MethodsThe author performed a literature review and incorporated published literature, interviewed health care providers experienced in end-of-life care, and drew from her own clinical experience. The author, a community health and hospice clinician, has over 30 years’ experience with hospice care. Show
IntroductionThe discussion a health care provider, including physicians, advanced nurse practitioners, nurses, and social workers, has with a patient about end-of-life care is often a challenge. The challenges can be influenced by a number of variables, such as the provider’s training and experience is this area, the provider’s comfort level in discussing the subject, and the availability of adequate time for having the discussion (Kamaka, 2010; Tait & Hodges, 2009). A provider may be challenged further when the patient’s cultural norms differ from the health care provider’s, particularly around end-of-life care, which can impact the provision of quality end-of-life care. American core values emphasize autonomy and individual rights to make life choices, especially health care choices. Photo by Prachatai (cc license).The Patient Self Determination Act (PSDA) of 1990 was developed to ensure those rights were protected, including the fundamental rights to treatment choices, informed consent, truth-telling and open communication with health care providers, and control over the individual’s own life and death (Electronic Code of Federal Regulations, 2011). These American core values may often be in conflict with the values of many ethnic and culturally diverse groups in the United States. These conflicts can lead to health disparities resulting in fragmented care, inadequate or inappropriate symptom management, miscommunication with the patient and family, and a difficult and poor death for the patient. There are numerous studies that support these conclusions (Campinha-Bacote, 2011; Doorenbos et al., 2010; Eues, 2007; Giger, Davidhizar, & Fordham, 2006; Huff & Kline, 2007b; Searight & Gafford, 2005a). Enhanced cultural competency with regard to improving end-of-life care continues to be an identified need for hospice nurses, social workers, family practice physicians, psychiatrists and other health care providers (Braun, Ford, Beyth, & McCullough, 2010; Rushton, Scanlon, & Ferrell 1999; Schim & Doorenbos, 2010; Schim, Doorenbos, & Borse, 2006). The focus of this article will be on cross-cultural issues at the end of life for ethnically and culturally diverse groups in the United States. The health care provider must have a clear understanding and recognition of the unique and specific influences culture has on a patient’s behavior, attitudes, preferences, and decisions around end-of-life care. It is important to remember that simply because a person is identified as a member of a particular ethnic group or practices a particular religion it does not necessarily mean that the person or person’s family maintains beliefs that may be associated with the ethnicity or religion. Additionally, an assessment should be made of how acculturated a person and their family are, their language skills, and whether an interpreter is needed. Be aware of some of the overall cultural values of the community and then explore the pertinent themes as they relate to providing health care for individual patients. Remember there is great diversity within a community. Experiences will vary greatly depending, for example, on whether people lived in rural or urban communities in their countries of origin, how long they have been in the United States, their immigration experiences, former occupations, and levels of education. Keep in mind that patients are individuals. The examples included are to illustrate concepts and are not meant to be all inclusive or representative of everyone within a particular community or of all ethnic groups. This resource will address three major areas of cultural relevance in end-of-life care:
Cultural Competency in Clinical PracticeDiversity in Our SocietyThe United States is rapidly moving towards becoming a more ethnically and culturally diverse country, with whites expected to account for less than fifty percent of the population by 2040 (Frey, 2012). The national trends continue to see ethnic minorities dominating national growth, with continuing immigration (largely from Latin America and Asia) resulting in an increase in the “minority majority” population (Frey, 2012). Four states and an increasing number of metropolitan areas and their suburbs have a minority majority population composed of over fifty percent non-whites and Hispanics (Frey, 2012). When immigrants relocate, they don’t leave their culture behind, but bring those values, beliefs, and norms to their new home. And depending on how acculturated a person is, aspects of his or her culture may have a strong influence on the person’s response to illness and health care. As America evolves into a multiethnic society, how health care providers manage that shift is critical in establishing culturally appropriate and effective care. Through cultural competency in clinical practice, health care providers can provide care that ensures the individual receives high quality of care regardless of culture or ethnicity. Cultural CompetencyCultural competency can be viewed as an ongoing journey of commitment and active engagement through the process of cultural awareness, cultural knowledge, cultural skills, cultural collaboration, and cultural encounter (Kachingwe & Huff, 2007; Leininger, 2002a). Cultural competency allows for the delivery of individualized health care services within the cultural context of the patient and the avoidance of stereotyping (Kagawa-Singer & Backhall, 2001). Trust is the underlying purpose behind cultural competency in the development of the health care provider and patient relationship. Without trust there cannot be an effective relationship, which increases health disparities (Campinha-Bacote, 2011; Huff & Kline, 2007b; Kachingwe & Huff, 2007; Leininger, 1999; Schim & Doorenbos, 2010; Tervalon & Murray-Garcia, 1998). Key Elements of Cultural CompetencyThe following are the key process elements that require a health care provider to commit to lifelong learning in order to enhance health care services (Campinha-Bacote, 2009, 2011; Kachingwe & Huff, 2007; Leininger, 2002b). Cultural Desire is the process of wanting to become culturally competent. It is the motivation that is behind the health care provider’s desire to actively engage and commit to becoming culturally competent. Humility is the key factor in this process. Humble health care providers have a genuine desire to discover what the patient is thinking and feeling. Also of critical importance is seeing each individual as a unique and worthy person to be treated with dignity, fairness, and deserving of quality of care. Cultural awareness is the process of becoming more sensitive, respectful, and attentive to the patient’s cultural beliefs and practices. Through this process the health care provider becomes cognizant and reflective of his or her own cultural identity, attitudes, biases, and prejudices and how they shape his or her behavior, specifically in the provision of health care services. Cultural knowledge is the process of developing an understanding of the differences and similarities between and within cultural groups. This includes learning about various cultural groups’ values, beliefs, lifestyle practices, and perspectives on life. Culture is a powerful determinant of behavior towards illness. Cultural skill is the process of cultural assessment, which obtains relevant information about the patient’s beliefs, values, and practices. A critical component of cultural skill is the development of interpersonal communication skills that convey respect, appreciation, and sensitivity to other cultures. Cultural collaboration is the process that requires a partnership approach between the health care provider, the patient, and the family. An important part of the collaboration is the development of mutually agreeable goals between the health care provider, patient, and family. Cultural encounter is the process of obtaining cultural experience through active engagement and, if possible, immersion in another culture. Meaningful encounters require being open to learning, understanding, and appreciating the other person’s viewpoint. The Relevance of Cultural Competency in End-of-Life CareIncense burning at Buddhist Temple, Ho Chi Minh City, Vietnam. Photo by Patrick Coolen.Working within the cultural context of the patient and family is an essential underpinning of end-of-life care. Cultural influences can significantly impact the patient’s reaction to the dying process and the decisions the patient and family make (Giger, et al., 2006; Kagawa-Singer & Backhall, 2001; Koenig & Gates-Williams, 1995; Searight & Gafford, 2005a). Fostering trust is vital to the care of the patient and family during this difficult time. End-of-life care means more than treating physical symptoms, but extends to the psychosocial, existential, and spiritual aspects of the patient’s needs. Numerous studies devoted to understanding culture’s relevance to death and dying found that communication was the greatest barrier between the health care provider and the patient and family during end-of-life care (Eues, 2007; Jovanovic, 2011; Klessig, 1992). A provider needs to consider the following (Lopez, 2007):
