CHAPTER 7—CULTURAL ASPECTS OF CARE
DOORWAY THOUGHTS IN CROSS-CULTURAL HEALTH CARE
PREFERRED TERMS FOR CULTURAL IDENTITY
RESPECTFUL NONVERBAL COMMUNICATION
HISTORY OF TRAUMATIC EXPERIENCES
ATTITUDES TOWARD NORTH AMERICAN HEALTH SERVICES
ATTITUDES REGARDING DISCLOSURE AND CONSENT
END-OF-LIFE DECISION MAKING AND CARE INTENSITY
ATTITUDES TOWARD ADVANCE DIRECTIVES
CULTURAL COMPETENCE: A FINAL WORD
As the cultural diversity of older Americans continues to grow, it will become increasingly important for clinicians caring for older adults to develop an approach to working with older adults from a broad range of cultural groups. The purpose of this chapter is to assist clinicians in developing and improving their skills during intercultural patient encounters. The chapter also appears in volume 1 of Doorway Thoughts, published by the American Geriatrics Society (see the annotated references at the end of the chapter). Other chapters in Doorway Thoughts demonstrate how the general approach outlined here in each topic relates to working with patients in seven specific minority cultural groups. It is very important to keep in mind when using Doorway Thoughts that although the cultural information offered in each chapter is accurate in general, the beliefs, traditions, customs and preferences of individuals in all cultural groups vary widely. The astute clinician never assumes that any person’s cultural background dictates his or her health choices or behavior. The culturally literate clinician remains alert to the differences among individual patients and families from a given culture and on guard against stereotyping an older person on the basis of his or her ethnic or cultural affiliation.
The key concepts discussed in this chapter are “doorway thoughts”—factors that the culturally competent practitioner reflects upon before walking through the doorway of any examining, consultation, or hospital room. These factors can shape intercultural health care encounters and relationships for good or for ill. Cultural and historical facts and issues relating to the members of an entire minority group can be in play in any cross-cultural encounter or relationship. The practitioner should be sensitive to the possibility that they may affect their relations with individual patients and families and may also affect patients’ willingness or ability to understand, accept, and adhere to prescribed regimens.
The quality of any encounter between a clinician and a patient from different ethnic or cultural backgrounds depends on the clinician’s skill and sensitivity. Questions about the individual patient’s attitudes and beliefs should be worked naturally and carefully into the clinical interview. The clinician must remember that no culture is monolithic; attitudes and beliefs vary widely from one individual to another within a single cultural group. Prior familiarity with a patient’s cultural background will not suffice, for it is inaccurate to assume that a person’s outlook is inflexibly determined by his or her cultural heritage. The concepts presented here are intended to serve as guides in choosing appropriate questions, and not as a rigid list of cultural attributes or clinical scenarios.
The terms referring to specific cultural or ethnic groups can change over time, and individuals in any one group do not always agree on the terminology that is appropriate. It is important to learn what the individual patient’s preferred term is for his or her cultural identity and to use that terminology in conversation with the patient, as well as in his or her health records.
Attitudes regarding the appropriate degree of formality in a health care encounter differ widely among cultural groups. Learning what a new patient’s preferences are with regard to formality and allowing that preference to shape the relationship is always advisable. Initially, a more formal approach is likely to be appropriate.
The patient’s correct title (eg, Dr., Reverend, Mr., Mrs., Ms, Miss) and his or her surname should be used unless and until he or she requests a more casual form of address. Another important issue is to determine the correct pronunciation of the person’s name.
It is also important to learn how the patient would prefer to address the clinician and to allow his or her preference to prevail. For example, in some cultures, trust in the physician depends on his or her assuming an authoritative role, and informality would undermine the patient’s trust. This is an aspect of the clinical relationship where the clinician’s personal preferences can be relinquished.
It is worthwhile to consider these questions early in the health care relationship to determine whether interpretation services are needed and to make certain that communication with the patient is effective. Even those who use English fluently may wish to discuss complicated issues in their native language. It is the clinician’s responsibility to explain medical terms and to ask the patient for explanations of any cultural or foreign terms that are unfamiliar.
Body position and motion is interpreted differently from one cultural group to another. Specific hand gestures, facial expression, physical contact, and eye contact can hold different meanings for the patient and the clinician when their cultural backgrounds differ. The clinician should watch for particular body language cues that appear to be significant and that might be linked to cultural norms that are important to the patient, in order to cultivate sensitivity to the conditions that make the flow of communication feel easy and effective.
Conservative body language is an advisable choice early in a relationship with a patient or when in doubt about a patient’s background or preferences; assume a calm demeanor, avoid expressive extremes such as very vigorous handshakes, a loud and hearty voice, many hand gestures or, on the other hand, an impassive facial expression, avoidance of eye contact, standing at a distance. Remain alert for signals that the person is comfortable or uncomfortable. Directly asking the patient questions about body language may also help. It is very important to avoid making negative judgments about a patient that are rooted in unconscious cultural assumptions about the meaning of his or her gestures, facial expressions, or body language.
