CULTURAL ASPECTS OF CARE

Transcription

1 CULTURAL ASPECTS OF CARE

2 Know and understand: OBJECTIVES How culture influences health behavior and preferences about provision of health care Principles of respectful communication with patients from a different cultural background Questions to include in history-taking Ways in which end-of-life care may need to be adapted Slide 2

3 TOPICS COVERED (1 of 3) Cultural Competence No Culture Is Monolithic Addressing the Patient Language and Literacy Respectful Nonverbal Communication Slide 3

4 TOPICS COVERED (2 of 3) Elephants in the Room History of Traumatic Experiences Immigration Issues Acculturation Tradition and Health Beliefs Slide 4

5 TOPICS COVERED (3 of 3) Attitudes toward Health Services Culture-Specific Health Risks Approaches to Decision-Making Disclosure and Consent Gender Issues End-of-Life Care Slide 5

6 CULTURAL COMPETENCE Not a form of political correctness Most definitions emphasize a careful coordination of individual behavior, organizational policy, and system design to facilitate mutually respectful and effective cross-cultural interactions Combines attitudes, knowledge base, acquired skills, and behavior An approach, not a technique Slide 6

7 NO CULTURE IS MONOLITHIC The cultural information in this presentation is accurately described in general Beliefs, traditions, customs, and preferences of the individuals in a cultural group vary widely Clinicians must never assume that any person s cultural background dictates his or her health choices or behavior Slide 7

8 ADDRESSING THE PATIENT Determine the patient s preferred term for cultural identity and use it in conversation and in health records Use the patient s title (eg, Dr, Reverend, Mr, Mrs, Ms, Miss) and surname unless the patient requests a more casual form of address Ask how to pronounce the patient s name Slide 8

9 LANGUAGE AND LITERACY What language does the patient feel most comfortable speaking? Will a medical interpreter be needed? Does the patient read and write English? If the patient is not literate, can someone assist at home with written instructions? Slide 9

10 RESPECTFUL NONVERBAL COMMUNICATION (1 of 2) Hand gestures, facial expression, physical contact, and eye contact can hold different meanings for the patient and clinician if their cultural back-grounds differ Watch for body language cues that appear to be significant to the patient Be alert to making negative judgments about a patient based on cultural assumptions about the meaning of body language Slide 10

11 RESPECTFUL NONVERBAL COMMUNICATION (2 of 2) Use conservative body language early in the clinical relationship or when in doubt Assume a calm demeanor Avoid expressive extremes such as very vigorous handshakes, a loud voice, excessive hand gestures, and impassive facial expression Determine what distance seems to be the most comfortable for each patient Slide 11

12 ELEPHANTS IN THE ROOM Lack of trust in health care providers and the health care system Fear of medical research and experimentation Fear of medications or their side effects Unfamiliarity or discomfort with the Western biomedical belief system Slide 12

13 HISTORY OF TRAUMATIC EXPERIENCES Include relevant questions in history-taking: Is the patient a refugee or survivor of violence or genocide? Are family members missing or dead? Have the patient or family members been tortured? Slide 13

14 Immigration status IMMIGRATION ISSUES Consider assuring each patient that information given will be kept in confidence, especially since patients may not have appropriate documents History of immigration or migration The history of a group can affect attitudes and behaviors of many generations of its members A person s migration history often provides insight into the key life transitions informing his or her outlook Slide 14

15 ACCULTURATION (1 of 2) A process in which members of one cultural group adopt the beliefs and behaviors of another group May be evidenced by changes in language preference, attitudes and values, and/or ethnic identification Can be an issue dividing families May greatly affect a person s health behavior and preferences about end-of-life care Slide 15

16 ACCULTURATION (2 of 2) Ask how long the patient has lived in North America and whether he or she was born here Remember that the degree to which a person is acculturated to Western customs and attitudes is the consequence of many factors, not just length of time since immigration It can be useful to ask patients directly about their adherence to cultural traditions Slide 16

17 TRADITION AND HEALTH BELIEFS Some non-western paradigms about illness: Illnesses have spiritual causation Illnesses result from imbalance in essential physical components or bodily humors Illnesses are caused by a person s actions in past lives Ask about use of alternative remedies and rituals Negotiate a common understanding of causation, diagnosis, and treatment Slide 17