Cultural Factors to Consider in End-of-Life CareDeath as a Taboo SubjectIn some cultures, talking openly about death and dying is not acceptable because it is considered disrespectful, bad luck, or causes loss of hope (Giger, et al., 2006; Kagawa-Singer & Backhall, 2001; Searight & Gafford, 2005a, 2005b). Many cultures actively protect dying family members from knowing their prognosis (Carteret, 2012; Giger, et al., 2006; Searight & Gafford, 2005a, 2005b). For example, some Filipinos may request the family member not be told he or she is dying because of concern for the person’s loss of hope and the belief that only God can decide a person’s fate. For many Southeast Asian families, the dying family member is not to be told about a terminal diagnosis because talking about death would bring it on sooner or doing so is disrespectful to the soon-to-be ancestor. Some Somalis consider it uncaring for the health care provider to tell the terminally ill family member he or she is dying (Stratis Health, 2010). And for some Muslims, talking about death is taboo and a religious leader may be needed to facilitate the conversation with the male family leader and the health care provider about end-of-life care. Collective Decision-makingCollective decision-making is the norm in many cultures, but it often clashes with the American value of autonomy and an individual’s right to make one’s own decisions about health and dying (Giger, et al., 2006). Collectivism’s core values can cause a treatment dilemma for the health care provider whose focus is on getting the patient involved in the treatment plan. In collective decision making, the family decisions will be family oriented. In these circumstances, it is important to understand and respect that the power of collectivism is more important than an individual (Huff & Kline, 2007b; Logan, Fukuda, & Baldwin, 2006). A family may expect information to be given to them first, so they can make the health care decisions (Countries and Their Cultures, 2012; Giger, et al., 2006; Klessig, 1992; Koenig & Gates-Williams, 1995). For example, Koreans and Mexican Americans are more likely to consider the family as the decision-maker regarding withholding of aggressive treatment, rather than the patient alone (Maly, Umezawa, Raliff, & Leake, 2006). For many Asians and Pacific Islanders, filial piety, as supported by Buddhism, Confucianism, and Christianity, requires family members to take over the decision-making role for the seriously ill elderly patient (Giger & Davidhizar, 2002). Filipino/Kamaaina Couple. Photo by Phyllis Coolen.Family and extended family ties are extremely important to the Filipino and Hawaiian communities, with the extended family participating in the discussions and decision-making for the seriously ill family member. Some Somalis believe that health care decisions involve the whole family, with a male family member being the spokesperson for the family and the father being the bearer of bad news to the patient (Carteret, 2012). When death is imminent, the Asian Indian male head of the household is responsible for deciding when the patient is to be told and when to inform the rest of the family members (Stratis Health, 2010). Perception of the Physician’s Status and Health Care Experience in Country of OriginImmigrant patients may come from countries where the physician makes all health care decisions and patients are unaccustomed to being asked to choose among treatment options (Kingsley, 2010). The patient and family may have the expectation that it is the physician’s role to decide on end-of-life care (Searight & Gafford, 2005b). For many Filipinos, physicians are held in high esteem and are given extensive authority, so questioning the physician’s treatment decision or being asked to make a decision about one’s own health care is not expected. They would expect the physician to make all decisions about their health care. Additionally, some immigrant patients may not be accustomed to or comfortable asking questions of the physician, even if aspects of the illness or treatment plan are not understood because of concern that they will be perceived as challenging the physician (Shavers, Bakos, & Sheppard, 2010). For example, Southeast Asian cultures value politeness and respect for authority, so questions or voicing concerns about the family member’s terminal illness or treatment may not occur. Perception of Pain and Request for Pain ReliefCulture can affect a person’s response to pain, both in the meaning and expression of pain. Pain may be seen as something positive, that it a sign that the body is fighting towards recovery or as a test of one’s faith through suffering or even as a punishment (Giger, et al., 2006; Shavers, et al., 2010). Therefore for some individuals, asking for pain medication may be considered a sign of weakness. Culture can influence the initiative a patient takes in asking for pain medication. For example, Cambodian culture values an indirect communication style, avoiding public display of emotion and confrontation, so rather than asking directly for pain medication, the patient may wait to be asked if medication is needed (Mahloch et al., 1999). For many Somalis, the concept of autonomy is foreign and they may wait for the health care provider to ask if the patient is experiencing pain (Countries and Their Cultures, 2012). For more information about pain, see the Pain Management section below. Role of Religion and FaithFor many ethnically diverse cultures, the approach to health and illness is through the interconnection of mind, body, spirit with nature or the environment. Faith and spirituality can play a significant role in the perception and response to the dying process (Countries and Their Cultures, 2012; Huff & Kline, 2007b; Kachingwe & Huff, 2007; Koenig & Gates-Williams, 1995; Mark & Lyons, 2010; Yee, 2007). For example, in the Vietnamese culture, health and religion are connected and therefore, suffering and illness are part of life. Death cannot be avoided or ignored as it is part of life. Vietnamese Buddhists believe that a person’s life is predetermined and prolonging life is futile. The family may want a monk to pray at the bedside to assist the person for a peaceful journey to the next life (Braun, Beyth, Ford, & McCullough, 2008). Maori spiritual healers strongly believe in reconnecting with their culture, their land, and their genealogy to restore the sense of identity and sense of belonging during serious illness. So, in order to heal the person’s spirit, the person must relearn the culture as part of a ritual health passage (Mark & Lyons, 2010). For Filipino Catholics, a priest would be requested to give the sacrament of the sick, so that the person may ask forgiveness for their sins in order to gain strength and peace as they go through the dying passage. In addition, some families will hold evening prayers with family and friends gathering together for support as they all go through the journey with the patient. Traditionally, Hmong believe that the soul is lost due to an evil spirit or that a curse is the cause of the illness. Spiritual ceremonies by a shaman are crucial to bringing back the lost soul. However, the Hmong also believe in reincarnation; when the person is dying, religious ceremonies by the shaman are conducted for the purpose of helping the person have a good journey to the next life (Carteret, 2012). As in other Asian and Southeast Asian cultures, such as in the Cambodian and Vietnamese cultures, there is a belief in the importance of harmony in and between the body, mind, and soul with the universe. Imbalance in these elements can cause a mild to life-threatening “wind illness.” Wind illness is associated with fever, dizziness, and sickness; however the more severe manifestation might be likened to a stroke or heart attack. Traditional healing practices are often used to treat wind illness. For more on wind illness, see EthnoMed article Ethnographic Study among Seattle Cambodians: Wind Illness. For many African Americans there is a strong belief that prayer and the power of God will heal the patient. In comparison with non-Hispanic whites, African Americans are more likely to consider religion as a coping strategy in dealing with end-of-life issues and advanced planning. It is important that the health care provider consider the role of spirituality and partner with spiritual leaders in end-of-life care discussions (Shrank et al., 2005). Native Hawaiians have a strong belief in a higher spiritual God and that prayer, chanting, and music will restore the balance of mind, spirit, and body (Logan, et al., 2006). To show respect to a dying elder, Hawaiian families – including extended family and community members – will gather, even in the hospital, to tell stories, pray, and play music. For some Thai Buddhists, when a person is dying, an effort is made to have the person focus upon Buddhist scriptures or repeat one of the names of the Buddha, such as Phra Arahant. If the person is too weak, then the name is whispered in his ear. Sometimes four syllables (ci, ce, ru, and ni) which represent the heart of the Buddhist teachings (Abhidharma) are written on a piece of paper and put in the mouth of the dying person. It is thought that if the person’s last thoughts are the teachings of the Buddha, the person will have a good next life (Buddhist Studies, 2012). Among many Somali Muslims, prayers assume a pivotal role at the end of life. Reciting from the Quran at the patient’s bedside is done to ensure that the last words the person hears before death are the words from the Quran, as the prayers allow the person’s soul to enter paradise after death. Also Muslims pray towards Mecca, so asking the family if the patient would like his or her bed positioned to face towards Mecca, if possible, would be an important part of the patient’s