The distance from others that individuals find comfortable varies, depending in part on their cultural background. The clinician should determine what distance seems to be the most comfortable for each patient and, whenever practicable, allow the patient’s preference to establish the optimal distance during the encounter.
Are there any issues that are critical to the success of the health care encounter that are present but that go unspoken? Remain alert for the possibility that such issues are indeed present. Examples include
In general, sensitivity to the possibility that such issues are in play is advised in all intercultural patient encounters.
Is the patient a refugee or survivor of violence or genocide? Are family members missing or dead? Have patients or family members been tortured? Such experiences could negatively affect the health care encounter without the clinician’s knowledge unless relevant questions are included among standard questions about the patient’s history.
It is important for clinicians to remember that in some historical periods and jurisdictions, health care providers have participated in torture and genocide. For example, during World War II, Nazi medical personnel were responsible in concentration camps for selecting individuals for gassing, supervising the gassing process, and administering lethal injections to inmates in “hospitals.” The methods and tools of torture employed have sometimes resembled legitimate clinical procedures and tools. Patients who have survived such experiences may not feel safe in medical or governmental settings, and contact with all clinicians may invoke feelings of vulnerability, fear, panic, or anger. Great sensitivity is necessary in providing health care for these individuals.
Some individuals may be residing in North America without the protection of appropriate immigration documents. Clinicians may wish to assure each patient that information given within the medical encounter will be kept in the strictest confidence.
The history of the movements of a whole ethnic or cultural group can affect the attitudes and behavior of an individual in that group even when he or she has not immigrated to North America from another country. In addition, understanding the specific migration history of a person often provides insight into the key life transitions informing his or her outlook. Knowing how a person came to reside in North America can be important. The time and effort the clinician invests in learning more about a minority group’s history and current situation can be repaid not only in a better relationship with the individual patient but also in an enhanced appreciation of the factors affecting clinical relationships with all patients from that group.
Acculturation is defined as a process in which members of one cultural group adopt the beliefs and behaviors of another group. Acculturation of a group may be evidenced by changes in language preference, adoption of common attitudes and values, and gradual loss of separate ethnic identification. Although acculturation typically occurs when a minority group adopts the habits and language patterns of a dominant group, acculturation may also be reciprocal between groups.
It is essential to keep principles of acculturation in mind during any intercultural health encounter. Begin by determining how long a person has lived in North America and whether he or she was born here. However, remember that the degree to which the person is acculturated to Western customs and attitudes is the consequence of many factors, and not just of the number of years since he or she immigrated. Older adults who follow the traditions of their cultural group may have been born outside of the United States or Canada, may be recent arrivals to the continent, or may even be lifelong North American residents.
A patient’s level of acculturation may greatly impact not only his or her health behavior but also preferences in end-of-life planning and decision making. Acculturation can also be an issue dividing family members, and a person’s resistance to or ease of acculturation may be a matter of pride or shame and guilt. Developing sensitivity about the issues of acculturation for one’s older minority patients is a key element in effective intercultural health care. Asking patients directly about their adherence to cultural traditions can be useful.
People from non-Western cultural groups may not conceive of illness in Western terms. Some may have highly developed concepts of the causes of health and disease that are incompatible with the concepts that form the foundations of Western medicine. Non-Western paradigms include beliefs that illnesses have spiritual causation or are the result of imbalance among bodily humors, or that they are caused by a person’s actions in past lives, to name but a few.
Patients may be making unexamined assumptions that are based on traditional beliefs, and these can cause confusion or create misunderstanding. The more the clinician knows about specific traditions, the more he or she can avoid such problems.
In addition, patients holding traditional beliefs may be using alternative remedies (eg, rituals, herbal preparations) that they do not mention, and questions about such practices should be included among other questions about the patient’s history. It is unrealistic to expect that a patient will simply “adapt” to Western approaches to health and health care, just as it is impractical to expect the clinician to accept a new paradigm of wellness and disease. Clinical communication and efficacy will be enhanced when patients and providers make an effort to negotiate a common understanding of causation, diagnosis, and treatment for a specific health problem while maintaining respect for the beliefs and constructs of both individuals.
Some minority patients may not feel comfortable in customary North American health care settings. Explanations for the discomfort, distrust, or uneasiness of some include lack of familiarity with Western practices, dissatisfying previous encounters with the health care system, or the belief that insensitivity or discrimination is inevitable for anyone in the cultural or ethnic group. Such feelings may result from having been stereotyped or treated insensitively or even unfairly by clinicians in the past. Sensitive exploration of these issues with patients is often both worthwhile and necessary. Generally, the clinician meeting a new patient from an ethnic or cultural minority group should be alert for signs of guardedness that signal an underlying lack of comfort or trust.
