Moving Beyond Cultural Stereotypes in End-of-Life Decision Making
Am Fam Physician. 2005 Feb 1;71(3):429-430.
Imagine that all of our patients are invited to attend a “cultural competence” workshop called “Understanding the Medical Culture,” where they will learn how the strange and mysterious environment of medical practice affects physicians, so that their otherwise incomprehensible behavior seems at least somewhat understandable. They will be offered handy tips that would allow them to predict physicians' behavior, such as the following:
• Physicians always want to be in control and typically interrupt patients after they have spoken for about 18 seconds.
•Physicians believe in always “doing something,” even if there is little scientific basis for it—especially if it is well-reimbursed.
• All physicians take Wednesday afternoons off to play golf.
This imaginative exercise should remind us of two important points. First, as physicians, we bring our culture (or cultures) to the clinic just as much as patients bring theirs. As was taught nearly 30 years ago,1 and as we have been reminded more recently,2 every physician-patient encounter is a cross-cultural exercise—even if the physician and patient grew up on the same street in the same small town.
Second, although the efforts of Searight and Gafford3 in this issue of American Family Physician are well-intentioned and potentially beneficial, ultimately we must go beyond focusing on the unfamiliar cultural characteristics of certain subgroups. We cannot predict a patient's preferences and values by categorizing him or her into a hyphenated ethnic group any more than someone else could predict exactly how we will behave by categorizing us as physicians. What begins as a genuine desire to respect our patients can too easily deteriorate into an attempt to over-simplify “culture” into something that can be diagnosed and treated.4,5
True cultural competence requires humility and curiosity, and the willingness and flexibility to understand and respond to our patients' beliefs and the way they wish to be treated. It may not be appropriate for certain patients to be told the truth about their condition or to be asked explicitly about end-of-life care planning or advance directives. But it is very unusual for persons from any culture to resent frank inquiries into the nature of their own cultural beliefs and practices, so family physicians need not fear beginning such a dialogue.
Avoiding cultural dissonance does not require physicians to learn the nature and history of a whole variety of cultural beliefs and practices. Instead, physicians involved in end-of-life care should be sensitive to the arbitrariness of their own cultural beliefs in the value of telling the truth to patients and allowing them to participate in decision-making. Effective cross-cultural care in this setting requires a willingness to learn each patient's preferences and to negotiate mutually acceptable alternatives. For example, patients who prefer not to know their prognosis should be allowed to designate a representative to receive information and make decisions for them.
Searight and Gafford remind us that there is at least as much variation within other cultures as there is in the white European-American population. Furthermore, many patients who might be expected to be closely aligned with our “physician culture” are instead turning to a variety of alternative therapies and practices. Allowing our patients and their families to be our educators and informants, and developing mutually acceptable alternatives to our habitual practice, takes time and resources. Family physicians should appreciate the great value of making this necessary investment and the profound cost of failing to do so.
1. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88:251-8.
2. Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Ann Intern Med. 1999;130:829-34.
3. Searight HR, Gafford J. Cultural diversity at the end of life: issues and guidelines for family physicians. Am Fam Physician. 2005;71:515-22.
4. Hunt LM. Beyond cultural competence: applying humility to clinical settings. Accessed online January 10, 2005, at: http://www.parkridgecenter.org/Page1882.html.
5. Santiago-Irizarry V. Culture as cure. Cultural Anthropol. 1996;11:3-24.
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