care (Klessig, 1992; Schim & Doorenbos, 2010). Use of Traditional HealingThe use of Western medicine is generally acceptable by ethnically diverse patients in the care of terminal illness, although the level of acceptance depends on a number of factors, including how assimilated the individual is to American culture (Le & Le, 2005). Alternative practices may be used simultaneously with Western medicine because of the perceived or real effectiveness of the treatments as experienced by the patient. Symptoms often experienced as a result of the disease and dying process include pain, nausea and vomiting, breathing difficulties, skin wounds, bowel and bladder problems, anxiety and depression, and sleep disturbances. To address these symptoms, patients may seek the care of spiritual healers and the use of alternative practices, such as coining, cupping, moxibustion, palm reading, use of astrological computations for life guidance, and herbal and folk remedies. Some Filipinos may seek medicinal healing through the use of halaman (herbs) and an herbolaryo (witch doctor), if they believe that evil spirits entering the body caused the illness. For more information on traditional medicine, see our Pharmacy clinical topic page. Hospice and Palliative CareAlthough the hospice and palliative care movements have been instrumental in increasing awareness in end-of-life issues, many people are still not familiar with these services. For some cultures, hospice and palliative care’s focus on comfort, harmony, family and support fits nicely with the culture’s values and beliefs. For cultures where dying at home is a valued norm, those values are congruent with hospice care. Providing services in the home is a hallmark of hospice care. Palliative care, which is generally provided on an inpatient basis, is designated for patients regardless of their life expectancy, who have a progressive, debilitating and/or life-limiting illness that adversely affects their daily functioning or will predictably reduce life expectancy (National Guideline Clearinghouse, 2011). The palliative care team works in conjunction with the primary care physician and can offer assistance with end-of-life care. This includes the treatment of pain and other symptoms, emotional and spiritual support, assistance with communication of bad news, support for patients and families in medical decision-making, and navigating the complex medical system (National Guideline Clearinghouse, 2011). Hospice also provides palliative care. However, hospice services are for patients who are no longer seeking curative therapy and have a prognosis of less than six months. Hospice care is provided in any setting that is considered the patient’s home, which includes the patient’s home, skilled nursing facilities, assisted living facilities, retirement homes, and even the hospital. Cultural AssessmentThere are numerous cultural issues germane to end-of-life care. A critical step in understanding cultural relevance in end-of-life care is performing a cultural assessment. A cultural assessment provides a systematic way of gathering and documenting information about the patient’s cultural beliefs, meanings, values, patterns, and expressions as they relate to the patient’s perception and response to an illness (Leininger & McFarland, 2002). Gathering of information is conducted through asking the patient and family specific questions and also through observations of the patient, including family behavior patterns. A cultural assessment can be performed by any health care provider, with modifications of the assessment tool based on the health care provider’s particular discipline, interests and therapeutic goals (Leininger, 2002a). It is critical that the assessment by each discipline and the documentation of the assessment be coordinated and incorporated into the patient’s treatment plan to ensure continuity of care. It is also important to remember to communicate the cultural assessment findings to all members of the patient’s health care team, including specialists to whom the patient is referred. Sharing the patient’s cultural assessment with the other health care team members lays the foundation for care and can provide a smooth transition for the patient as he or she moves through the health care system. There are a number of assessment tools available. Regardless of which is utilized, the focus must be on the uniqueness of the individual patient and how culture shapes his or her response to dying and end-of-life care. An approach to beginning an assessment might be to say, “I would like to learn more about you and your culture, so that I can be sure and meet your needs and provide the best care for you.” Kleinman and Campbell’s Patient Explanatory Assessment ModelKleinman’s (Kleinman, Eisenberg, & Good, 1978) patient’s explanatory assessment model devised eight simple questions that clarify cultural generalizations and provide insight into the patient’s personal meaning of the illness. Campbell et al. (Campbell, McDaniel, & Cole-Kelly, 2003) added family-focused questions to be included along with Kleinman’s questions. The questions may be varied and individualized depending on the patient’s problem or if the questions are being asked of the family members. The term “illness” can be substituted with a specific symptom or a term that may be commonly used by the patient, such as “sickness,” “pain,” or “fluid in your stomach area” to help the health care provider understand the patient’s perception of the effects of the illness. The questions are:
Giger-Davidhizar and Huff Cultural Assessment ModelsGeiger-Davidhizar’s Cultural Assessment Model considered six components relevant to end-of-life care: communication, space, time, environment control, social organization, and biological variation (Giger, et al., 2006). The author added additional assessment from her own practice as well as from Huff’s assessment model to the table in the sidebar in order to enhance information gathering (Huff & Kline, 2007a). Kagawa-Singer & Blackhall’s ABCD Cultural Assessment ModelKagawa-Singer and Blackhall developed a cultural assessment mnemonic approach to assess the degree of cultural adherence to help avoid stereotyping and decrease the risk of miscommunication (Kagawa-Singer & Backhall, 2001). The ABCD cultural assessment is outlined in the accompanying table (in sidebar). Advance DirectivesThe Patient Self-Determination Act (PSDA) of 1990 (Electronic Code of Federal Regulations, 2011) requires health care facilities to ask patients if they have an advance directive and if not, requires them to provide patients with information about advance directives. The intent of the advance directive is to improve end-of-life care. There are two types of advance directives: a document called an advance directive which is also known as a living will, personal directive or advance decision, and a durable power of attorney for health care (WSMA, 2012). Key Points to Know About an Advance Directive
Key Points to Know About a Durable Power of Attorney for Health Care
Cultural Issues around Advance DirectivesStudies indicate that ethnic minorities in comparison to whites continue to have lower rates of completing advance directives (Kwak & Haley, 2005). These lower rates are due to a lack of knowledge and understanding by the patient and family about the advance directive; a distrust in the American health care system and concern that the person’s wishes won’t be carried out; fear of death; and cultural differences regarding the need for an advance directive, which relate back to “death is a taboo subject” (Campinha-Bacote, 2009; Giger, et al., 2006; Searight & Gafford, 2005a). The key in discussing advance directives is in the planning process. Fostering a trusting relationship between the health care provider and the patient and family is a critical component in the planning process which requires discussing the patient’s values, preferences, and options with the health care provider (Braun, et al., 2010). The following are specific areas of concern:
Many Southeast Asians are Buddhist and believe in the cycle of life, karma, reincarnation, and that death is part of life. Aggressive treatment may be viewed as disturbing the natural ebb of life and a sign of a bad death (Jagaro, 2004). The palliative and hospice focus of comfort care with peaceful and family support aspects may be more acceptable and in line with Buddhist beliefs and values. Patients and families may be more open to the discussion about and acceptance of advance directive planning. In some cultures, such as the Samoan, Vietnamese, and Asian Indian cultures, there is belief that dying away from home can lead to disturbances of the spirits. Some people may also believe that there are too many disturbing spirits in the hospital, so dying in the hospital should be avoided (Countries and Their Cultures, 2012: Yee, 2007). For Koreans, dying at home is a norm encouraged in the culture (Kwak & Salmon, 2007). Patients and families from these cultures may consequently be more open to discussion about advance directives and hospice services. On the other hand, many Chinese avoid dying at home, because of the belief that ghosts will linger in the home (Koenig & Gates-Williams, 1995). Approaches to Consider When Discussing Advance DirectivesThe following are approaches to consider when discussing advance directives in order to provide an open and supportive environment:
The following are examples of scripts for the discussion on advance directives. Adjust the script if the discussion is with the family. Remember, asking permission to have the discussion shows respect.
