Cultural Competency in Caring for Diverse Populations

1.                                   C                                                  C                 Cultural Competency in Caring for Diverse Populations Fern R. Hauck, MD, MS Department of Family Medicine University of Virginia Health System POM-1, September 21, 2009

2. Cultural Beliefs and Health Care Cultural beliefs influence how people: • Understand normal bodily functions • React to signs and symptoms • Identify abnormal functions • Classify diseases • Speculate about and determine etiologies • Determine their prognoses • Consult others • Choose healers and treatments • Expect healers to behave • Evaluate results • Make medical decisions

3. Different understandings about these concepts can contribute to disagreement between healthcare professionals and their patients!

4. The Case of MH* • MH was a healthy 70-year-old Hmong, widowed woman with an asymptomatic goiter who suddenly had trouble breathing. • Step-sons brought her to the ER, physicians diagnosed thyroid cyst had ruptured and compressed her trachea. • They intubated her with an endotracheal (ET) tube after quickly getting permission from family without presence of a trained interpreter. • Days 2-3: Surgical team recommended operation to remove the blood, remove the thyroid and place a temporary tracheostomy until the swelling decreased. • Family: refused surgery, preferring to wait and re-evaluate *Culhane-Pera KA, Vawter DE. J Clin Ethics 1998;9(2):179-90.

5. The Case of MH (Cont’d) • Day 4: Surgeons asked for assistance from family physician who understands the culture and speaks Hmong, a Hmong patient advocate, and a trained interpreter. • Family continued to refuse surgery. • Patient pleaded to have ET tube removed because of discomfort and being restrained, felt she could breathe without it. • Day 5: Patient and family requested extubation; family felt swelling had decreased and asked for trial period of extubation. Family said it would be ok to re-intubate if needed, patient did not.

6. 0 0 of 30 Would you extubate MH? • Yes • No • Unsure, need more information

7. What would you like to know about the Hmong to help you make a decision?

8. What would you like to know about the Hmong? • Who are the Hmong? Social structure? Religious beliefs? • Beliefs about illness/thyroid disease? Preferred treatments? • Reactions to surgery? Fears? Concerns? • How do people make medical decisions/role of family?

9. Hmong Culture • Who are the Hmong? Social structure? Religious beliefs? • Began coming to U.S. 30 years ago from Laos after Vietnam War—they fought on side of U.S. About 187,000 reside in U.S., mostly in CA, WI, MN. • Previously had been subsistence farmers; exposure to modern U.S. culture has caused in some Hmong debilitating chronic illnesses. • Patriarchal society that values family-based decision making. • Animist religion: spirit world and everyday world live side by side.

10. Hmong Culture • Beliefs about illness? Thyroid disease? Preferred treatments? • Illness results from: • Natural causes (imbalance between yin and yang, buildup of air or wind in body, change in weather, germs) • Social causes (fights between people, curses) • Spiritual causes (loss of soul due to fright, fate) • Supernatural causes (spirits) • Healing and healers: • Coining, herbs, massage • Soul callers and chanting • Shamans who communicate directly with wild and tame spirits • Goiter: caused by build-up of wind in the neck, which if symptomatic could be relieved by coining and poking with a needle to release the wind and decrease the pressure (MH’s family denied that they had done this)

11. Hmong Culture • Reactions to surgery? Fears? Concerns? • Fear of loss of soul, as well as morbidity and mortality • Unable to fulfill social roles • Suspicious of doctor’s motivations • Adverse effects in next life: mutilation, metal in body • Usually not accepted unless tests show that surgery is required for a cure

12. Hmong Culture • How do people make medical decisions/role of family? • Family is responsible for sick people and consequences of treatment • Sons need to be good sons • Frequently, clan leader, male family leader, or other patriarchal figure makes decisions

13. Perspectives of All Parties • Surgeons: • Life-saving treatment, would die without ET tube or tracheostomy • Confused by different approaches of patient and sons • Couldn’t guarantee re-insertion of ET tube • They have the superior biomedical view

14. Perspectives of All Parties Patient: • ET tube miserable, causing suffering • Swelling had decreased, could breathe on own • Up to her to decide, not doctors • Multiple explanations and alternatives available to explain the problem • Considered her needs in this life, next life, and afterlife

