Care of the Dying Patient

7. Cultural Sensitivity in End-of-Life Discussions - David A. Fleming

7 Cultural Sensitivity in End-of-Life Discussions David A. Fleming Encounters between physicians and patients of different cultures are increasingly common in today’s diverse society. The need for cultural awareness by health-care providers is therefore becoming more important. This is especially true in end-of-life discussions, where cultural beliefs and traditions may strongly influence decisions made by patients and their families. Attitudes regarding death and dying vary significantly between countries and even between groups of different cultural backgrounds within countries.1 Questions pertaining to disclosure of information, advance directives, assisting death, and the withholding or withdrawing of treatment are some of the major ethical challenges confronted during terminal illness that are influenced by cultural background. Health-care professionals experienced in palliative care tend to have similar attitudes about caring for dying patients regardless of their sociocultural context.2 This suggests that certain attitudes about death and dying are shared universally by health-care professionals in spite of the wide variation of beliefs and the typically strong influence of religion and cultural background. But these attitudes may differ markedly from those held by patients and their families. Cultural demographics are changing dramatically in this country. The trends in growth and concentration indicate a need for greater awareness and sensitivity to the cultural 84 85 Culture Sensitivity in End-of-Life Discussions needs of ethnic minorities, especially in geographic areas where expansion has been greatest. Using as an example one midwestern state, the population of Missouri increased from 5,117,073 in 1990 to 5,595,211 in 2000. Overall, Missouri’s population grew by 9.34 percent, but central Missouri’s grew by 14.57 percent. The African American population grew by 14.1 percent in the state, and was up 33.46 percent in central Missouri. Missouri’s Hispanic population nearly doubled, increasing by 168 percent in the central corridor of the state. Though Hispanics comprise only 2.1 percent of Missouri’s population, many areas of the state are densely populated due to cultural cohesiveness. In Saline County, for instance, 4.4 percent of the population is Hispanic. Asians and Native Americans make up 1.4 percent and 1.1 percent of Missouri’s population , respectively, but there are some areas where the Asian population is more concentrated. In Boone County, Asians comprise 3 percent of the population.3 These numbers indicate that cultural diversity is not coming to Missouri —it is already there. Similar cultural demographic shifts are occurring in other states. With these increases in minority populations, the urgency of considering the variability of beliefs and values among patients who are dying has never been more pressing. The task of this chapter is to review the cultural perspectives that influence decisions at the end of life and to encourage clinicians to be sensitive to these influences. The risk of misunderstanding can be minimized by gaining awareness that cultural influences exist, learning about these influences , responding to these differences respectfully, and taking into account the values and beliefs of each individual patient. On the other side of the coin, cultural stereotyping can be disruptive, and consideration of this potential source of conflict reemphasizes the importance of being patient centered and maintaining good communication when dealing with end-of-life issues. 86 Care of the Dying Patient The Historical Context of Death The ideal of helping people to “die well,” with the focus on relieving pain and suffering, occupied the core of medical moral discourse for over two thousand years.4 Death in most societies was an accepted part of life and was often welcomed as a means of escape from suffering. But the expectancy that life will lead to death has been blurred by the modern advancement of medical science. The ability to postpone death through repeated medical interventions has created unreasonable expectations of longevity, regardless of the disease, severity of illness, or prognosis. An ethical paradox has resulted. The societal emphasis on cure rather than care, and the medical emphasis on continued intervention and treatment, has led to fear by many patients that they will suffer needlessly at the end of life.5 Today, people live longer, and at least 70 percent of Americans die in hospitals or other institutions, rather than at home.6 Many spend their last days on life support and in critical-care settings despite their own health-care directives to the contrary.7 Death, once an...