Pain ManagementHealth Disparities in Pain ManagementThere is strong evidence that health disparities continue to exist among ethnically diverse groups. In comparison to their white counterparts, ethnic minorities experience higher rates of mortality, shorter life expectancy, greater difficulty with access to health care services, higher rates of chronic disease, lower rates of cancer screening, and higher rates of having a more advanced stage of cancer at the time of diagnosis (Ho, Muraoka, Cuaresma, Guerrero, & Agbayani, 2010; Kline & Huff, 2007; Minority Health Initiatives, 2006; Politzer, Yoon, Hughes, Regan, & Gaston, 2001; Shavers, et al., 2010). The 2010 National Healthcare Disparities Report indicates that disparities in quality of care and access to care are common, and that ethnically diverse groups such as African-Americans, Hispanics, American Indians/Alaska Natives, Asians/Pacific Islanders, and the poor receive worse care than whites and people with higher incomes (Agency for Healthcare Research and Quality, 2011). With regard to palliative and end-of-life care, the 2010 National Healthcare Disparities Report (Agency for Healthcare Research and Quality, 2011) found when comparing African-Americans, Asians/Pacific Islanders, American Indians/Alaska Natives, and Hispanics to whites:
Health disparities in quality of care and access to care have also lead to disparities in the treatment and management of pain during end-of-life care. Shaver et al.’s review of the literature found disparities in pain management for ethnically diverse patients (Shavers, et al., 2010). These disparities are likely due to a lack of access to care, lack of appropriate access to analgesics and opioids, lack of access to pain specialists, and language barriers. The patient’s fear of addiction and the provider’s lack of knowledge about effective pain management during end-of-life are other contributing factors. Examining the cancer pain experience among non-Hispanic whites, African American, and Asian participants, miscommunication between the provider and patient regarding the patient’s perception and expression of cancer pain was a common theme found across all ethnic groups (Im et al., 2010). Chung et al. (2009) found that Chinese- and Japanese-American cancer patients’ pain intensity was significantly underestimated by both physicians and nurses, while Anderson et al. (2000) found that physicians significantly underestimated the pain severity of African American and Hispanic patients with recurrent and advanced cancer. Other studies found that minorities were more likely not to receive pain medication or would receive a lower dose of an analgesic even if the patient had advanced cancer or was receiving end-of-life care (Green, Montague, & Hart-Johnson, 2009; Mossey, 2011; Payne, Medina, & Hampton, 2000; To, Ong, Rawlings, Greene, & Currow, 2012). Additionally, underreporting of pain intensity by minority patients was a significant barrier to effective pain management (Dhingra, 2008; Mossey, 2011; Shavers, et al., 2010). Cultural Influence on Pain ResponsePain is more than a response to a physical/biological injury. It is a complex event that encompasses psychosocial, emotional, and social components, which any treatment of pain must take into consideration (Fortier, Anderson, & Kain, 2009). A key element of palliative and hospice services is to assess and relieve suffering from not only physical pain, but also from psychological, social, and spiritual distress (National Guideline Clearinghouse, 2011). In order to provide culturally sensitive pain management, a patient’s pain must be considered within the context of the individual’s beliefs and values, as culture may influence the individual’s perception and response to pain, whether or not the patient will ask for pain medication, or whether the use of traditional healing practices take precedence over Western medical treatment (Dhingra, 2008; Im, et al., 2010; Mossey, 2011; Narayan, 2010; Shavers, et al., 2010). It is important to remember there are variations among individuals within a cultural group with regard to their perception and expression of pain. However, understanding the broader aspects of cultural influence affecting response to pain can provide the health care provider with the necessary foundation for assessing specific and individual cultural influences and providing effective pain treatment. The use of certified medical interpreters for limited English proficient (LEP) patients can facilitate effective communication between the health care provider and the patient about end-of-life care, including the difficult issues around pain management (Norris et al., 2005). Supporting the use of the interpreter as a cultural broker can also enhance the communication between the health care provider and patient through greater understanding of the cultural aspects and perspectives of the patient (Norris, et al., 2005). The following examples of miscommunication are based on several of the author’s clinical observations and experiences and are intended to illustrate the issue. When a Cambodian hospice patient was asked if he had pain, he pointed to his heart. The clinician assumed that the patient was having cardiac pain and further assessment and treatment focused on eliminating the cardiac pain, without effective results. Upon further discussions with the family it was revealed that the patient’s “heart pain” was referring to his health and how painful it was to him and his family to see him so ill, as well as worrying about his family and the burden his illness placed on them. For Cambodians, the heart symbolizes love, kindness, willingness to help others, and health (National Head Lung and Blood Institute, 2010). Another example of miscommunication is that of an elderly Chinese woman, who when asked if she had any pain, she pointed to her head. The hospice clinician’s treatment was then focused on treating the patient’s “headache.” Much time was spent on treating the patient’s headache without effective elimination of the pain. It was finally realized through persistent assessment and working with the family that the patient’s reference to the pain in her head was not due to a headache, but that the patient had been referring to her anxiety and stress about her illness. In these two examples the patient and family were frustrated by not being able to effectively communicate their concerns, and the health care providers were frustrated by not being able to effectively manage the patient’s pain. The use of a medical interpreter as a cultural broker would have improved communication between the health care providers, the patients and their families, with greater likelihood of positive results in more timely, effective, and appropriate treatment and support. In addition to language barriers, the way a person expresses pain due to cultural influences can make it difficult for the health care provider to effectively assess the patient’s pain. For some elderly Chinese patients, stoicism and fatalism can create barriers to effective pain management (Carteret, 2011; Dhingra, 2008). Fatalism as influenced by Buddhist and Confucian beliefs proposes that pain should be endured, as it could lead to spiritual growth (Carteret, 2011). Stoic patients may be less likely to openly express their pain verbally and non-verbally, and may prefer to be left alone in order to bear their pain and suffering. Being stoic and hiding one’s pain may influence requests for pain medication or result in the underreporting of pain. Studies have found stoic pain behavior is more often found among Mexican Americans, American Indians, and Asian Americans (Carteret, 2011; Narayan, 2010; Shavers, et al., 2010). Health care providers may assume that if the patient is not expressing pain, that pain does not exist, resulting in under treatment. On the other hand, patients from Middle Eastern or Mediterranean cultures may be more expressive in their communication and more likely to openly express their concerns about their pain. Being openly expressive does not necessarily mean their pain is intense, but may indicate the need to validate their suffering (Carteret, 2011; Im, et al., 2010; Shavers, et al., 2010). According to a study by Im et al. (2010), some Asians and Hispanics felt that since cancer was related to death, increasing pain meant their cancer was getting worse and since death was a taboo subject, talking about pain was not appropriate or they minimized the amount of pain they were having (Im, et al., 2010). Not acknowledging pain or the intensity of the pain also results in barriers to effective pain management. In many cultures, religious or spiritual belief in fate and karma (“God’s will”) explain why an individual has developed a life threatening illness and that pain is seen as a test of one’s fate, spiritual beliefs, as a means of achieving higher religious status, or even as a punishment for a sin (Carteret, 2011; Shavers, et al., 2010; Yee, 2007). If these beliefs are held, patients may not ask for pain medication or expect pain relief. On the other hand, the role of religion and spirituality can be considered a positive pain coping strategy, as seen in some studies of African-Americans, with the result of lowering pain scores, more positive pain and symptom attitudes, and greater acceptance of pain medication (Shavers, et al., 2010). In some cultures, not wanting to be a burden to the family by not complaining may lead to increasing pain intensity. Pain that is out of control may be more difficult to effectively manage. The following is an example taken from the author’s experiences: A Hawaiian woman with stomach cancer was experiencing abdominal pain but did not inform the family about her increasing pain because she did not want to be to a burden. Only when the pain became so severe that it was affecting her ability to eat and sleep did she finally tell her daughter. The daughter, who was her caregiver, was very frustrated with her mother for not sharing that she was in pain and that it took a long time before her mother’s pain was brought under control. Some patients may not want to take opioid pain medication for a variety of reasons, including preference for traditional healing practices, fear of addiction, fear of being overly sedated, a lack of access to insurance coverage, and a lack of access to opioids at their local pharmacies (Narayan, 2010). In the author’s experience, sometimes even hospice clinicians have difficulty obtaining opioids for their patients as the local pharmacies either stock a very limited supply or do not stock them at all due to an increased risk of robberies. In addition, studies have found that some health care providers associate some minority groups and low income people with drug-seeking and drug addiction behavior, with the result of under treatment of legitimate pain (Coolen, Best, Lima, Sabel, & Paulozzi 2009; Narayan, 2010). Pain AssessmentObtaining a comprehensive, culturally sensitive pain assessment will allow the health care provider to have a better understanding of the patient’s pain and to effectively manage it. The nurse or physician can perform the pain assessment, which should then be documented in the patient’s treatment plan. The pain assessment results should be shared with the patient’s health care team in order to ensure continuity of care and eliminate pain management disparities. Utilizing Kleinman’s assessment questions can provide cultural insight into the meaning of the patient’s pain (Kleinman, 1980):
