Annals of Long Term Care

**sub**Introduction to Cultural Considerations in End-of-Life Care **endsub**
Fred A. Kobylarz,  MD, MPH Assistant Director of Family Practice and Assistant Professor of Family Medicine at UMDNJ – Robert Wood Johnson Medical School, New Brunswick, NJ, opened the symposium with statistics on minority groups among the elderly in the United States. Presently, over 16% of American older adults belong to ethnic minority groups, with an increase of 217% projected for the future. Hispanic-Americans are predicted to increase by 320%; African-Americans by 130%; Asian-Pacific Islanders by 295%; and American-Indian and Alaskan-Native people by 147%. Advances in technology have resulted in dramatic changes in health care since the turn of the century, as the average age of death went from 46 years then to 78 today. “Medicine—not culture, religion, or family—has become the dominant framework for understanding old age and death,” noted Dr. Kobylarz. In addressing end-of-life issues and making decisions, cultural sensitivity has become a growing need. The purpose of this symposium was to underline the importance of providing culturally-sensitive decision making in end-of-life care to improve patient outcomes and the well-being of their families. Summaries of two selected presentations on the subject are provided below.

**sub**Understanding Culturally Appropriate Protocols in End of Life Care**endsub**
Gema G. Hernandez, DPA, former Secretary of the Department of Elder Affairs in Florida, and currently a private consultant to health care organizations and hospitals, presented critically important information on implementing culturally competent programs in end-of-life care. Cultural diversity has become a reality, and often the physician suffers a cultural shock upon encountering a patient from a different ethnic and/or religious background who holds beliefs that are fundamentally different from his or her own. According to Dr. Hernandez, this shock creates grave barriers in the delivery of medical services to the patient, often leading to misdiagnosis and decreased patient compliance with treatment and/or prevention programs. Instituting culturally competent programs in practice is a way to begin dismantling these barriers.

“In order for the physician or clinical social worker to be effective, cultural shock needs to be eliminated,” remarked Dr. Hernandez. Information that causes cultural shock is unsettling because it represents a viewpoint that does not make sense to the recipient, and the tendency is to block out such information. As a result, information that may be critical to the patient’s well-being might be disregarded. “Our role as clinicians is to facilitate healing and ultimate outcomes, but on the basis of our patients’ and their family members’ definitions of these terms, and not on our own,” pointed out Dr. Hernandez. “ We need to understand that in every culture, health, illness, death, caring, and healing are defined differently.”

A complaint that is frequently voiced by physicians is that patients do not follow protocols. Dr. Hernandez suggested that perhaps physicians are not always listening when patients give them clear indications that they are not willing to follow a particular treatment regimen: “We don’t want to listen because we have already decided on this treatment—‘I’m the doctor.’”

Communication with the patient may involve a language barrier that can create misunderstandings with dire consequences. Dr. Hernandez stressed the importance of never resorting to the patient’s family member for translation. She pointed out that such translation has inherent bias and shortcomings. Alternatively, the speaker urged the audience to hire the services of a professional interpreter to guarantee complete, objective translation of the patient–doctor dialogue. Regarding financial cost of this alternative, the speaker reminded listeners of the significant expense of medical errors.