18 ATTITUDES TOWARD NORTH AMERICAN HEALTH SERVICES Minority patients may be uncomfortable due to: Lack of familiarity with Western practices Dissatisfying previous encounters Belief that insensitivity or discrimination is inevitable for anyone in the cultural or ethnic group Having been stereotyped or treated insensitively or even unfairly by clinicians in the past Slide 18

19 CULTURE-SPECIFIC HEALTH RISKS Epidemiologic and medical research has identified numerous differences among ethnic and cultural populations with regard to specific health risks Clinicians who treat many patients from a specific group should stay abreast of the latest findings in relevant areas Slide 19

20 APPROACHES TO DECISION-MAKING In many non-western cultures, decisionmaking about health care is family- or community-centered Autonomy principles allow competent persons to involve others in their health decisions or to cede those rights to a proxy decision maker Ask patients if they would prefer to involve or defer to others about decision-making Slide 20

21 DISCLOSURE AND CONSENT Some cultures believe that patients should not be informed of a terminal diagnosis, as this may damage health or hasten death It can be difficult to obtain informed consent from these patients Early in the clinical relationship, explore each patient s preferences regarding disclosure of serious findings, and reconfirm these wishes at intervals Slide 21

22 GENDER ISSUES Cultural norms for men and women can influence their expectations about interaction with providers, and their health behavior, decision-making, disclosure, and consent Explore each patient s decision-making preferences and their attitudes toward their autonomy early in the clinical relationship, confirm these preferences at intervals, and follow the patient s wishes whenever possible Slide 22

23 END-OF-LIFE DECISION-MAKING AND CARE INTENSITY Listen carefully to the patient s goals and concerns and avoid making culture-based assumptions The assumption that no one would want to live in that condition or that everyone would want treatment in this situation is likely to be faulty Strive to understand the overall approach to life and death, and as far as possible provide care congruent with that approach Slide 23

24 ATTITUDES TOWARD ADVANCE DIRECTIVES Be sensitive to the possibility that some minority older persons will prefer to: Use verbal directives Dictate directives to family members or others Avoid discussing directives so as to observe proscriptions against talking about death Allow patient to indicate the interventions they do want as well as those they do not want Slide 24

25 SUMMARY Cultural competence is a nuanced understanding of the impact of culture on health care encounters Culture influences health behavior and patient preferences about treatment Clinicians should remain alert to differences among patients from a given culture It is important to explore the patient s attitudes about such issues as disclosure, consent, and decision-making early in the clinical relationship Slide 25

26 QUESTION 1 (1 of 2) Name 3 ways to demonstrate respectful non-verbal communication during an intercultural patient encounter. Slide 26

27 QUESTION 1 DISCUSSION (2 of 2) Determine what distance seems to be most comfortable for the patient. Use a calm voice. Avoid vigorous handshakes. Avoid excessive hand gestures. Continually assess the patient for discomfort or puzzlement. Slide 27

28 QUESTION 2 (1 of 2) Name 2 questions that could be included in the history of individuals from outside the US. Slide 28

29 QUESTION 2 DISCUSSION (2 of 2) How long have you lived in North America? What traditions from your country of origin are very important to you? Do you and your children have different views about health care? Have you changed your views on any health care matters since moving to North America? Slide 29

30 QUESTION 3 (1 of 2) Name 2 approaches to end-of-life care and/or advanced directives for persons from non-western cultures. Slide 30

31 QUESTION 3 DISCUSSION (2 of 2) Ask who makes health care decisions for the patient. Determine whether a patient would like to know his or her diagnoses. Ask about the patient s goals irrespective of the country of origin. Try to learn the patient s overall approach to life and death. Slide 31

32 ACKNOWLEDGEMENTS GRS6 Chapter Author: Reva N. Adler, MD Consulting Slide Editors: Gwen Yeo, PhD MD Brangman, MD Carmel Dyer, Sharon A. Medical Writers: Beverly A. Caley, Faith Reidenbach Managing Editor: Andrea N. Sherman, MS American Geriatrics Society Slide 32