The Explanatory Model Interview for Pain Assessment is another tool that provides cultural insight into the patient’s perception and response to pain (Lasch, 2000; Narayan, 2010):
There are a number of scales available for assessing pain among culturally diverse populations, such as the Wong-Baker FACES™ Pain Rating Scale, the 0-10 Numeric Rating Scale, the Visual Analogue Scale (VAS), and the Memorial Pain Assessment Card (MPS), which have been validated for appropriate use with ethnically diverse populations, including African-Americans, Hispanics, Asian Americans, and Native Alaskans (Badr (Zahr), Puzantian, Abboud, Abdallah, & Shahine, 2006; Hunter & Cassey, 2000; Kim & Buschmann, 2006; Luffy & S., 2003; Newman et al., 2005; Ramer et al., 1999; Shavers, et al., 2010; Shin, Kim, Kim, Chee, & Im, 2008; Tomlinson, von Baeyer, Stinson, & Sung, 2010). Patients usually indicate on the various scales by pointing to the area that best depicts their level of pain. The Wong-Baker FACES™ Pain Rating Scale has a series of 6 gender-neutral face circles that range from depicting a neutral facial expression of “no pain/no hurt’ to the “worst possible pain/hurt worst” depicting a crying face. The Wong-Baker FACES™ Pain Rating Scales is available in 13 different languages, including Spanish, French, Vietnamese, Chinese and Romanian (see Figure 1). Free access to download the scale can be obtained at FACES Download - Wong-Baker FACES Foundation. The Wong-Baker FACES ™ scale has been validated with African American, Thai, Asian, Hispanic, and older Korean American populations. A modified Wong-Baker FACES™ scale used on fabric dolls with Lebanese children also validated the effectiveness of the scale. Curtin and Goldstein (Curtin & Goldstein, 2010), who work with the Native Alaskan Yup’ik culture, effectively utilized the modified Wong-Baker FACES™ scale, known as the Northern Pain Scale, which depict Native Alaskan faces to improve communication about pain with patients (Curtin & Goldstein, 2010; Ellis et al., 2011). Copyright 1983, Wong-Baker FACES™ Foundation, www.WongBakerFACES.org. Used with permission. Originally published in Whaley & Wong’s Nursing Care of Infants and Children. ©Elsevier Inc.The 0-10 Numeric Pain Rating Scale consists of a vertical line that has been evenly marked with numbers from 0-10, with 0 being “no pain” to 10 being the “worst possible pain.” This scale was considered reliable and validated for measuring pain in older African-Americans and older Koreans (Kim & Buschmann, 2006; Shavers, et al., 2010).The Visual Analog Scale (VAS) consists of a 10-centimeter horizontal line with “no pain” anchored on the left side and “worse possible pain” anchoring the right side. The patient marks the area on the line that indicates the intensity of his/her pain and the mark is then measured from the left side of the anchor (Kim & Buschmann, 2006). A VAS color-coded slide ruler can also be used, which the patient moves to indicate the intensity of his/her pain. The far left side of the ruler is color coded blue, indicating “no pain,” and the far right side is color coded red, indicating “pain as bad as it could possibly be.” The back of the ruler has a 100 millimeter scale that quantifies the pain intensity (Ramer, et al., 1999). The VAS scale was considered reliable and validated for measuring pain in older African-Americans, older Koreans, non-Hispanic whites, and Asians with cancer pain (Kim & Buschmann, 2006; Shavers, et al., 2010). Case StudiesThe following three case studies have been developed to address the complex issues surrounding cultural relevance in end-of-life care. These case studies are a compilation of a number of clinical situations and the purpose of the case studies is to examine real-life situations and provide the reader with guidance for reflective practice in the clinical setting. After reviewing the case studies, the reader may want to reflect on the following questions:
Case Study 1: Mr. SScenarioMr. S is a 53-year-old Cambodian immigrant with incurable metastatic colon cancer diagnosed three months ago. Mr. S has been in the United States for 25 years and has limited English proficiency. His wife is Cambodian, 35 years old, and has been in the U.S. for 10 years. English is her second language. They have three young children. Mr. S worked as a day laborer. His wife has never worked outside the home. They follow Theravada Buddhism. Mr. S has been referred to hospice services. Mr. S has been admitted to inpatient services for placement of a peritoneal drainage catheter for malignant ascites. Nurses’ notes indicated that since admission “Mr. S has been stable with no complaints of pain or discomfort. His wife accompanied him on admission and stayed until evening. Mr. S was given one Vicodan tablet before bedtime. Neither the patient nor the wife appears to understand English well. Interpreter services will be needed when his wife is taught how to manage the peritoneal catheter.” The only medication the physician has ordered is Vicodan, 1-2 tablets every 6 hours as needed for pain. Upon entering his room, the hospice health care provider, who is not Cambodian, greets Mr. S and his wife with the traditional Cambodian Sampheah greeting of bowing with the hands together at chest level and says in English, “Good Morning. How are you this morning?” Mr. and Mrs. S return the greeting with a smile, although it is clear that the effort of putting his hands together and bowing is very taxing for Mr. S. Mrs. S immediately expresses her concerns about her husband’s pain. She is obviously distressed and explains that Mr. S has been suffering with severe pain in his stomach, did not sleep last night, and has been sick to his stomach. She states that he threw up this morning, but that she cleaned him up and had not told the nurse. She wonders if something can be done to make him more comfortable. She also revealed that she does not want to bring their children to visit because they are too young to understand and she does not want them to see their father in so much pain. Mr. S. has not participated in the conversation but lies quietly in bed. However with any slight movement he grimaces, moans, and opens and closes his fist. The health care provider asks Mr. S the following questions and verifies with Mr. S’s wife that he understands the questions: HCP: “Mr. S, you seem to hurt. Can you tell me if you are in pain and where is your pain?” Mr. S: “Pain here” (pointing to his stomach and back). HCP: “What does your pain do to you? How does it work?” Mr. S: “It make me very sick. I cannot do anything. I cannot walk. Too weak. I cannot sleep.” HCP: “What do you think caused your pain?” Mr. S: (He does not answer, but moans and grimaces.) Mrs. S: “He wants to go home. He suffers, but it is too much for him. Doctor told him he has a tumor. Can he have a stronger pill to take the pain away?” HCP: “Mr. S, how bad is your pain? Is it there all the time or does it go away sometimes?” Mr. S: “Pain very bad. No sleep, no eat, no move. I suffer much.” HCP: “Do you take anything for your pain that helps?” Mrs. S: (She explains he uses Tylenol and koah kshal (coining) but that they do not seem to help. She said the pill the nurse gave him last night also did not help his pain.) (For more information on coining and other traditional Cambodian healing practices, see the Traditional Medical Practices section of the Cambodian Cultural Profile. HCP: “Mr. S, when you are having pain, will you ask the nurse for a pill?” Mrs. S. “He will not ask for anything. He will wait for the nurse to bring him something.” Reflective Questions and DiscussionWhat are your impressions regarding this scenario? A limited cultural awareness and sensitivity on the part of some of the health care providers added to the inadequate management of Mr. S’s pain and symptoms. Interpreters should be used for initial and ongoing assessment, not only for teaching at discharge. How could an understanding of the cultural beliefs assist the hospital staff in providing effective end-of-life care? If the staff performed a cultural assessment on Mr. S they would gain valuable information and insight into his behavior, reactions and decisions. The assessment would guide the staff in the development of appropriate interventions within the cultural context of Mr. S and his family. For example, an assessment would ascertain how well Mr. and Mrs. S understood English and if interpreter services were needed to prevent misunderstandings with his treatment. For many Cambodians, pain and other symptoms are often endured with stoicism. Questions must be asked directly and specially about each symptom the patient may be experiencing. General questions or fleeting questions are meaningless. An assessment, such as using Kleinman’s Eight Questions (see Cultural Assessment in this unit) would help providers understand Mr. S’s behavior, his response to his pain, and his expectations about treatment. This would result in pain and symptom management, including providing pain medication on a routine basis, rather than waiting for him to ask for medication. What are some key elements that should be included in Mr. S’ treatment plan in anticipation of potential problems or concerns?
