Culture and Health Care: Caring for a Diverse Population

1. Anita Ho, PhD Ethicist, Ethics Services, PHC Assistant Professor, Center for Applied Ethics, UBC Culture and Health Care:Caring for a Diverse Population

2. Are We Debating the Wrong Things?

3. 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

4. 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

5. Clinical Safety • Contemporary high-tech medicine offers promising clinical results

6. 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

7. 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

8. 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?

9. 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

10. 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”

11. 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

12. 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

13. ABCDEF: Working with Culturally Diverse Populations • Attend • Bridge • Comment • Decide • Empathize • Follow up • Acknowledgement: Dr. David Kuhl, Centre for Practitioner Renewal

14. Attend – Be Mindful Self 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? • What do I (not) know about the Iraqi culture and health-care 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?

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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