1. Cultural Competence for Healthcare Professionals Part C: Practical Applications Continued

2. Workshops Session A  Introduces health disparities, the immigrant experience, social determinants of health (SDOH), and clinical cultural competence. Session B  Develops knowledge and skills on collaborative communication, cross-cultural communication, and clinical cultural competence as it pertains to parenting, mental health and pain management. Session C  Develops knowledge and skills on clinical cultural competence in the use of complementary and alternative therapies, bereavement and grief. Participants will have an opportunity to practice with Standardized Patients

3. Learning Objectives Participants will be able to:  Recognize differences across cultures in regards to: –bereavement and grief –complementary and alternative medicine  Describe strategies for providing culturally competent care to patients and families during the bereavement and grief period  Describe strategies for integrating complementary and alternative medicine into practice  Apply cross-cultural competency skills in clinical situations (by interacting with simulated patients) 3

4. Complementary and Alternative Medicine (CAM)

5. Health and Illness  We practice a Westernized, biomedical model in relation to health and illness  Patients and families may feel strongly about anecdotal evidence  Decisions are often based on cultural perceptions of health and illness  Conflicts may arise when dealing with CAM therapies 5

6. Justine’s Story Worlds Apart, 2007 6

7. Definition of CAM “…a healing resource that encompasses all health systems, modalities and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and well-being…” (National Institutes of Health, Institute of Medicine, 2005) 7

8. SickKids Goal: Evidence-Based Practice 8 “ Those treatments with the best evidence of effectiveness, suited to agreed upon treatment goals for the child, should always be promoted at SickKids regardless of whether they are considered conventional, complementary, or alternative.” (SickKids CAM Policy)

9.  Acupuncture  Chiropractic  Homeopathy  Naturopathy  Aroma Therapy  Ayurveda  Faith Healing  Iridology  Reiki Common CAM Therapies  Native Healing  Oligotherapy  Osteopathy  Reflexology  Rolfing  Shiatsu  Therapeutic Touch  Traditional Chinese Medicine 9

10. Utilization of CAM Therapies  In Canada, around $7.84 billion was spent on CAM products and services in 2005 (Fraser Institute, 2007)  More than 70% of Canadians use CAM therapies each year (Fraser Institute, 2007)  Demographics of CAM users= female, age 18-34 years, better educated, middle class, ethnically diverse (NCCAM, 2007; Fraser Institute, 2007) 10

11. Toronto CAM/Natural Health Product (NHP) Study  49% of those surveyed in the SickKids ER used at least one type of NHP or CAM practice  Of the children using NHP/CAM: –85% children used at least one NHP –5% children used at least one CAM practice –10% used both 11 (Goldman & Vohra, 2004)

12. Toronto CAM Study  Children using NHP who take prescribed medications at the same time: 30.5% 12

13.  Did you tell your family physician/pediatrician that your child was on NHP therapy? YES – 45% 13 Toronto CAM Study

14. Why didn’t you tell your doctor? Doctor didn’t ask or it didn’t come up13% Didn’t feel it is necessary or important3.5% Hasn’t seen doctor2.1% No need to tell the doctor1.5% Feel it’s safe.80% Asked pharmacist about interactions before buying.34% Because another family member uses it.34% (Goldman & Vohra, 2004.) 14

15. Ethical Values and Principles at Stake  Choice  Respect  Trust  Safety (protection from harm)  Justice  Best Interests

16. CAM: Key Considerations  The ‘Best Interests’ standard is applicable to all care providers and substitute decision makers  We should presume parents are motivated by doing what is best for their children, and treat the family respectfully  Collaboration with the family is the ideal; in conflict situations parents wishes should prevail unless there is likely to be identifiable harm to the child –In some cases, health care providers have a legal and moral duty to the child to contact child protection authorities 16

17. Strategies for Prevention and Management of Conflict  Meet with the team and the family  Offer collaboration with CAM practitioners  Attempt a shared understanding of the following: –Medical facts –Rationale and/or medical necessity of treatment –Consistency with belief or value system  Identify and utilize all available conflict resolution methods 17

18. Take Home Messages  Involving children in decision-making can increase their feelings of control –However, culture may have an impact on when parents wish to involve children in decision-making  Preservation of relationships is an important value (i.e. parent-child, healthcare professional – family, healthcare professional – child) –Encourages disclosure of CAM use –Allows ongoing monitoring of the child –Increases levels of trust –Avoids causing distress to the child 18

19. Case Study

20. Bereavement and Grief

21.  The vocabulary and expressions of bereavement and grief are determined by culture  The definitions of dying, death, and life vary between cultures (Rosenblatt, 1993) 21

22. Grief Across Cultures  How do you think grief varies across cultures? 22

23. Grief and Loss Different reasons why parents grieve:  The diagnosis itself  Loss of normalcy  Loss of dreams and goals for their child  Anticipatory loss –Preparing for and grieving the potential death or disability of a child 23

24. Grief and Loss Parents may feel:  Concerned about not meeting the needs of siblings when caring for a sick child  Stressed about the loss of their own roles/routines  Relationship strains (between partners and extended family)  Financial loss 24

