1. CROSS-CULTURAL ENCOUNTERS IN END-OF-LIFE CARE James Hallenbeck, MD VA Hospice Care Center and Stanford Hospice

2. Challenges Language Misunderstandings Differing values, meaning History Imposed relationships Underestimation of power of ritual Pearl: Most things that don’t make sense from the outside DO make sense if understood from the inside.

3. Dealing with Issues of Truth Telling Statement of respect Why has this request been made? Where does the patient stand? Statement of own values Prepare/permission to negotiate Set ground rules Talk with patient

4. Explanatory Model Questions What –Do you call the problem? –Do you think the sickness does? –Do you think the natural course of the illness is? –Is it you hope for/fear? Why –Do you believe this problem occurred?

5. What, Why, How, Who continued... How –Do you think the illness should be treated? Who –Should one turn to for help? –Should be involved in care and decision making?

6. Questions about Dying and Death How do people communicate about death and dying? What preparation is made for death? How are symptoms such as pain understood, expressed and addressed? Food, feeding considerations?

7. Questions about Dying and Death Desired location for dying Spiritual/religious needs –Before death –At time of death –Following death What happens to the person after death? Care of the body Grief practices Attitudes toward autopsy, organ donation Funeral practices

8. Discussing Death Related Practices Statement of respect/desire to learn about the other culture –You are not discussing the death of the dying patient What is important- –For a dying person to do? –For family/caregivers? prior to, at the time of, after death Are there important things that we should know NOT to do?

9. Discussing Death Related Practices Special concerns or fears that we should know about? How could we be most helpful to the patient and family? –In the dying process, at the moment of death, after death? Reaffirm intent to help – Give permission to tell us of mistakes