Ethics Grand Rounds presentation given at Providence Health Care on 3/29/16 discussing how to deliver bad news for a diverse patient population

1. Care Across Cultures:
Communicating About
Serious Illness
Andrea Chatburn, DO, MA
Medical Director for Ethics, PHC
March 29, 2016

2. Learning Objectives
• Explore when and how to disclose
serious illness
• Enhance understanding of own culture
• Expand understanding of diverse
cultural perspectives
• Improve communication across cultures
and reduce conflict with patients and
families

3. Nothing to disclose financially
Other disclosures:
I am not a sociologist or an
anthropologist

4. We are diverse

5. Vast amount of diversity
• What can caregivers be expected to
know about individual cultures?
• How can we respond to cultural issues
in an ethically appropriate manner?

6. Avoid stereotypes
• Do not make value assumptions based
on patient’s cultural heritage
• Culture is not monolithic

7. Importance of Professional Translator
“The difference between the right word
and the almost right word
is the difference between lightening
and a lightening bug.”
-Mark Twain

8. OR:

14. Elements of a Culture Group

15. Influence of Values in Healthcare
• Expectations about health
• Language used in describing symptoms
• Expectations about medical care
• Professional relationships
• Decision making style

18. Providence Model for Ethics
Clinical Integrity Beneficence
Autonomy
Justice &
Non-Maleficence

19. Worldview
• Collectivis
– Interdependent with group
– Good outcome includes group wellbeing
– Lower need for individual privacy
– Privacy need may be a group privacy

20. Worldview
• Individualis
– Independent of group
– Good outcome dependent on expression of
autonomy
– High need for privacy

21. Worldview
• Teleology
– Rules-based decision making
• Deontology
– Consequences based decision making

22. Worldview

23. Individualist Collectivist
Rule-based
Style Preferences
Consequences

24. Individualist Collectivist
Rule-based
Style Preferences
Consequences
Values mostly
independent,
consequence-based
decision making
Values mostly
independent, rule-
based decision
making
Values mostly group
consequence-based
decision making
Values mostly group
rule-based decision
making

25. Layers within Culture
• National
• Regional
• Social & Employment
• Gender
• Generation
• Function
• Immigration & acculturation

26. Competing Cultural Influences
• African American cultural influences on
End of Life Care
– Experience of slavery, Tuskegee syphilis
experimentation, racial profiling
Death as obstacle to overcome
– Rich spiritual tradition
Death as “Welcome friend”

27. Core Values & Virtues
• Identifying the values in conflict
• Reflection on own personal values
• Reflection on application of values to
the situation

28. Ring Theory of Personhood
Societal
Relational
Individual
Innate
Krishna, 2014.

29. It’s all about relationships
• Related family vs. family of choice
• Who does the patient trust?
• Who does the family trust?
• Calm vs. Storm

30. Resources for cultural knowledge
• Asking the patient
• Literature- medical and narrative
• Colleagues with culture knowledge
• Cultural Interpreters & Religious leaders

31. Providence Model for Ethics
Clinical Integrity Beneficence
Autonomy
Justice &
Non-Maleficence

32. What is a “good” outcome?
5 yo girl Lia Lee
from Laos living in
California with
severe epilepsy

33. How do we ask about culture?
Case #1
•Mr. Z – 70 year old
•Spanish-speaking
•Change in bowel habits, weight loss
•Dx: Colon cancer
•Son and daughter ask physician to not
tell their father he has cancer

34. How do we ask about culture?
• Health Literacy:
– 1 in 5 American Adults read at or below 5th
grade level
– Most healthcare materials are written
above 10th
grade level

35. Guess the Grade Level:
“Do you have a sharp
shooting pain or
a dull aching pain?”

36. Answer: 3rd
Grade

37. Guess the Grade Level:
“What are your information
seeking preferences?”

39. Answer: 10th
Grade

40. Guess the Grade Level:
“If your heart were to stop
would you want us
to restart it?”

42. Answer: 2nd
Grade

43. Guess the Grade Level:
“Are you worried about
suffocating?”

45. Answer: 10th
Grade

46. Case #2
• Ms. P is a 25 yo woman
• Russian-speaking only
• In ER with fever, confusion
• Family refuses LP but requests we
“do everything”

47. Fear or Love?
Fear as motivator for behavior
•I am AFRAID that I will lose what I have
•I am AFRAID I will NOT get what I want

48. Difficulty is about unmet needs
• Difficult patient and family behaviors
may be a surrogate for communicating
unmet needs
• Failure to meet needs may be real or
percieved

49. Responding to difficult encounters
Layering exercise

50. What does it mean to
“reveal God’s love?”
• Routinely ask patients how they would
like to receive information, test results
• Work to understand the concerns and
values of the patient and family
• Open ended questions
• Seek to understand what is a good outcome,
what do they fear?
• Find common ground

51. Bibliography
• Crawley, L., et. al. Palliative and End of Life Care in the African American
Community. JAMA 2000; 284:2518-2521.
• Crawley, L., et al. Strategies for Culturally Effective End of Life Care. Annals of
Internal Medicine. 2002;136:673-679.
• Duxbury, J. Difficult Patients. Oxford: Butterworth-Heinemann. 2000.
• Gurmankin AD, et al. The effect of numerical statements of risk on trust and
comfort with hypothetical physician risk communication. Medical Decision
Making 2004; 24:265-271.
• Health Literacy: A Prescription to End Confusion Lynn Nielsen Bohlman,et al.,
eds. Committee on Health Literacy, Institute of Medicine, National Academy of
Sciences
• Krishna, LKR. Accounting for Personhood in Palliative Sedation: the Ring
Theory of Personhood. Medical Humanities. 2014. 40:.17-21
• Lo, Bernard. Resolving Ethical Dilemmas: A Guide for Clinicians, 5th
ed. 2013.
Philadelphia. LWW. Ch. 44, p. 323-331.
• Periyakoil, VJ. Hear today Gone Tomorrow: Health Literacy. AAHPM 2014.
• Wessler, R. et al. Succeeding with difficult clients: Application of cognitive
appraisal therapy. Academic Press.
• https://www.tamu.edu/faculty/choudhury/culture.html