15. Perspectives of All Parties • Family: • Condition had improved (they were examining her neck often) • Remove ET tube, but re-insert if needed • Avoid surgery and tracheostomy • They and patient have right to decide • Family responsible for consequences • Underlying spiritual etiology had been taken care of (divination ritual determined that dead father was angry with sons for being disrespectful of their step-mother. Sons made verbal amends.) • Distrust of surgeons • Need to be good sons

16. 0 Now, what would you do regarding the patient’s and family’s request to extubate? • Would not extubate. • Would extubate. • Would transfer to a different physician who would extubate her. • Extubate, but would reintubate if she has trouble breathing without the ET tube.

17. How the Story Ends • Ethics Committee (Day 6) and Hospital lawyer (Day 7) consulted: • Patient and family have right to refuse therapy as they are competent and understand consequences • Surgeons are not required to act against their moral values • Family is responsible for decisions and subsequent outcomes • Care transferred to another surgeon who removed the ET tube • Patient breathed w/ minimal difficulty and was discharged to home • Patient found to be doing well at follow-up visit

18. Meaning & importance of symptoms Etiologic understandings Perceptions of appropriate treatments Psychosocial contexts for illness Autonomy, self-efficacy Prevention orientation and activities Family involvement & perspectives Pain expression & management End of life decision-making Informed consent Expectations of health professionals Willingness to participate in groups & classes Diet and food No matter which cultures are involved, these areas cause the most difficulty when patient and provider are from different cultures: Source: Kaiser Permanente, 2003. Cultural Issues in the Clinical Setting.

19. The LEARN Model for Effective Cross-Cultural Communication and Negotiation* • Listen with sympathy and understanding of the patient’s perception of the problem • Listen to the patient’s and family’s concepts of illness, reactions to biomedical approaches, and desires for therapy • Explain your perceptions of the problem • Explain your biomedical assessment, using drawings and other methods that can facilitate understanding *Berlin EA, Fowkes WC. Western J Med 1983; 139:934-8.

20. The LEARN Model for Effective Cross-Cultural Communication and Negotiation* • Acknowledge and discuss the differences and similarities • Acknowledge differences and similarities between Hmong and biomedical perspectives; emphasize common ground • Recommend treatment and listen to their responses • Negotiate treatment and all areas of care, accommodating the patient’s and family’s beliefs and practices

21. Linguistic Competency • Minority populations currently comprise ~30% of the U.S. population • By 2030, estimated to reach at least 40% • 45 million people in the U.S. speak a language other than English at home • Spanish is the most common language spoken by limited English proficient (LEP) individuals • Therefore, medical interpreting has become a priority for health care in the U.S.

22. Linguistic Competency Legislation • August 2000: Department of Health and Human Services Office of Civil Rights issued “policy guidance on the prohibition against national origin discrimination as it affects persons with limited English proficiency.” • Recommended that entities develop procedures for identifying language needs of patients, provide interpreters, and establish and distribute policies regarding interpreter services

23. Linguistic Competency Legislation • December 2000: Office of Minority Health published Standards on Culturally and Linguistically Appropriate Services (CLAS): • 14 standards directed primarily at health care organizations, but individual providers encouraged to use. • 4 are currently mandated for recipients of federal funds: • Offer and provide language assistance services at no cost to LEP patients during all hours of operation • Provide patients in their own language notices of their right to receive language assistance services • Assure competence of language assistance; family/friends should not be used (unless requested by patient); children should never be used • Provide patient-related materials and post signs in commonly encountered languages of that service area • Small practices are not required to provide the same level of language services as bigger offices or hospitals • Certain amount of flexibility permitted

24. Working with Interpreters • UVA has Language Office • When appointments made, system automatically sends request to Language Office • Language Office schedules internal interpreters (Spanish) and requests outside interpreters for other needed languages (included ASL) • Telephone interpreters available 24/7 as backup via CyraCom service (“blue phones”) and you can access also via any phone

25. Working with CyraCom Interpreters

26. Other Resources • Health Sciences Library Website, click on Culture and Communication in Health • Numerous books and articles about specific cultures and practices • Numerous internet resources • NY Times Sept. 20, 2009: A Doctor For Disease, A Shaman For the Soul.