Epidemiologic and medical research has identified numerous differences among ethnic and cultural populations with regard to specific health risks. The clinician who treats many patients from a specific group is advised to make every effort to stay abreast of the latest findings in relevant areas.
The influence of specific cultures on approaches to health decision making has been the subject of many studies. Western bioethics emphasize individual autonomy in all health decisions, but for many other cultures, decision making is family or community centered. Autonomy principles allow competent persons to involve others in their health decisions or to cede those rights to a proxy decision maker. The clinician should ask patients if they prefer to make their own health decisions or if they would prefer to involve or defer to others into the decision-making process. Some may wish to assign the decision-making authority wholly to another individual or a group. In some cultures, the definition of family may include fictive kin. In families where the degree of acculturation of the generations differs, the older person may defer to or depend on younger relatives, even though the tradition might suggest that the reverse would occur.
Establishing an understanding of each patient’s decision-making preferences early in the clinical relationship will, in most instances, promote better communication and avoid the difficulties inherent in trying to address the issues at a time of crisis. When the patient’s and clinician’s cultural backgrounds differ, careful exploration of the issues is all the more important because the clinician cannot proceed as if he or she and the patient are starting from common assumptions.
Cultural attitudes toward truth telling and disclosure of terminal diagnoses vary widely. In some cultures, it is commonly believed that patients should not be informed of a terminal diagnosis, as this may be injurious to health or hasten death. Obtaining informed consent from patients with this belief may prove to be difficult. There is no consensus in bioethics concerning the rigorous application of full clinical disclosure in every situation. However, it is generally agreed that incorporating a patient’s beliefs concerning disclosure and truth telling into clinical planning whenever possible is desirable. Some patients may prefer not to know if they are terminally ill and ask that family members or other caregivers receive all diagnostic information and make all treatment decisions. It is advisable to explore each patient’s preferences regarding disclosure of serious clinical findings early in the clinical relationship and to reconfirm these wishes at intervals.
Each culture has intricate traditions and structures with regard to gender roles. Societies seemingly based on the same patriarchal or matriarchal model may vary widely in their expressions of the model. A person’s gender influences the sorts of experiences he or she has had, not only within the family but in the community and health care system as well. Another level of complexity may be added to health care encounters when an older adult’s group struggles with conflicting traditional and contemporary views on gender roles. Cultural norms for men and women can profoundly influence their health behavior, and these norms for the genders vary widely from one culture to another. These norms also affect decision making, disclosure, and consent.
It is highly advisable for the clinician to explore each patient’s attitudes regarding the interplay among gender, autonomy, and personal decision making early in the patient-provider relationship, to confirm his or her preferences at intervals, and to follow the individual patient’s wishes whenever possible.
Culture is an important influence in a person’s formation of his or her attitudes toward supportable quality of life, approach to suffering, and beliefs about medical feeding, life-prolonging treatments, and palliative care. Some cultures value a direct struggle for life in the face of death, and both patients and families will expect an intensive approach to treatment. Other cultures ardently avoid direct confrontation of death and dying and will prefer to leave such decisions to the clinician. Still others will take a direct approach to death and dying but will reject too aggressive an approach.
Research has shown that physicians and patients from shared cultural backgrounds have similar values in these areas; the implications of such findings for clinicians and patients from differing backgrounds are obviously important. Both physicians and patients bring their own attitudes and beliefs to any clinical encounter. It is important for clinicians to be aware of their personal views and cultural set when discussing end-of-life plans with patients and to respect patients’ beliefs and preferences even when they are different from their own.
In negotiating end-of-life decisions with a patient whose background is different from his or her own, the clinician must listen especially carefully to the patient’s goals and concerns and exert every effort to avoid making culture-based assumptions that do not apply. For example, the assumption that “no one would want to live in that condition” or that “everyone would want treatment in this situation” is likely to be faulty. To ensure that end-of-life plans and decisions reflect an individual’s rights and wishes, the clinician must strive to understand the older person’s overall approach to life and death, and as far as possible provide care that is congruent with that approach.
The use of advance directives and health care proxies has become more common on the past 20 years, but research indicates that the use of written directives may be more common among older persons in the dominant North American culture than among older persons in minority cultural groups. It is advisable in intercultural situations, when discussing attitudes and beliefs regarding written directives with a patient, to be sensitive to the possibility that some minority older persons will prefer to use alternatives—verbal directives or directives dictated to family members or others—and others will need to avoid any such discussion so as to observe proscriptions against talking about death. In view of the fact that preferences for care intensity may also differ according to cultural background, patients should also be given the opportunity to indicate the interventions they do want as well as those they do not want in any written or verbal directive used.
