powers of attorney are strategies to prolong autonomy in situations in which patients can no longer represent themselves. Other cultures, however, de-emphasize autonomy, perceiving it as isolating rather than empowering. These non-Western cultures believe that communities and families, not individuals alone, are affected by life-threatening illnesses and the accompanying medical decisions. 27 Cultures valuing non-malfeasance (doing no harm) may try to protect patients from the emotional and physical harm caused by directly addressing death and end- of-life care. Many Asian and Native American cultures value beneficence (physicians’ obligation to promote patient welfare) by encouraging patient hope, even in the face of terminal illness. Patient or family member preferences for nondisclosure of medical information and family-centered decision making may also be surprising to American-trained physicians. Physicians may improve their rapport with ethnically diverse patients simply by showing interest in their cultural heritage, and more importantly, in each individual’s respective approach to both suboptimal news, and approach to death and dying. Here are some example questions and situations that reflect a culturally sensitive approach to patient interactions: 25 “Some people want to know everything about their medical condition, and others do not. What is your preference?”
“Do you prefer to make medical decisions about future tests or treatments for yourself, or would you prefer that someone else make them for you?” To patients who request that the physician discuss their condition with family members: “Would you be more comfortable if I spoke with your (brother, son, daughter) alone, or would you like to be present?” If the patient chooses not to be present: “If you change your mind at any point and would like more information, please let me know. I will answer any questions you have. When discussing medical issues with family members, particularly through a translator, it is often helpful to confirm their understanding: “I want to be sure that I am explaining your mother’s treatment options accurately. Could you explain to me your understanding about your mother’s condition and the treatment that we are recommending?” “Is there anything that would be helpful for me to know about your family or religious views about serious illness and treatment?” “Sometimes people are uncomfortable discussing these issues with a doctor who is of a different race or cultural background. Are you comfortable with me treating you? Will you please let me know if there is anything about your background that would be helpful for me to know in working with you or your (mother, father, sister, brother)?”
THE PHYSICIAN’S ROLE IN MANAGING HOSPICE PATIENTS
Hospice is based on the idea that the dying patient has physical, psychological, social, and spiritual aspects of suffering. Hospice is a philosophy, not a specific place, and can be provided in any setting, including patients’ homes, nursing homes, and hospitals. 28 Hospice typically involved an interdisciplinary team providing access to a wide range of services to support the primary caregiver, who is responsible for the majority of the patient care. In 2017 about 1.5 million Medicare beneficiaries received hospice care, a 4.5% increase from the previous year and nearly 200,000 more people than used hospice in 2012. 29
To be eligible for hospice, a patient must have a terminal illness and an estimated prognosis of less than six months. Patients with non-cancer diagnoses (e.g., congestive heart failure, chronic obstructive pulmonary disease, stroke, dementia) currently represent about 70% percent of all hospice decedents. 29 The responsibility for hospice referral in a non-cancer diagnosis often falls to the primary care physician, facilitating continuity of care for the patient in his or her final days and months. In making an appropriate referral, physicians should be aware of some common misconceptions about hospice care (see Table 4).
Book Code: CA23CME
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