HECTOR LÓPEZ, DO

COUNCIL ON MINORITY HEALTH

ISSUES

“Grave” Lessons in End of Life Care

EOL Learning Objectives

1. Enjoy light-hearted vignettes about “Grave” EOL issues.2. Participants will learn how to initiate and conduct a patient-

centered EOL discussion with diverse minority patients and their families.

3. Participants will discover the importance of discussing a DPAHC (Durable Power of Attorney for Health Care).

4. Participants will learn to dispel myths and misinformation about a multiplicity of EOL issues.

5. Participants will learn how to discuss medical treatments that ease dying rather than those that prolong suffering and death.

6. Participants will learn to perceptively discuss CPR and DNR status of patients with different cultural background than their own.

7. Participants will be better able to provide cultural competent care to diverse minority groups.

First Video clip

MODERN DAY REAPER

Patient’s values, desires & needs

Uneasy with our own mortality/training

DO must ease death process, not prolong it

Get big picture from patient

Base on patients’ concept of death/EOL issues

What concerns patient the most?

Patient’s values, desires…

Emotions and desires of family/patient

Ethnicity/culture versus patient’s goals

Patient’s spiritual beliefs/rituals/unresolved issues

Limit medical jargon: procedure/prognosis/diagnosis/resuscitation/

Resuscitation and DNR discussion with patient.

☺Second video clip☻

Wrong way to explain CPR

& Resusitation

Just D.O. it

Studies: 95% patients want DO to discuss EOL care.

Kaiser: Drs. brief, gave few numerical CPR outcomes*

Address fears, beliefs & frame talk based on outcomes

Avoid euphemisms “restart your heart” Emanuel LL, Barry MJ, Stoeckle JD, et al. Advance directives for medical care—a case for greater use. N Engl J Med 1991;324(13):889-95 . *Grave Words video Dr. Bernard Lo

Just D.O. it

Only 1-12% survive CPR, patients think 90% do.

Potential versus Imminent death.

Negotiate with pt and family. May need different terms

Ensure a “good” dignified & peaceful death.

Cultural Competent Care

Don’t stereotype all patients of one culture

Seek each patient’s individual wishes

Is patient able to grasp grim diagnosis?

Confirm understanding, maybe pts “didn’t See what they Heard”

Cultural Competent Care

Note cultural pain differences

Discuss advance directives, only 10-15% have AD.

If no AD form, document in chart, or NOT VALID!

Cost savings with AD. Blacks, Latinos cost more at EOL *

Cultural Competent Care

Engage patient, family, other Decision Makers. Initiate discussions as scenarios that affected other patients Monitor non-verbal cues In some cultures, discussing death directly is taboo Use qualified interpreters.

Don’t apply the Golden rule.

*Arch of IM vol 169 #5, 3/9/09

Wilner, A, Pain Management Across Cultures. 10/14/2008, Medscape Neurology & Neurosurgery

Green CR, Ndao-Brumblay SK, West B, et al Differences in prescription opioid analgesic availability: comparing minority and white pharmacies across MI. J Pain. 2005;6:689-699

Patients & EOL Discussion

Experienced a greater sense of trust and well-being.

Believe treatments and technology will be geared to their goals and wishes.

No adverse patient effects seen by having these EOL discussions.

Virmani J, et al. Relationship of ADs to physcian-patient communication. AIMed.1994;154:154:909-913.

Smucker WD, Ditto PH, et al. Elderly outpatients respond favorably to a physician-initiated irective discussion. J Am Board Fam Pract

1993;6(5):473-82.

Tierney WM, Dexter PR, et al. The effect of discussions about advance directives on patients' satisfaction with primary care. J Gen Intern Med 2001;16:32-40

Third video clip….

A Sensitive Caring D.O.

EOL Cultural Competency Resources

http://www.fanlight.com/catalog/films/456_hyb.php http://www.fanlight.com/downloads/HoldYourBreath.pdf http://medethicsfilms.stanford.edu/holdyourbreath/howto.html http://www.aahpm.org/about/index.html  http://ajh.sagepub.com/cgi/content/refs/23/5/404 http://goliath.ecnext.com/coms2/gi_0199-6837217/Cultural-

competency-key-in-end.html http://cat.inist.fr/?aModele=afficheN&cpsidt=21884256 http://www.amazon.com/Cultural-Issues-Life-Decision-Making/dp/

0761912177  http://www.ncbi.nlm.nih.gov/pubmed/12442876 The American Academy of Hospice and Palliative Medicine ( Cultural

competence group )

A minority patient’s verbal statement about their live support views is not considered valid unless documented

in an advance directive.

Tru

e

Fal

se

0%0%

1. True2. Fals

e

Approximately 42% of people in the USA have completed a Durable Power of Attorney for Health Care.

Tru

e

Fal

se

0%0%

1. True2. False

The racial and ethnic health care disparities in the USA are pervasive until the time minority patients die.

Tru

e

Fal

se

0%0%

1. True2. False

Research shows that most minority patients find discussions about life support and end of life planning

disturbing or upsetting.

Tru

e

Fal

se

0%0%

1. True2. False

Doctors and family members usually make decisions for incompetent patients that reflect the patient’s own wishes

as opposed to their own values.

Tru

e

Fal

se

0%0%

1. True2. False

The survival to discharge outcomes of CPR in general in-patient wards is usually >35%.

Tru

e

Fal

se

0%0%

1. True2. False