25. Disclosure: Cultural Considerations  Disclosure desired because: –Speaking candidly is an established tradition in Western medicine –Individual rights and autonomy are underlying values  Disclosure NOT desired because: –Individuals may exercise autonomy by choosing "not to know“ –Many new Canadians feel it is bad luck to talk about death as a there may be a view that what will happen is in God’s hands 25

26. Decision-Making  In North America, when someone is considered “brain dead” decisions regarding “do not resuscitate” orders are seen as necessary.  In some cultures, the soul is what gives life and thus there is difficulty in understanding brain death and ‘end of life’ decisions. Decision-Making: Cultural Considerations

27. Hospice Care  Many cultures feel it is the duty of the family to take care of its own members, others believe it is too hard for the dying to let go in the presence of loved ones.  Cultures may believe that certain things need to be in place at the time of death (i.e. a suit with no buttons to enable the soul to slip out easily). 27 Hospice Care: Cultural Considerations

28. Organ Donation  Some cultures resist organ donation because the family does not want the person to be born in the next life with the donated organ missing (Braun & Nichols, 1997)  Other cultures may interpret organ donation as a method of helping others Organ Donation: Cultural Considerations

29. The 4-Fs Cultural exploration in end of life care involves: 1.Feelings 2.Family 3.Faith 4.Finality (Pottinger, Perivolaris & Howes, 2007) 29

30. Bereavement and Grief: Key Considerations  What are the cultural and religious practices for coping with dying, the deceased person’s body, the final arrangements, and honouring the death?  What are the family’s beliefs about what happens after death?  How does the family express grief and loss?  What are the roles of family members in handling the death?  Who is involved in decision-making? 30

31. Case Study

32. Resources  Palliative and bereavement care services –NICU/ICU Bereavement Coordinators  Chaplaincy  Social work  Family Resource Centre  Palliative care “Death Package”  Psychology 32

33. SickKids Policies  Deaths  After-death care of child and family  CPR  Organ donation after cardio-circulatory death  Consent to treatment  Levels of treatment guidelines  Clinical Guideline (in draft)  Care of infants, children, and adolescents with life limiting conditions  Task force looking at standardization of bereavement practices across the organization 33

34. Helping family members deal with the loss of a loved one often means showing respect for their particular cultural heritage and encouraging them to actively determine how they will commemorate those they have lost. 34

35. Standardized Patients

36.  Standardized patients are trained healthy individuals that simulate a health care scenario including physical symptoms, emotional response and personal histories.  Standardized patients are trained to provide constructive feedback from the perspective of a patient.

37. Cultural competence includes:  Awareness of personal cultural and family values  Awareness of personal biases and assumptions  Awareness and respect for cultural differences  Understanding how the dynamics of differences impact interactions  Embracing diversity 37 Summary of Cultural Competence Workshops

38. Key strategies:  Apply collaborative communication techniques and cross-cultural assessment framework  Use resources known to be effective in cross-cultural communication (i.e. Language Line/Interpreter Services)  Recognize how culture and the new immigrant experience impact parenting, pain management, use of CAM therapies, mental health and bereavement and grief 38

39. Acknowledgements Collaborative Conversations  Michelle Durant  Brenda Spiegler Parenting  Jennifer Butterly  Jennifer Coolbear  Lee Ford-Jones 39

40. Acknowledgements Mental Health  Michelle Peralta  Abel Ickowicz  Joanne Bignell  Sarah Cowley  Stephanie Belanger  Diversity in Action Initiative 40

41. Pain  Shelly Philip LaForest  Lori Palozzi  Lorraine Bird  Fiona Campbell  Jennifer Stinson  Jennifer Tyrell  Danielle Ruskin  Lisa Isaac 41 Acknowledgements

42. Complementary and Alternative Therapies  Christine Harrison  Ted McNeill  Darka Neill Bereavement and Grief  Gurjit Sangha  Maria Rugg 42 Acknowledgements

43. THANK YOU!! 43

44. References Fraser Institute. (2007). Complementary and alternative medicine in Canada: Trend in use and public attitude, 1997-2006. Vancouver, British Columbia: Fraser Institute. Goldman, R.D, & Vohra, S. (2004). Complementary and alternative medicine use by children visiting a pediatric emergency department. Canadian Journal of Clinical Pharmacology, 11:e247. Hospital for Sick Children. (2001). Possible use of complementary and alternative therapies. Toronto, Ontario: Author. Institute of Medicine. (2005). Complementary and Alternative Medicine in the United States. Washington, DC: National Academies Press. Goldman R.D, Vohra S, & Rogovik, A.L P(2009). Potential vitamin-drug interactions in children at a pediatric emergency department. Pediatric Drugs. 11(4):251-257 Pottinger, A., Perivolaris, A., & Howes, D. (2007). The end of life. In Srivastava Rani (Ed.), The Healthcare professional’s guide to clinical cultural competence. Toronto, Ontario: Elsevier. Rosenblatt, P. C. (1993). Cross-cultural variation in the experience, expression, and understanding of grief. In D. P. Irish, K. F. Lundquist, & V. J. Nelsen, (Eds.) Ethnic variations in dying, death and grief: Diversity in universality (pp. 13-19), Washington. D. C.: Taylor & Francis.