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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 • • • • • • 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