A variety of resources including information on specific cultures and cultural practices, end of life care, and guidelines on cultural assessments should be made available to staff. This may include having access to consultation services with palliative care or hospice providers or access to resources on the internet such as The National Cancer Institute. What assessment and strategies are needed to improve communication between the health care providers and Mr. and Mrs. S? An assumption was made that Mr. and Mrs. S did not speak or understand English well. Consider how that information was determined and passed on to other staff, as well as the impact it had on his care. An initial assessment should include determining how well the patient and family speak and understand English and if there is a need for a certified medical interpreter. If the family does not want interpreter services, check with the organization’s policy on the use of interpreter services. Having a family member translate is not ideal and can result in significant misunderstandings. Listening with empathy and patience to Mr. and Mrs. S’s perceptions of pain and other symptoms is an important part of effective communication. Clarifying and acknowledging the differences and similarities in the practitioner’s perception of Mr. S’s pain and other symptoms can provide an understanding of Mr. S’ behavior and response to his pain and vomiting. The information can then be incorporated in the development of an effective treatment plan, such as routinely monitoring and asking Mr. S about any pain or symptoms he may be having, rather than waiting for him to tell the nurse. Respect is central to Cambodian culture. Greeting the patient and family with the traditional Cambodian greeting shows great respect and can open the door towards a trusting relationship. The health care provider in this scenario knew that the initial greeting of respect would be helpful to establishing good rapport. Though it may not be practical for health care providers to learn phrases of greeting for all their LEP patients, demonstrating an interest in the patient’s culture or language in other ways can go a long way towards building rapport. Case Study 2: Mrs. VScenarioMrs. V is a 68-year-old Filipino Hawaiian widow with end-stage chronic obstructive pulmonary disease (COPD). She is also an insulin dependent diabetic. Last year she moved in with her son, daughter-in-law, and four grandchildren because she was no longer able to live independently. Mrs. V is by herself all day. She is very short of breath with minimal activity and uses oxygen. She uses a wheeled walker to get around the house. In the past couple months she has gotten weaker and has fallen a couple times, tripping over rugs and “stuff” on the floor. In addition, her diabetes is not well controlled as she continues to eat peanut butter and jelly sandwiches, juice, and cookies for both breakfast and lunch, as “that is the only thing I like to eat.” Mrs. V is Catholic and her faith is very important to her. English is her primary language. The health care provider asked Mrs. V a series of questions to assess Mrs. V’s condition. Mrs. V did not answer the questions directly. HCP: “How is your breathing today?” Mrs. V: “You know, when I lived in Hawaii, I loved to watch and smell the burning sugar cane fields. I felt so free and relaxed. I moved to the mainland to be near my son and daughter. I used to have my own house, but my son, he wants to take care of me, and so I moved in with him. I don’t like being a burden to him. I miss Hawaii. I wish I could go back there to die. I think the air is much cleaner in Hawaii. Some days I have a very hard time breathing. It can be scary.” HCP: “How is your strength? Have you fallen lately?” Mrs. V: “I took care of my mother when she was very sick and we never left her alone. That is expected in our culture—to take care of our parents. My son takes good care of me, but his wife is not a good housekeeper. The house is cluttered, but this is not my home. I am here by myself until the family comes home from school or work. I usually stay in my room and watch TV and only get up to eat or go to the bathroom. I still manage. I don’t want to be a burden. God watches over me and gives me strength and protection. He gives me the strength not to be afraid of dying.” HCP: “It is noted that for breakfast and lunch, you only like to eat peanut butter and jelly sandwiches with juice and a cookie. Why is that? You know that is not a good choice because of your diabetes.” Mrs. V: Laughing she says, “I was a great cook. I loved cooking Filipino and Hawaiian dishes. It is important in our culture to welcome guests into our home and to share our food. The kitchen belongs to my daughter-in-law and I do not feel comfortable cooking in her kitchen. It is hard to get around and I don’t have the strength to do a lot of cooking. I don’t want to be a burden and make waves with my daughter-in-law. My youngest grandson, he likes to do things for me. He likes to make my breakfast and lunch. He is only in the third grade. Peanut butter and jelly sandwiches are easy for him to make. I don’t like to make a fuss and complain.” Reflective Questions and DiscussionWhat would be helpful in understanding the cultural aspects of communication by Filipinos/Hawaiians? For many Filipinos and Hawaiians, “talk story” is a common means of communicating. Instead of answering a question directly, “talk story” is a sharing of personal experiences and opinions, which may initially appear unrelated. It is a powerful communication tool, if the provider takes the time to listen and participate in the conversation, because often it reveals in-depth insight into the thinking and concerns of the individual. However, allowing the patient to “talk story” requires the willingness to take the extra time to listen, and to follow up by asking open-ended questions to encourage the individual to talk, and share some of one’s own personal insights. What are some key points Mrs. V revealed during her “talk story”? The key points Mrs. V revealed were:
What cultural issues may be influencing Mrs. V’s response to her health care issues?
Case Study 3: Mr. WScenarioMr. W is a 70-year-old Chinese American man who lives with his wife of 40 years. Mr. W was diagnosed with lung cancer two years ago, but is now failing rapidly. He is very weak. He can no longer eat due to increased difficulty swallowing and breathing. He does not complain of pain, but his wife says that his back hurts. His two sons live nearby. His daughter moved in recently to help her mother care for him. Mr. W’s primary care physician wants to make a referral to hospice services. Mr. W says the doctor must talk with his sons first. In a telephone conversation with the sons, the sons agree to hospice services. However, the older son does not want his father to know he is dying and does not want the word “death” to be used when talking with his father. The son tells the doctor, “We do not tell our father that he is dying. Telling him is harmful, causing undue emotional burden for him. We are responsible for protecting him from harm.” Mr. W does not take part in the conversation nor does he make his wishes known. Mr. W does not have an advance directive. A week later, Mr. W is admitted to the hospital with aspiration pneumonia. He is barely conscious, febrile, and his breathing is slow and irregular. The family continues to encourage Mr. W. to eat. The older son is considering aggressive treatment and the use of a feeding tube and antibiotics. The wife and older son refuse to discuss or participate in the conversation regarding end-of-life care with the nurse or physician. However, the younger son acknowledges that his father is dying. After much discussion and tension within the family, the family agrees to allow Mr. W to die peacefully with comfort measures only and without aggressive treatment. Mr. W dies within 24 hours of admission. Reflective Questions and DiscussionFor this case, describe ways in which the issues of self-determination and informed consent can be approached with the family that respect their cultural values/wishes.
What Essential Components of a Cultural Assessment should be Performed Relevant to End-of Life Care?Please see the table listing essential components of a cultural assessment in the sidebar (Geiger, et al., 2006; Huff & Kline, 2007a). What could an interdisciplinary team do to improve end-of-life care for Mr. W and his family?
