CROSS-CULTURAL ENCOUNTERS

IN END-OF-LIFE

CARE

James Hallenbeck, MD

VA Hospice Care Center and Stanford Hospice

Challenges

• Language

• Misunderstandings

• Differing values, meaning

• History

• Imposed relationships

• Underestimation of power of ritualPearl: Most things that don’t make sense from the outside DO make sense if understood from the inside.

Dealing with Issues of Truth Telling

• Statement of respect

• Why has this request been made?

• Where does the patient stand?

• Statement of own values

• Prepare/permission to negotiate

• Set ground rules

• Talk with patient

Explanatory Model Questions

• What– Do you call the problem?– Do you think the sickness does?– Do you think the natural course of the illness

is?– Is it you hope for/fear?

• Why – Do you believe this problem occurred?

What, Why, How, Whocontinued...

• How– Do you think the illness should be treated?

• Who– Should one turn to for help?– Should be involved in care and decision

making?

Questions about Dying and Death

• How do people communicate about death and dying?

• What preparation is made for death?

• How are symptoms such as pain understood, expressed and addressed?

• Food, feeding considerations?

Questions about Dying and Death• Desired location for dying• Spiritual/religious needs

– Before death

– At time of death

– Following death• What happens to the person after death?

• Care of the body• Grief practices• Attitudes toward autopsy, organ donation• Funeral practices

Discussing Death Related Practices

• Statement of respect/desire to learn about the other culture– You are not discussing the death of the dying patient

• What is important-– For a dying person to do?

– For family/caregivers?• prior to, at the time of, after death

• Are there important things that we should know NOT to do?

Discussing Death Related Practices

• Special concerns or fears that we should know about?

• How could we be most helpful to the patient and family?– In the dying process, at the moment of death,

after death?

• Reaffirm intent to help– Give permission to tell us of mistakes