Cultural Dimensions of End-of-Life Care

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Cultural Dimensions of End-of-Life Care

• Presenters Chaplain David F. Berg, MA, MDiv
  Doretta E. Stark, MA, LICSW, Email
  dberg1_at_fairview.org dstark1_at_fairview.org

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Workshop Outline

• Introduction
• Cultural Heritage Exercise
• Framework for Culture in EOL Care
• Palliative Care
• Resources
• Question Answer

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• Our first task in approaching another people,
  another culture, another religion, is to take off
  our shoes, for the place we are approaching is
  holy. Else we may find ourselves treading on
  mens peoples dreams, more serious still, we
  may forget that God was there before our
  arrival.
• John V. Taylor

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Patient Focused, Culturally Competent Health Care

• The secret of the care of the patient is caring
  for the patient...the good physician knows
  his(her) patient through and through. The
  treatment of a disease can be impersonal. The
  care of a patient must be completely personal.
• Francis Wold Peabody 1927
• It is much more important to know what sort of a
  patient has a disease, than what sort of disease
  a patient has.
• Sir William Osler, 1911

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Competence

• Stems from Latin verb competere meaning to
  strive together.
• Acquiring cultural competence is a journey of
  many partners

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Cultural Competency Continuum

• Unconscious Competence
• Conscious Competence
• Conscious Incompetence
• Unconscious Incompetence
• Josepha Campinha-Bacote and Larry Purnell

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Cultural Blind Spot Syndrome

• The belief that Just because the client looks
  and behaves much the way you do, you assume that
  there are no cultural differences or potential
  barriers to care.
• Buchwald, 1994

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Cultural Humility

• Cultural humility is a more suitable goal than an
  understanding of cultural competence as mastery
  of a finite body of knowledge.
• Cultural competence is a journey, not a
  destination.
• Cultural humility incorporates a life-long
  commitment.
• Tervalon and Murray-Garcia, 1998

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Three Dimensions of Humanness

• Every person is in certain respects
• like all others, human nature - universal
• like some others, culture - local
• like no other, personality - individual
• (Kluckhohn and Murray, Personality in Nature,
  Society and Culture, Knopf, 1948)

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• Camphina-Bacota Model of Culturally Competent Care

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Key Components ofYour World View
Age
Important Values
Sexual Orientation
Ethnic Heritage
Gender
Regional Background
Family Background
Social Class
Mental/Physical Disabilities
Mental/Physical Abilities
ME
Occupation/Career
Educational Experiences
Language
Group Memb./Participation
Travel Experiences
Relationship Status
Economic Status/Class
Race
Religious Tradition
Political Affiliations
Nationality
Culture
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Explanatory Models of Illness

• Germ Theory Explains illness in a biological or
  physical way
• Equilibrium Theory Health is promoted by
  maintaining balance, for example energy, between
  self, others, nature and Creator, hot/cold
  balance
• God and Spirits Beliefs, spirits and misdeeds
  are the causes of health and sickness
• Magical Causation The idea that human beings can
  use supernatural power to cause harm to others

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Worldview

• A set of metaphorical explanations used by a
  group of people to explain lifes events (Boyle
  Andrews, 1989)
• The way individuals or groups of people look at
  the universe to form values about their lives and
  the world around them (Purnell,1998)

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Cosmology

• Circular (reincarnation)
• Linear (eternal life)
• Parallel (spirit always lives)
• This is it (no life after death)

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LEARN Process for Improved Communication

• L Listen with empathy to the clients perception
  of the problem
• E Explain your perceptions of the problem
• A Acknowledge and discuss the differences and
  similarities
• R Recommend treatment
• N Negotiate agreement
• (Berlin, E.A. Fowkes, W.C. 1983)

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Prerequisites for cross-cultural communication

• Self-awareness understand own culture
• Understanding and respect of others
• Mutual sharing and learning
• Analysis of culture relative to health
• Communication on deeper levels beliefs and
  values
• Find common ground build bridges

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Suggestions for Cross-Cultural Communication

• Inquire regarding culturally sensitive rules of
  etiquette for greeting people
• Learn correct pronunciation of names
• Avoid assumptions, always ask questions
• Be sensitive to topics that may be taboo
• Avoid use of slang, idioms, and jargon
• Recognize the meaning of non-verbals
• When using an interpreter, speak directly to the
  patient

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Outcomes of Mindful Intercultural Communications

• The feeling of being understood.
• The feeling of being respected.
• The feeling of being supported.
• Ting-Toomey, 1999
• Confirmation is the process through which
  individuals are recognized, acknowledged, and
  endorsed.
• Laing, 1961

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Religion versus Spirituality

• From Latin religio
• Formalized system of beliefs and practices
• Influenced by historical, social, and cultural
  circumstances
• The map
• Community

• From Latin spiritus
• A dynamic process
• Gives meaning and purpose to life events and
  relationships
• Often expressed through religion
• The journey
• Individual

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Culture/Spirituality in EOL Care

• Spirituality becomes more important in EOL care
• Spiritual well-being, faith practices and hope
  are all significant in study of older adults with
  cancer
• Culture becomes more important in EOL care
• Primary relationships become more important in
  EOL care
• Ferhring, Miller Shaw (1997).Oncology Nursing
  Forum, 24(4), 663-671.

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Negotiating Cross-Cultural Issues at the EOL

• you got to find out the identity of a person to
  even get to know them, Mr. G
• Advanced directives used differently across
  cultures
• Differing worldviews impact EOL decision making
• African -American community reflects heightened
  spirituality in EOL my life is on Gods hands,
  when He calls Ill be ready
• Assessment information serves to identify areas
  for negotiation
• Singer Kagawa-23), 2993-3001.

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Cross Cultural Communications in EOL Care

• How much information does the patient desire?
• Should communications be direct or non-direct?
• Who is family spokesperson?
• What is preferred decision making style?
• Who is family?

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Cross Cultural Communications (cont.)

• Communication /Language Barriers
• Working with Interpreters
• Truth Telling
• Identify supportive religious practices,
  spiritual elders, psychosocial supports

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Cultural Dimensions of EOL Care

• Culture/Spirituality matters
• Culture/Spirituality doesnt necessarily make
  care simpler or easier
• Cultural/Spirituality attentiveness
• Barbara Koenig, Florence Schorske Wald Lecture, U
  of MN, April 18, 2002