___________________________________________ Palliative Care and Pain Management at the End of Life
speak a language other than English in the home, with more than 16.1 million of them (5.2% of the population) reporting that they speak English less than “very well” [135]. Clinicians should ask their patients what language is spoken at home and what language they prefer for their medical care information, as some patients prefer their native language even though they have said they can understand and discuss medical information in English [136]. When the healthcare professional and the patient speak different languages, a professional interpreter should be used. Studies have demonstrated that the use of professional interpreters rather than “ad hoc” interpreters (untrained staff members, family members, friends) facilitates a broader understanding and leads to better outcomes [137; 138]. Using a family member as a translator confuses the role of that member in the family, may involve confidentiality issues, and may lead to a modified message to protect the patient. In addition, individuals with limited English language skills have indicated a preference for professional interpreters rather than family members [139]. Professional interpreters have recom- mended that clinicians can further enhance the quality of care by meeting with interpreters before discussions of bad news and by explicitly discussing with the interpreter whether strict interpretation or cultural brokering is expected [140]. Knowledge of the family’s health literacy is important for achieving treatment goals and good outcomes, yet most indi- viduals lack adequate health literacy. Studies have indicated that as many as 26% of patients have inadequate health literacy, which means they lack the ability to understand health information and make informed health decisions; an additional 20% have marginal health literacy [141; 142; 143]. Health literacy varies widely according to race/ethnicity, level of education, and gender, and clinicians are often unaware of the literacy level of their patients and family [134; 144]. Several instruments are available to test the health literacy level, and they vary in the amount of time needed to admin- ister and the reliability in identifying low literacy. Among the most recent tools is the Newest Vital Sign (NVS), an instru- ment named to promote the assessment of health literacy as part of the overall routine patient evaluation [145]. The NVS takes fewer than three minutes to administer, has correlated well with more extensive literacy tests, and has performed moderately well at identifying limited literacy [134; 144]. Two questions have also been found to perform moderately well in identifying patients with inadequate or marginal literacy: “How confident are you in filling out medical forms by yourself?” and “How often do you have someone help you read health information?” [134]. Clinicians should adapt their discussions and educational resources to the patient’s and family’s identi- fied health literacy level and degree of language proficiency and should also provide culturally appropriate and translated educational materials when possible.
Cultural competency is essential for addressing healthcare disparities among minority groups [132]. Clinicians should ask the patient about his or her cultural beliefs, especially those related to health and dying, and should be sensitive to those beliefs [146]. In addition, information sharing and the role of decision maker vary across cultures, and the healthcare team must understand the family dynamics with respect to decision making [117]. Clinicians should not make assumptions about the preferences of the patient or family on the basis of cultural beliefs. Even within a single culture or ethnicity, the level of information desired, preferences for treatment, role of other family members in decision making, and goals of care differ among patients and families [40; 117]. Clinicians should ask their patients about these issues, as well as other family and social factors and religious or spiritual views [40].
The Institute for Clinical Systems Improvement asserts that clinicians caring for patients with serious illness should examine their own cultural values and assumptions about what constitutes “good” care for patients nearing the end of life,
recognizing not all patients will share these same values, and ensure goals and decisions remain centered around the patient’s values/beliefs. (https://www.icsi.org/wp-content/uploads/2021/11/ PalliativeCare_6th-Ed_2020_v2.pdf. Last accessed October 14, 2024.) Level of Evidence : Expert Opinion/Consensus Statement Communication in the End-of-Life Setting Patients and families have noted that communication about end-of-life care is one of the most important skills for clinicians to have [147]. Experts in end-of-life communication note that physicians have an obligation to discuss medical, psychosocial, and spiritual needs with seriously ill patients in a timely and sensitive manner [148]. In addition, communication guide- lines developed by an Australian and New Zealand Expert Advisory Group recommend “all patients with advanced progressive life-limiting illnesses be given the opportunity to discuss prognosis…and end-of-life issues” [117]. At what point in the trajectory of serious illness such conversations should commence is not clear. Studies show that most older adults (older than 65 years of age) prefer to begin a discussion of life expectancy/end-of-life issues with their physician at about six months before anticipated end of life, rather than waiting until weeks or days before [528].
17
MDCA1525
Powered by FlippingBook