CULTURAL DIVERSITY: BEING SENSITIVE TO THOSE WE SERVE

Cultural Clues: The Hispanic/Latino Presented By Dr. Gilbert Marez & Dr. Carmen Santiago, RN, WOCN/ET

OBJECTIVES  Identify various cultural signs that may increase a clinician’s and support staff’s awareness about concepts and preferences of patients regarding: – Dealing with illness; and – End-of-life care

OBJECTIVES  Describe how cultural attributes affect medical decisions of Hispanics/Latinos.  Identify cultural norms and nuances.

STATISTICAL INFORMATION  Census 2005 : 41,926,302 people living in U.S. identified as Hispanic/Latino.

Source: Pew Hispanic Center Tabulations of 2000 Census and 2005 American Community Survey

RECOGNIZE DIFFERENCES  Subcultures include Mexicans, Cubans, PuertoRicans, Argentines, Guatemalans, Panamanians etc…  The Latino (subcultures) population in the USA: – – – – – – –

Mexican presence = 63.9% Central American presence = 7.5% South American presence = 5.4% Puerto Rican presence = 9.1% Dominicans = 2.7% Cubans = 3.5% Other = 8.1%

Source: Pew Hispanic Center tabulations 2005 American Community Survey

GETTING TO KNOW THE HISPANIC/LATINO CULTURE  Cultural nuances or unwritten rules that govern social interaction and possibly impact the way in which individuals perceive, seek and receive services. – La familia (family) – Respeto (respect) – Personalismo (personalism) – Confianza (trust) – Espiritu (spirit), body and mind Purnell, L., (2001); Pontón M. & León-Carrión, J., (2000)

GETTING TO KNOW US  Family involvement often is critical in the health care of the patient.  Traditionally, Hispanics include many people in their extended families, parents, siblings, grandparents, aunts, uncles cousins and compadres, close friends and godparents (padrinos).  This can be a problem when admitted into the hospital.

THE AMERICAN HOSPITAL VS THE HISPANIC/LATINO FAMILY  American hospitals are built by Americans for Americans and are thus not equipped for more than one or two visitors at a time.  Visiting hours are often limited.  Visiting is a way of showing love and concern for sick/dying family members and is thus both expected and important.  Hispanic/Latinos attempt to maintain cultural norms and routines for their loved ones, seen through visiting patterns and the need to monitor the care given by staff.  Especially respect to elders.

GETTING TO KNOW US  Traditionally Hispanics emphasize interdependence over independence. (This can be a problem with our western philosophy: where ethical health care decision making is based on autonomy, beneficence, nonmaleficence, and justice).  Consideration: – Including family members in the consultation is often critical to the care of the patient and may contribute to a patient’s ability to adhere to the recommended treatment.

GETTING TO KNOW US  Respect (encompasses loyalty, generosity, having “soul” or character and maintaining a patient’s dignity)

 Respect dictates appropriate deferential behavior towards others based on age, sex, social position, economic status and authority.  Health providers, by virtue of their education and training are afforded a high level of respeto as authority figures.

GETTING TO KNOW US  Out of sense of respect many Hispanic patients tend to avoid disagreeing or expressing doubts to their health care provider in relation to the treatment. – May even be reluctant to ask questions or admit they are confused about their medical instructions or treatment.

 Latinos, in general, regard the kind of personal treatment they receive from a health care provider as the crucial test of respect.

GETTING TO KNOW US  Personalism – Hispanics tend to stress the importance of personal relationships. – Expect health providers to be warm, friendly, and personal and take an active interest in the patient’s life. – Tends to conflict with the health system’s trend towards managed care, the eight-minute visit, and physician rotations in public clinics.

GETTING TO KNOW US  Trust (confianza) – For the provider it means having the patient’s best interests at heart. – Over time, by respecting the patient’s culture and showing personal interest, a health care provider can expect to win a patients’ trust. – Once this occurs the patient will value the time they spend talking and believe what they say.

GETTING TO KNOW US  Espiritu (spirit) – Hispanics view health from a more synergistic point of view that is expressed as the continuum of body, mind, and espiritu. – Many Hispanics may use traditional medicine in combination with other approaches (curanderas, espiritistas, sobadores and jerberos) – Recognizing values such as family, respect, personalism, trust and spirit can allow the clinician insight into the Hispanic’s worldview.

DEALING WITH ILLNESS  May see illness as an imbalance, occurring between the internal and external sources (e.g. hot and cold, natural vs. supernatural, the soul is separated from the body.  There are folk-defined diseases such as empacho (stomach illness), susto, and standard western medically defined diseases, such as measles, asthma, & TB. Source: University of Washington Medical Center, ( April, 2005)

DEALING WITH ILLNESS  Don’t be condescending if patient expresses a supernatural cause, instead attempt to get more information on patient’s opinion of what caused illness.  Depression may be considered to occur due to supernatural cause (embrujado); treat with respect.  Usually the family would prefer to hear about bad medical news before the patient is informed. – With patient consent, meet with the identified persons to strategize how to communicate medical news.