ReferencesAgency for Healthcare Research and Quality. (2011). 2010 National Healthcare Disparities Report. (11-0005). Rockville, MD: AHRQ Anderson, K., Mendoza, T., Valero, V., Richman, S., Russell, C., Hurley, J., DeLeon, C., Washington, P., Palos, G., Payne, R., Cleeland, CS. (2000). Minority cancer patients and their providers pain management attitudes and practice. Cancer, 88(8), 1929-1938. Badr (Zahr), L., Puzantian, H., Abboud, M., Abdallah, A., & Shahine, R. (2006). Assessing procedural pain in children with cancer in Beirut, Lebanon. Journal of Pediatric Oncology Nursing, 23(6), 311-320. Braun, U., Beyth, R., Ford, M., & McCullough, L. (2008). Voices of African American, Caucasian, and Hispanic surrogates on the burdens of end-of-life decision making. Journal of General Internal Medicine, 23(3), 267-274. Braun, U., Ford, M., Beyth, R., & McCullough, L. (2010, July). The physician’s professional role in end-of-life decision-making: voices of racially and ethnically diverse physicians. Patient Educ Couns, (80, 1). NIH Public Access, Washington DC. Buddhist Studies. (2012). Personal Ceremonies: Funerals in Thai, Burmese, Laotian, Sri Lankan, and Chinese Traditions. Campbell, T., McDaniel, S., & Cole-Kelly, K. (2003). Family issues in health care. In R. Taylor (Ed.), Family Medicine Principles and Practice (6th ed., pp. 24-32). New York: Springer. Campbell, T., McDaniel, S., & Cole-Kelly, K. (2003). Family issues in health care. In R. Taylor (Ed.), Family Medicine Principles and Practice (6th ed., pp. 24-32). New York: Springer. Campinha-Bacote, J. (2009). A culturally competent model of care for African Americans. Urologic Nursing, 29(1), 49-54. Campinha-Bacote, J. (2011). Delivering patient-centered care in the midst of a cultural conflict: the role of cultural competence. Journal of Issues in Nursing (Online), 16(2). doi: 10.3923/OJIN.Vol16No02Man05 Carteret, M. (2011). Cultural aspects of pain management, from http://www.dimensionsofculture.com/2010/11/cultural-aspects-of-pain-management/ Carteret, M. (2012 Accessed). Cultural Group Guides. Dimensions of Culture Cross-Cultural Communications for Healthcare Professionals, from http://www.dimensionsofculture.com Chrisman, N. (Access 2011). Cultural competence in community health nursing. University of Washington School of Nursing, (Unpublished manuscript). Seattle, Washington. Chung, S., Masaki, K., Somogyi-Zalud, E., Sumida, K., Wen, A., & Blanchette, P. (2009). Assessment of pain in older Asian Americans with cancer. Hawaii Medical Journal, 68(9), 62-65. Coolen, P., Best, S., Lima, A., Sabel, J., & Paulozzi , L. (2009). Overdose deaths involving prescription opioids among medicaid enrollees-Washington 2004-2007. Morbidity and Mortality Weekly Report(No. 42), 1171-1174. Countries and Their Cultures. (2012), 2012, from http://www.everyculture.com Curtin, M., & Goldstein, L. (2010). An osteopath’s experience in Southwestern Alaska with Native Americans provides a perspective on how cultural differences may confound and complicate pain management. 2. Dhingra, L. (2008). Pain in ethinic Chinese cancer patients: role of cultural factors in assessment and treatment. The Pain Practitioner, 28-34. Doorenbos, A., Lindhorst, T., Schim, S., Van Schaik, E., Demiris, G., Wechkin, H., & Curtis, J. (2010). Development of a web-based educational intervention to improve cross-cultural communication among hospice providers. J Soc Work End Life Palliat Care, 6(3-4), 236-255. Electronic Code of Federal Regulations. (2011). Title 42: Public Health. Part 489 – Provider Agreements and Supplier Approval Subpart 1 Advanced Directives Retrieved November 3, 2011, from http://thomas.loc.gov/cgi-bin/query/z?c101:H.R.4449.IH: Ellis, J., Ootoova, A., Blouin, R., Rowley, B., Taylor, M., DeCourtney, C., . . . Gaboury, I. (2011). Establishing the psychometric properties and preferences for the northern pain scale. International journal of Circumpolar Health, 70(3), 274-285. Eues, S. (2007). End-of-life care: improving quality of life at the end of life. Professional Case Management, 12(6), 339-344. Five Wishes. (Access 2012), 2012, from https://fivewishesonline.agingwithdignity.org.https://fivewishesonline.agingwithdignity.org Fortier, M., Anderson, C., & Kain, Z. (2009). Ethnicity matters in the assessment and treatment of children’s pain. Pediatrics, 124, 378-380. Frey, W. (2012). The State of Metropolitan America, from http://www.brookings.edu/opinions/2011/1220_census_demographics.aspx Giger, J., & Davidhizar, R. (2002). The Giger and Davidhizar transcultural assessment model. Journal of Transcultural Nursing, 13(2), 185-188. Giger, J., Davidhizar, R., & Fordham, P. (2006). Multi-cultural and multi-ethnic considerations and advanced directives: developing cultural competency. Journal of Cultural Diversity, 13(1), 3-9. Green, C., Montague, L., & Hart-Johnson, T. (2009). Consistent and breakthrough pain in diverse advanced cancer patients: a longitudinal examination. Journal of Pain and Symptom Management, 37(5), 831-847. Ho, R., Muraoka, M., Cuaresma, C., Guerrero, R., & Agbayani, A. (2010). Addressing the excess breast cancer mortality in Filipino women in Hawai’i through AANCART, an NCI community network program. Hawai’i Medical Journal, 69(7), 164-166. Huff, R., & Kline, M. (2007a). The cultural assessment framework. In M. V. Kline & R. M. Huff (Eds.), Health Promotion in Multicultural Populations (Second ed., pp. 123-145). Los Angeles: SAGE. Huff, R., & Kline, M. (2007b). Health promotion in the context of culture. In M. Kline & R. Huff (Eds.), Health Promotion in Multicultural Populations (2nd ed., pp. 3-22). Los Angeles, London, New Delhi, Singapore: SAGE. Hunter, M., & Cassey, J. (2000). An evaluation of the faces pain scale with young children. Journal of Pain and Symptom Management, 20(2), 122-129. Im, E., Lee, S., Liu, Y., Lim, H., Guevara, E., & Chee, W. (2010). A national outline forum on ethnic differences in cancer pain experience. Nursing Research, 58(2), 86-94. Jagaro, A. (2004). Death and Dying in Buddhism True Freedom. Bangkok: Buddhadhamma Foundation. Jovanovic, M. (2011). Culutral competency and divertiy among hospice palliative care volunteers. American Journal of Hospice and Palliative Medicine. Kachingwe, A., & Huff, R. (2007). The ethics of health promotion intervention in culturally diverse populations. In M. Kline & R. Huff (Eds.), Health Promotion in Multicultural Populations (2nd ed., pp. 40-56). Los Angeles, London, New Delhi, Singapore: SAGE. Kagawa-Singer, M., & Backhall, L. (2001). Negotiating cross-cultural issues at end of life. Journal of American Medical Association, 286(3001), 2993-. Kamaka, M. (2010). Designing a cultural competency curriculum: asking the stakeholders. Hawai’i Medical Journal, 69(6), 31-34. Kim, E., & Buschmann, M. (2006). Reliability and validity of the face pain scale with older adults. International Journal of Nursing Studies, 43, 447-456. Kingsley, C. (2010, March). Cultural and socioeconomic factors affecting cancer screening, early detection, and care in Latino populations, from https://ethnomed.org/clinical/cancer Kleinman, A. (1980). Patients and Healers in the Context of Culture. Berkley,CA: University of California Press. Kline, M., & Huff, R. (2007). Health promotion in multicultural populations (2nd ed. Vol. Chapter 1-3). Los Angeles, London, New Delhi, Singapore: SAGE. Klessig, J. (1992). Cross-cultural mediciine a decade later: the effect of values and culture on life-support decisions. The Western Journal of Medicine, 157(3), 316-322. Kline, M., & Huff, R. (2007). Health promotion in multicultural populations (2nd ed. Vol. Chapter 1-3). Los Angeles, London, New Delhi, Singapore: SAGE. Koenig, B., & Gates-Williams, J. (1995). Understanding cultural differences in caring for dying patients. The Western Journal of Medicine, 163(3), 244-249. Kwak, J., & Haley, W. (2005). Current research findings on end-of-life decision making among racially or ethnically diverse groups. Gerontologist, 45(5), 634-641. Kwak, J., & Salmon, J. (2007). Atitudes and preferences of Korean-American older adults and caregivers on end-of-life care. J AM Geriar Soc, 55(11), 1867-1872. Lasch, K. (2000). Culture, pain, and culturally sensitive pain