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SAN FRANCISCO - May 26, 2007 - In America where individualism
is celebrated, doctors tend to treat death and illness as a personal
matter. On the other hand, in Asian and Latino communities the family
often determines what treatment should be administered to their loved
one, and even on how he should be allowed to die.
“Dying,” observed Dr. Mark Smith, president and executive director of
the independent philanthropy, California HealthCare Foundation (CHCF),
“is so culturally determined, perhaps more than any other thing.”
“That’s one of the reasons why it so difficult for health care providers
in the U.S. to offer end-of-life care” to patients from ethnic
communities, said Dr. LaVera Crawley, a Stanford University medical
ethicist who was commissioned by the CHCF to research racial disparities
that affect end-of-life care in California. “We are not trained in
cross-cultural ways.”
Smith released some of the key findings of that study May 22, at a media
briefing for the ethnic press organized by New America Media. Eighteen
reporters attended, where they also heard two other leading California
health care providers, Dr. Sandra Hernandez and Dr. Alice Chen, on the
subject.
Aside from the role Asian families and friends play in the life of a
family member facing a major illness or death, other findings of the
CHCF report included the importance of having a health care workforce
that can provide linguistically and culturally-sensitive services to
racial minorities who are facing death.
The report also pointed out that not all ethnic communities, perhaps for
cultural reasons, “value planning ahead” for the end of life care
services they would like to receive, said Smith.
Chen, who worked for several years at the Oakland-based Asian Health
Services before she moved to San Francisco General, concurred with
Crawley’s findings. She asserted that doctors should try to win the
“trust and respect” of their patients and their families before they can
broach the sensitive issue of dying.
“You have to understand the sense of family is so strong among them,”
Chen said, noting that “a lot of Asian families ask you not to share the
prognosis with the patient,” fearing he may not be able to handle it
well. That makes it difficult for Western health care providers, she
said, because we “are trained for full disclosure.”
She also emphasized that the end-of-life care provided to ethnic
communities, who are fast becoming the new face of California and many
other states, should address their spiritual needs.
“We need continuing medical education,” Chen said. “We have very little
training in end-of-life care.”
Noting that “death and dying is a contemporary issue to all of us,”
Hernandez, who once served as director of public health for the City and
County of San Francisco, and who said she witnessed a great deal of
death and dying during the AIDS epidemic in California, said it’s
important to explore the “culture of dying.” As Smith noted, most
doctors are trained to be “good engineers, not poets.”
Citing from her own experience when her 87-year-old father died of a
heart attack in the comfort of his home. Despite having made it clear
that he did not want “to die connected to tubes,” Hernandez said, he was
subjected to resuscitation in a hospital. Such traumatic
miscommunication suggests something is wrong with the delivery of health
care in the U.S.
Physicians, she said, are trained in administering medications to
patients and hooking them up to tubes to get some form of life back even
“when a perfect death” occurs.
She said palliative care and hospice care have their origins in European
culture and are foreign to many other cultures, particularly Asian and
Latino.
“So part of what we need to think about is what language should we use”
when dealing with those other cultures. “Unless we do this, hospice care
will continue to be underutilized.”
Echoing her sentiments, Smith pointed out that most doctors are trained
to be “good engineers, not poets,” more skilled as diagnosticians than
cultural mediators.
In his presentation, Smith said that of those who died in hospice care,
only 4 percent were Asian American, six percent were African American
and 15 percent were Latino. The overwhelming majority, 74 percent, were
white.
NAM’s executive director Sandy Close urged the media at the briefing to
let their audiences realize the importance of talking about death and
dying. Hernandez suggested for instance, in her case her father made his
living will when some of his close friends were dying.
Smith said that those with chronic illnesses – and a large number of
Californians have more than one chronic condition – should discuss
end-of-life care with their health care providers.
He pointed out that financial incentives offered by Medicare encourage
health care providers to engage in intensive treatment to all patients.
More than 20 percent of Medicare spending goes to end-of-life care, he
said.
In a separate interview with NAM, Crawley said that health care
providers who have “cultural humility” are more likely to persuade
ethnic communities to access end-of-life care services.
Viji Sundaram is the Health Editor at New America Media. The briefing on
end-of-life care was supported by a grant from the California Health Care
Foundation. |
