiesReviewed common culturalfactors that influence decisionmaking and provided strategies tomore effectively assess andaddress these issues15

1/5/2015 ResourcesEthnoMed - Provides information on cultural issues which impact health care, patienteducation and communication toolsMedical Leadership Council on Cultural Proficiency Resources for language access, cultural proficiency, and continuing educationNational Standards on Culturally and Linguistically Appropriate Services (CLAS) The14 CLAS standards are primarily directed at health care organizations;however, individual providers are also encouraged to use the standards tomake thei

beliefs about the nature of disease and the human body, cultural ... The Culture of Western Medicine Full disclosure Withholding bad news Patient as sole decision-maker Family plays key role in decision-making ... What kinds of care have you sought to treat your illness?