2.
Goals
reflect core values and identity
consist of what is desired and what is to be avoided
Needs
coping toolbox
consist of information flow, control over events and
decisions, access to people and resources, connection back
to normal life
Preferences
what annoys and comforts
consists of food, clothing, mementos, environmental design
Culture in Health Care
3.
Ask the patient
Use your knowledge of world and current events to be
sensitive
Use your experience as a health care worker to be sensitive
to possible personal tender points
Use clues of behavior, comments, visual statements of
identity as a doorway to knock on, not as a proxy for
asking
Keys to Eliciting Patient’s Cultural Landscape
4.
Scenario: You have ALS at age 40. You are in hospice
care and very weak, but compos mentis. Pain from
weight of head, discomfort from not eating.
Goals: what is desired, what is to be avoided
Needs: information, control, access, tools, resources
Preferences: comforts and annoyances
Exercise: Your culture as a palliative care
patient
5.
Goals: Are we aligning his treatment plan with his
desires and protecting him from what he fears?
Needs: Are we checking to make sure that he has
what he needs from us to cope as well as possible?
Preferences: Are we alert to what he would like for
comfort and to what he gets annoyed about?
For each patient:
6.
Woman with metastatic CA in hospital bed, prognosis of
weeks
Family has insisted for past year that word tumor be used
instead of cancer, very controlling of all communication
with care team
Nurse is alone with patient for a few minutes, patient asks
her what is really going on
Issues of culture: decision making pathways, control of care,
access to information, assumptions of family and of care
team regarding patient’s goals, needs, and preferences
Scenario A
7.
38-year old male gay patient dying on inpatient unit of
CA, has been on unit for a month
aged mother arrives from distant city, aware that
situation is serious
mother refuses to accept death as possibility, is very
hostile to team discussing this, plants herself in room
mother refuses to allow longterm male partner to visit,
acts out and bullies patient if he appears, partner stops
coming to visit, patient is depressed
Cultural issues: family dynamics around challenging
mother, homophobia of mother, denial of Dx, fear of jinx,
religious faith of mother, issues of access to and by loved
one.
Scenario B
8.
67 year old male patient dying of liver cancer and multiple organ
failure, prognosis 1 to 3 days, inpt.
patient has internal blood loss, very low perfusion
patient wants to survive a day more for son’s arrival from distant
place
team offers one transfusion to allow survival for a day, patient
accepts when alone with team and interpreter, after discussion
wife is Jehova’s Witness, opposed to blood products, also
emotionally distant from patient
wife attacks patient verbally for agreeing to transfusion and tells
him he is dying and does not need any more interventions,
accuses team of pushing transfusion
Cultural issues: Decision-making pathway, goal of patient, goal of
wife.
Scenario C
9.
Elderly male patient slowly recovering from stroke, may
go home eventually IF he becomes able to do ADLs
patient repeatedly hears care conferences, but does not
make any move to feed himself, wash himself, or become
more mobile or do ADLs.
family feeds patient, supports patient while ambulating,
washes him, tells care team he cannot do things himself
care team cannot discharge, but no medical reason to
keep forever on unit
Cultural issues: identity of patient in family unit, goals of
patient, goals of family.
Scenario D