There is no gold standard definition of cultural competence. Most definitions emphasize a careful coordination of individual behavior, organizational policy, and system design to facilitate mutually respectful and effective cross-cultural interactions.
Cultural competence combines attitudes, knowledge base, acquired skills, and behavior. It is an approach, not a technique. Cultural competence is not a form of “political correctness.” Ideally, it is a nuanced understanding of the determining role that culture plays in all of our lives and of the impact culture has on every health care encounter, for both the clinician and the patient.
Cultural competence cannot be achieved exclusively by reading, but we hope that this chapter will provide clinicians who care for older persons from all minority groups with basic information and a foundation for further investigation. We would encourage clinicians to view each intercultural encounter as an opportunity to learn more, not only about the individual patient and his or her culture, but also about themselves. We also recommend that clinicians learn more about the impact of culture on health decisions by reading the publications listed in the annotated references, exploring available Web sites, and attending workshops. We also urge clinicians to work with the entire interdisciplinary health care team, including administrators, to promote cultural competence in the health care organizations where they practice. Finally, we encourage clinician educators to develop their own teaching materials and educational programs designed to meet the needs of specific communities.
■ American Geriatrics Society, Adler R, Kamel H. Doorway Thoughts: Cross-Cultural Health Care for Older Adults.Vol. Boston, MA: Jones and Bartlett; 2004.
This book addresses the health care issues raised by the increasingly multicultural state of North American society. It focuses on the ways clinicians who care for older adults can develop an understanding of various ethnic and cultural groups that will enhance their ability to care for older minority patients. Chapters address the cross-cultural health care issues that relate to all older patients as well as to those from the following groups: African Americans, American Indians and Alaska Natives, Asian Indian Americans, Chinese Americans, Hispanic Americans, Japanese Americans, and Vietnamese Americans. Volume 2 in the series, to appear in 2006, contains chapters on Arab Americans, Cambodian Americans, Filipino Americans, Haitian Americans, Korean Americans, Pakistani Americans, Portuguese Americans, and Russian Americans.
■ Blackhall LJ, Murphy ST, Frank G, et al. Ethnicity and attitudes toward patient autonomy. JAMA. 1995;274(10):820–825.
This influential paper was the first of its kind in the medical literature to report the findings of a survey conducted with 200 older persons from specific ethnic groups in Los Angeles, California. Study data revealed that Korean Americans and Mexican Americans were far less likely than European Americans or black Americans to believe that a patient should be told of a terminal prognosis or make decisions regarding end-of-life treatment and that they were more likely than other groups to believe that family members should receive information and make health decisions for older relatives facing illness with a grave prognosis.
■ Bowman KW, Singer PA. Chinese seniors’ perspectives on end-of-life decisions. Soc Sci Med. 2001; 53(4):455–464.
This study draws on data from semi-structured interviews with 40 Chinese adults over 64 years of age living in Toronto. Study participants had low acculturation as measured on the Marin Acculturation scale. Many expressed beliefs that the future is preordained and held indifferent or negative attitudes toward the use of advance directives. Respondents expressed the opinion that advance care planning should be avoided in order to prevent distress. Most believed that they would not want life-sustaining treatment if terminally ill, citing a wish neither to suffer personally nor to inflict suffering on family. They stressed the importance of family consensus in decisions regarding end-of-life treatments. These findings have broad implications for practice, pointing to the potential limitations of the use of advance directives or single proxy decision makers when working with this population of older adults.
■ Cykert S, Joines JD, Kissling G, et al. Racial differences in patients’ perceptions of debilitated health states. J Gen Intern Med. 1999;14(4):217–222.
This study compares self-reported perceptions of debilitated health states of European and African Americans. Sixty-four consecutive patients (ages 50 to 75) who met criteria for breathing impairment were surveyed in a community hospital pulmonary medicine clinic while awaiting appointments. The measurements of interest were individuals’ strengths of preference for a range of theoretical limitations in physical function. In multivariate analysis, self-identified African American cultural background was found to be the only predictor of high acceptance of bed-to-chair limitation and permanent facility placement. These results suggest that attitudes and values should be explored carefully when crafting health care plans for older adults facing severe limitations.
■ Vydelingum V. South Asian patients’ live experience of acute care in an English hospital: a phenomenological study. J Adv Nurs. 2000;32(1):100–107.
This qualitative investigation explored the experience of individuals of South Asian descent from a variety of religious and cultural backgrounds while hospitalized for 6 days or more on acute-care units. All participants were born outside of the United Kingdom. Key findings include extreme patient loneliness and isolation (significantly exacerbated by language barriers), covert practice of religious and cultural rituals (so as not to alienate staff and fellow patients of European descent), mismatched dietary choices (eg, for vegetarians and Muslims requiring halal meats), and dissatisfaction with information exchange and arrangements at discharge.
Reva N. Adler, MD, MPH