THE ROLE OF RELIGION  It is estimated that 70 % to 75% of Hispanics are Roman Catholics, 19% Protestant and 5% Other of 35 million Hispanics in US Source: Pontón & León-Carrión

– A 1999 report by the National Conference of Catholic Bishops project that by 2050 Hispanics will constitute 24% (94 million) of the US population and more than 50% will consider themselves of U.S. Catholics Source: S. G. Leaugminas, (2001)

 Catholicism not only is a denomination, but a lifestyle. Note: US current census 294,602,012; Year 2050 392 million

CONCEPT OF ILLNESS & DEATH  Fatalism and Religious Beliefs Refers that there is little an individual can do to alter fate. Hispanics are fatalisticyou live, you suffer, you die. “That’s the way life is.” Source: Pontón & León-Carrión

FATALISMO:FATALISM “Si naciste pa’ martillo, del cielo te caen los clavos” (If you were born a hammer, nails will rain from heaven) Rubén Blades, 1984 “Así los dispuso Dios, que le vamos a hacer” (This was God’s design, there’s nothing I can do)

FATALISMO:FATALISM  Fatalism may affect the patient’s motivation for treatment, their sense of purpose for the future, their understanding of whether an illness or accident is part of divine punishment for sins past and present, and their willingness to access resources for future treatment. Source: M. Pontón & J. León-Carrión, (2000)

IMPORTANT!  RECOGNIZE THAT FATALISM DOES NOT MEAN THE CLIENT DOES NOT HAVE HOPE!

End-of-Life Issues in Advanced Disease  Minority patients experience disproportionately higher rates of heart disease, hypertension and diabetes and its complications, such as amputations, strokes and end-stage heart, liver and renal disease. These conditions lead to increased morbidity and morality.

Understanding the Challenges Of End-of-Life Care For Hispanics Advance Directives is translated to “Directiva Anticipada”. Medical Power of Attorney is translated to “Declaracion Referente al Poder Medico”. Out-of-Hospital DNR is translated to “La Orden de no revirir fuera del hospital”.

Understanding the Challenges Of End-of-Life Care For Hispanics How can we, as professionals, help patients to understand Advance Directives? - Living Will - Medical Power of Attorney - DNR- Do Not Resuscitate - Organ Donations

Understanding the Challenges Of End-of-Life Care For Hispanics Professionals who can help with Advance Directives – Registered Nurses – Social Workers – Attorneys – Physicians

Understanding the Challenges Of End-of-Life Care For Hispanics  The notion of Self-Determination and the ethical principle of Autonomy in health care is totally foreign to the Spanish-speaking world. Most Hispanics understand the principal of beneficence, “Doctor you know what is best for me”. Therefore, advanced directives, living wills, medical power of attorney and Out of Hospital DNR are foreign concepts to the Spanish-speaking world.

Understanding the Challenges Of End-of-Life Care For Hispanics  Knowledge among Mexican-American population in Dallas/Fort Worth, Texas  Qualitative Study Approach – Focus Groups 8 questions aimed at assessing:  Knowledge  Beliefs  Influence area for decision making

Advance Directive Planning among Mexican-Americans in Dallas – Fort Worth Summary of findings in General Group II Group I (65 years old +) Unawareness about circumstances of when A.D. were needed

(18 years old to 64) Similar findings as Group I

“If I fill out an A.D. It will be like I’m “Decision made earlier in their rushing my death to happen right illness is a less emotional away.” decision” “I consult with the priest about dealing with A.D.

“I will be influenced by religious convictions but more likely would make the decision with the doctor.”

Family involvement is important in Similar findings as Group I Decision making Source: Santiago, C. Advance Directives- Planning Among Mexican-Americans in Dallas Fort Worth 2005 University of North Texas Health Science Center Fort Worth

Understanding the Challenges Of End-of-Life Care For Hispanics  A series of “platicas”, i.e., small sessions may be helpful.  First visit start with a short introduction of who you are and probe the origin of the patient and their family..”what tribe are you from?’  Second visit ask what is hurting the patient, is someone suffering and what can I do to help, i.e., facilitate communications with Doctor(s), need of a translator, etc.  Third visit offer your services and then discuss advance care planning.

Strategies to Overcome the Obstacles in Hispanic/Latino Health Care  Patient and family + extended family centered care is the goal  Be aware of patients values and preference pattern  Simplify referral to specialist  Use proven tools for communication when dealing with socio-cultural diverse population  Tailor intervention and recommendation (Don’t use one size fits all)  Keep up with results and finding in the Hispanic/Latino community by credible institution findings e.g. CDC, NIH, Medicare, Medicaid, State Health Department, AHRQ, Agency for HealthCare Research and Quality

QUESTIONS