Cultural Proficiency in End-of-Life Care

The American Academy of Family Physicians has published guidelines on cultural proficiency for family physicians.

Cultural proficiency guidelines exist, but few resources are available to family physicians regarding ways to apply them to direct patient care.

In addition, sensitivity to cultural diversity is integrated within the AAFP's policy statement on ethical principles for end-of-life care.

Ethnic minorities currently compose approximately one third of the population of the United States.

When compared with whites of European descent, ethnic minorities exhibit greater variability in their preferences.

Cultural factors strongly influence patients' reactions to serious illness and decisions about end-of-life care. Research has identified three basic dimensions in end-of-life treatment that vary culturally: communication of "bad news," locus of decision making, and attitudes toward advance directives and end-of-life care.

There are cultural differences in how patients value autonomy, beneficence, nonmaleficence, and justice.

In the United States, many patients value autonomy. In cultures where patients are not directly informed about a serious prognosis, family members may want the physician to discuss the patient’s condition with them.

The consumer movement, legal requirements, and emphasis on patient informed consent have all contributed to health-related "truth telling" in the United States.

Outside the United States, health care professionals often conceal serious diagnoses from patients.

Physician strategies commonly employed to minimize direct disclosure include using terminology that obscures the seriousness of a condition or communicating diagnostic and treatment information only to the patient's family members.

Many African and Japanese physicians, when discussing cancer with patients or family members, choose terms such as "growth," "mass," "blood disease," or "unclean issue," rather than specifically describing a potentially terminal condition.

Hispanic, Chinese, and Pakistani communities in the United States often protect terminally ill patients from knowledge of their condition by deliberately not translating diagnosis and treatment information to them.

There are four primary reasons for non-disclosure: (1) certain cultures view discussion of serious illness and death as disrespectful or impolite; (2) some cultures believe that open discussion of serious illness may provoke depression or anxiety in the patient; (3) some cultures believe that direct disclosure may eliminate hope; and (4) some cultures believe that speaking aloud about a condition, even in a hypothetical sense, makes death or terminal illness real.

The emotional reaction of patients to news of serious illness is thought to be directly harmful to their health.

Direct disclosure of bad health news may eliminate patient hope.

Asian values of reverence for family members and concern for the elderly may be especially pronounced in elderly patients who, because of their frailty, are perceived as more vulnerable to being upset by bad news.

Direct disclosure of bad health news may be avoided in order to maintain patient optimism.

Native American, Filipino, and Bosnian cultures emphasize the importance of words being carefully chosen because once spoken, they may become a reality.

The reluctance of Chinese patients and their families to discuss possible death is based on the belief that direct acknowledgement of mortality may be harmful.