Transcript Title of Presentation - Providence Health Care

Culture and Health Care:
Caring for a Diverse Population
Anita Ho, PhD
Ethicist, Ethics Services, PHC
Assistant Professor, Center for Applied Ethics, UBC
Are We Debating the Wrong Things?
What is Culture?
• Shared attitudes, values, goals, and practices that
characterizes an institution, organization or group
• Way of life
• The map of one’s world
• Part of one’s identity
Medicine – “Foreign” Culture
• Identity shift
• Patients in sterile settings are
studied and prodded by
unfamiliar instruments in
mechanical ways
• Overworked professionals
often attend to patients under
very specific clinical
circumstances
• Patients with full histories and
relational identities become
diseased body parts and
medical jargons
Clinical Safety
• Contemporary high-tech
medicine offers
promising clinical results
What About Cultural Safety?
• The cultural appropriateness of health care
– inclusion of non-western practices
– minority health care providers
• Importance of being understood and able to
manage the power structures within medicine
• More than sensitive communication at an individual
level -- environment
• The ability to process presented materials may
partly depend on whether the patient feels culturally
safe
Case
• Mr. A: 95-year old patient with dysphagia and dementia
• Hospitalized: aspiration pneumonia, malnutrition,
dehydration
• When Mr. A got ill and stopped eating, daughter tried to
feed him
• Team met with the daughter -- explained the patient’s
conditions, risks of oral feeding, and likely decline
• Daughter concerned about “starving” her father -requested IV fluid and feeding tube
• Daughter wants to protect Mr. A from all the bad news -filial piety important in Mr. A’s culture
Minority Experience
• Western medicine as contrast to holistic models
• Difficult to relate to professionals of different
backgrounds
• Those who are marginalized cannot take
professionals' claims of beneficence for granted
– Tuskegee syphilis study
– Minority patients get less time
• Language and cultural barriers accentuate
weaknesses in an already troubled system
• Is western bioethics focusing on the right things?
Multiculturalism in Canada
• 1901 Census: 25 different ethnic groups
• 2006 Census: 200
• 2006: > 5 million visible minorities --16.2% of the
total population (1981: 1.1 million or 4.7%)
• Between 2001 and 2006, the visible minority
population increased at 27.2%, five times faster
than the 5.4% increase in general population
• Diverse patient and staff populations offer
challenges and opportunities
Immigrant Experience in BC
• Half don’t speak, read or write English at arrival
• 2001: 25% of the BC population reported a single
mother tongue other than English
• 30% of all immigrants are family immigrants
admitted for reunification purposes
• Linguistic and cultural barriers affect access to
health information and services, contributing to
health disparities
• “Healthy immigrant effect”
Clash of “Cultures”
• All parties bring in assumptions, beliefs, and biases
• The Spirit Catches You When You Fall Down by
Anne Fadiman
• Many professionals are anxious when immigrant
patients don't fit the pattern they trained to work with
• Respect for persons warns against inadvertent
cultural imperialism
• Hierarchy may affect negotiation of differences
• Redefining the “melting pot”
• How we perceive another group may say more
about us than about that group
Lost in Translation
• Iraqi-Cdn patient in her 80s; dementia; no English
• Grieving for husband who died a few months before
• Involuntarily hospitalized upon cognitive and functional
decline -- daughter not notified
• Patient often in tears and confused about why she had to
take medications, but would calm down when daughter
visited
• Daughter wanted to take the patient home
– Had difficulty accepting her mother’s condition/care needs
– Surprised to hear that her mother had Alzheimer’s
• Team tried to find nursing home placement
– Daughter would only agree to the one close to her home
ABCDEF: Working with Culturally Diverse Populations
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Attend
Bridge
Comment
Decide
Empathize
Follow up
• Acknowledgement: Dr. David Kuhl, Centre for Practitioner Renewal
Attend – Be Mindful
Self
• What do I (not) know about
the Iraqi culture and healthcare system?
• What was my experience
working with PRFs in similar
cultures?
• What are my presumptions
and biases about this
population?
• What are other things on my
mind?
PRF
• What was the PRF’s prior
experience with the social
and health care system?
• Is there anything about the
patient’s culture and value
system that are relevant to
their preferences and
expectations?
• What are non-clinical
issues they may be thinking
about?
Bridge – Between Professional and PRFs
• Establish rapport with PRF
– Potential mistrust based on prior experience and social
marginalization
– Acknowledge difficult situations and past experience
• Recognize the dependency relationship
• Inquire into the PRF’s support network and needs
• Invite family involvement and explore family
concerns as appropriate
• Emphasize respect
Comment -- Explain as Culturally Appropriate
• Define technical terms in lay language
• Explain various options and their implications
• Inquire into respectful ways to communicate
– Some families may want to avoid certain words
• Provide opportunities for questions and explain
their concerns
– PRFs may need multiple “doses” of information
• Address disagreements – different goals vs
different understanding of what would achieve
the goal
Decide – Shared Process with PRF
• Engage all appropriate and available
stakeholders
– Are there other family members who should be
involved and/or can offer support to the daughter?
• Shared decision-making process can help build
trust and determine creative actions that respect
their dignity
• Recognize contribution from all stakeholders –
clinical perspectives are only part of the picture
Empathize – Acknowledge emotions
• Recognize that difficult issues take time to
process
• Empathizing with PRF help prevent perception
of abandonment
• Acknowledgment of PRF’s emotions is part of
good care
• PRFs are often more concerned about
relational issues than simply clinical matters
– Daughter concerned about not “abandoning her
mother to a nursing home
Follow Up – Proactive Approach
• Some PRFs may need to talk about the
issues with others before making decisions
• Follow up can promote open communication
and trust – provides opportunities to clarify
various issues
• Debriefing within teams can help to minimize
moral distress
Promoting a Caring Culture
• Attendance to cultural values can help improve
trust, facilitate communication and understanding,
build rapport, and promote patient welfare
• Aren't we working towards the same goal?
• Going back to autonomy and informed consent
• Respect for cultural values as part of good clinical
care