Cultural Diversity Poses Challenge for the Physician Trying to Have ‘The Hospice Discussion,’ Expert Says

   One of the most difficult things family physicians do -- presenting bad news to patients -- is something for which there is little formal training. “Most of us ‘fly by the seat of our pants,’” said Jerry Old, MD, FAACP, an authority on end-of-life issues, in a presentation to the annual Scientific Assembly of the American Academy of Family Physicians in Denver. 

   One factor that can make the physician’s role even more difficult is the cultural diversity on the increase in the United States. Ethnic minorities currently compose one half of the population of the United States, and, Dr. Old says, “Cultural factors strongly influence patient’s reactions concerning serious illness and decisions about end-of-life care.”

   “Black patients overall are about one half as likely as whites to accept DNR status and more likely than whites to later change DNR orders to more aggressive levels of care,” he said.

   Further, in some European and Hispanic cultures “It is detrimental to let older patients know about the seriousness of their illness to spare them the pain and worry,” Dr. Old noted. In those cases, “It is the family’s obligation to bear the burden for the patient. One negotiation method is to ask the patient ‘How much do you want to know?’”

   In some cultures, discussion of serious illness and death is disrespectful or impolite. Open discussion provokes unnecessary depression and anxiety. Disclosure eliminates hope. And speaking aloud about a condition makes death or terminal illness real because of the power of the spoken word.

   Do you think that having a translator is an automatic plus? According to Dr. Old, “They may deliberately not translate the diagnosis and treatment information to the patient, but rather translate into the culture.” In that case, the physician might conceal the diagnosis, as, for example, “mass,”

“growth,” or “blood disease.”

   American middle-class culture places high value on direct communication, such as “‘Should we keep your mother on the ventilator or pull the plug?’” Dr. Old said. “Our culture is very unusual in this. Most cultures prefer indirect communication as being more respectful.” The family physician might try something like “Let me tell you a story about a similar patient I had.”