care. Pain Management Nursing, 1(3), 16-22. Le, Q., & Le, T. (2005). Cultural attitudes of Vietnamese migrants on health issues. Paper presented at the AARE -The Association for Active Educational Researchers Conference 2005, Australia. Leininger, M. (1999). What is transcultural nursing and culturally competent care? Journal of Transcultural Nursing, 10(1), 9. Leininger, M. (2002). Culture care assessments for congruent competency practices Transcultural Nursing (3rd ed., pp. 117-143). New York: McGraw-Hill. Leininger, M. (2002). Culture care theory: a major contribution to advance transcultural nursing knowledge and practices. Journal of Transcultural Nursing, 13(3), 189=192. Leininger, M., & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice (3rd ed.): McGraw-Hill. Logan, K., Fukuda, M., & Baldwin, C. (2006). Hawaiian medicine, where did it come from? where is it now? Journal of Multicultural Nursing & Health(Summer). Lopez, S. (2007). Honoring cultural diversity. Social Work Today, 17(636). Luffy, R., & SK, G. (2003). Examining the validity, reliability, and preference of three pediatric pain measurement tools in African-American children. Pediatric Nursing, 29(1), 54-59. Mahloch, J., Jackson, C., Chitnarong, K., Sam, R., Ngo, L., & Taylor, V. (1999). Bridging cultures through the development of a cervical cancer screening video for Cambodian women in the United States. Journal of Cancer Education, 14(2), 109-114. Maly, R., Umezawa, Y., Raliff, C., & Leake, B. (2006). Racial/ethnic group differences in treatment decision-making and treatment received among older breast carcinoma patients. Cancer 106(4), 957-965. Mark, G., & Lyons, A. (2010). Maori healers’ view on wellbeing: the importance of mind, body, spirit, family, and land. Social Science & Medicine, 70, 1756-1764. Matsumura, S., Bito, S., Lihu, H., Kahn, K., Fukuhara, S., Kagawa-Singer, M., & Wenger, N. (2002). Acculturation of attitudes toward end-of-life care: a cross-cultural survey of Japanese Americans and Japanese. Journal of General Internal Medicine, 17(7), 531-539. Minority Health Initiatives. (2006). Quick facts: disparities in health care. Families USA, 1-5. Mossey, J. (2011). Defining racial and ethnic disparities in pain management. Paper presented at the Symposium: AAOS/ORS/ABJS Musculoskeletal Healthcare Disparities Research Symposium. Narayan, M. (2010). Culture’s effects on pain assessment and management. American Journal of Nursing, 110(4), 38-47. National Guideline Clearinghouse. (2011). Palliative Care. Rockvile, MD. National Head Lung and Blood Institute. (2010). Cardiovascular risk in the Cambodian community. National Institute of Health Retrieved from http://www.nhlbi.nih.gov/health/prof/heart/other/cambodian.pdf. Newman, C., Lolekha, R., Limkittikul, K., Luangxay, K., Chotpitayasunondh, T., & Chanthavanich, P. (2005). A comparison of pain scales in Thai children. Archives of Disease in Childhood, 90, 269-270. Norris, W., Wenrich, M., Nielsen, E., Treece, P., Jackson, J., & Curtis, J. (2005). Communication about end-of-life care between language-discordant patients and clinicians: insights from medical interpreters. Journal of Palliative Medicine, 8(5), 1016-1024. Payne, R., Medina, E., & Hampton, J. (2000). Quality of life concerns in patients with breast cancer. Paper presented at the Summit Meeting on Breast Cancer Among African-American Women, Washington DC. Perkins, H., Geppert, C., Gonzales, A., Cortez, J., & Hazuda, H. (2002). Cross-cultural similarities and differences in attitudes about advance care planning. Journal of General Internal Medicine, 17(1), 48-57. Politzer, R., Yoon, J., Hughes, R., Regan, J., & Gaston, M. (2001). Inequality in America: the contribution of health centers in reducing and elminating disparities in access to care. Medical Care Research and Review, 58, 234-248. Ramer, L., Richardson, J., Cohen, M., Bedney, C., Danley, K., & Judge, E. (1999). Mutimeasure pain assessment in an ethnically diverse group of patients with cancer. Journal of Transcultural Nursing, 10, 94-101. Rushton, C., Scanlon, C., & Ferrell , B. (1999). Designing an agenda for the nursing profession on end-of-life care. Fairfax, Virginia: American Association of Critical-Care Nurses. Schim, S., & Doorenbos, A. (2010). A three-dimensional model of cultural congruence: framework for intervention. Journal of Social Work End Life Palliattive Care, 6(3-4), 256-270. Searight, H., & Gafford, J. (2005a). Cultural diversity at the end of life: issues and guidelines for family physicians. American Family Physicians, 71(3), 515-522. Searight, H., & Gafford, J. (2005b). “It’s like playing with your destiny”: Bosnian immigrants views of advance directives and end-of-life decision-mkaing. Journal of Immigrant Health, 7(3), 195-203. Shavers, V., Bakos, A., & Sheppard, V. (2010). Race, ethnicity, and pain among the U.S. adult population. Journal of Health Care for the Poor and Underserved, 21(1), 1-20. Shin, H., Kim, K., Kim, Y., Chee, W., & IM, E. (2008). A comparison of two pain measures for Asian American cancer patients. Western Journal of Nursing Research, 30(2), 181-196. Shrank, W., J., K., Richardson, T., Mularski, R., Fischer, S., & Kagawa-Singer, M. (2005). Focus group findings about the infuences of culture on communications preferences in end-of-life care. Journal of General Internal Medicine, 20(8), 703-709. Stratis Health. (2010). Asian Indians in Minnesota. Culture Care Connection, 2012, from www.stratishealth.org Stratis Health. (2010). Somalis in Minnesota. Culture Care Connection, 2012, from www.stratishealth.org Tait, G., & Hodges, B. (2009). End-of-life care education for psychiatric residents: attitudes, preparedness, and conceptualizaions of dignity. Academy of Psychiatry, 33(6), 451-456. Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125. To, T., Ong, W., Rawlings, D., Greene, A., & Currow, D. (2012). The disparity between patient and nurse symptom ratings in a hospice population. Journal of Palliative Medicine, 15(5), 1-6. Tomlinson, D., von Baeyer, C., Stinson, J., & Sung, L. (2010). A systematic review of face scales for the self-report of pain intensity in children. Pediatrics, 126(5), e1168-e1198. Washington, K., Bickel-Swenson, D., & Stephens, N. (2008). Barriers to hospice use among African Americans: a systematic review. Health & Social Work, 33(1), 267-274. WSMA, W. S. M. A. (2012). Patient resources, from http://www.wsma.org/patient_resources/advance-directives.cfm Xiao, H., Kwong, E., Pang, S., & Mok, E. (2011). Perception of a life review programme among Chinese patients with advanced cancer. Journal of Clinical Nursing, 1-9. Yee, B. (2007). Health and health care of Southeast Asians American elders. University of Texas Medical Branch, Glaveston: Texas Consortium of Geriatric Education Center. When a cultural assessment is performed knowledge of a patient's country of origin and its history and ecological context is known as what?Knowledge of a patient's country of origin and its history and ecological contexts is significant to health care and is known as ethnic heritage and ethnohistory.
Which term refers to nursing care that recognizes cultural diversity and is based on the patients unique cultural and spiritual needs?Cultural competence in nursing implies the ability of health care workers to give the best medical care to patients while demonstrating cultural awareness for their beliefs, race, and values. It entails having knowledge of patients' cultural diversity and treating them with this in mind.
When assessing variables from a cultural perspective it is most important for the nurse to?It is important for the nurse to acknowledge cultural differences that may influence the delivery of health care. In order to do this, the nurse must do which of the following? Confront the nurse's own bias and influence of his or her culture. You just studied 72 terms!
When asked to describe the differences between ethnicity and race what should the student nurse explain?4. When asked to describe the differences between ethnicity and race, what should the student nurse explain? 1. Ethnicity refers to a shared identity, whereas race is limited to biological attributes.
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