Module 4: Cultural Considerations in Palliative Care

Key Learning Objectives At the completion of this module, participants will be able to: Identify three dimensions of culture that may influence palliative care for Veterans across the life span. List six shared military values of Veterans that may impact palliative care. Discuss military stoicism as it relates to care at end of life Name four considerations of cultural communication

Culture Defined System of shared values Provides security, integrity, belonging Constantly evolving Making meaning out of illness Not limited to sociodemographic characteristics Andres & Boyle, 2012; Mazanec & Panke, 2015; Purnell, 2013

Elements of Culture Culture refers to integrated patterns of human behavior Cultural Competence: congruency; behaviors & attitudes Cultural Awareness Cultural Knowledge Cultural Skill Cultural Encounters Cultural Desire AACN, 2008 & 2011; Campinha-Bacote, 2007, Douglas et al., 2014; Neubauer et al. 2016; HHS/OMH, 2005

Social Categories Race Ethnicity Gender Age Religion and spirituality Sexual orientation Douglas & Pacquiao, 2010; Mazanec & Panke, 2015 Differing abilities Financial status Place of residency Employment Education level Cause of death

Cultural Demographics of Veterans 23.8 M living Veterans 7.5% are women 14% of deployed US forces are women Largest group from Vietnam (7.9 M) 60% live in urban areas White male (primary gender and race) Older Veterans Reinberg, 2010, US Veterans Advisory Council, 2009a

Military Culture

Military Culture Shared experience of serving in military as one organism with a common creed of values Begins with basic training or a boot camp experience Although the majority of U.S. Veterans were not in combat situations, all were prepared for that possibility through training

Military Culture (continued) Range of expression of those military experiences from pride and patriotism to ambiguity and indifference Each war has its own defining traumas and communal hardships that serve to tightly bind together for life, those who serve Rituals and symbols portray important meaning and significance to Veterans Military lifestyle extends to and has significant impact on the family.

Values that bind all who serve in the military Duty Valor Loyalty Honor Courage Commitment to comrades, unit and nation Good of the unit and mission above the good of the individual

Military Culture and Stoicism Stoicism is a major tenet of military training, beginning in basic training Stoicism is the automatic suppression of emotions Stoicism assures that hardship, pain and grief as well as joy and pleasure, do not interfere with the shared military mission

Stoicism and the opportunity for a peaceful death May interfere with the Veteran’s ability to prioritize personal health and well-being including healthy grief and grieving pain management, especially at end of life

Veterans by Period of Service by Race and Ethnicity (in percent) White Black AIAN Asian Other Race 2+ More Race Hispanic Post-911 65.5 15.4 0.7 3.0 0.2 2.7 12.4 Pre-911 69.5 16.8 0.8 1.9 2.0 8.7 Vietnam Era Only 82.7 9.2 1.2 0.1 5.0 Korean Conflict Only 88.5 5.4 0.4 1.1 0.5 4.1 World War II Only 91.9 3.8 0.0 0.6 2.4 Peacetime Only 78.8 12.2 1.4 5.7

Cultural Demographics: Women in the Military Veterans (VA, 2014) Total women Veterans: 2 M States with largest number of women Veterans: Texas, California, Florida, Virginia, Georgia Active military (DoD, 2016) 15% of DoD Active Duty Personnel are women 161,415 female enlistees across all services As of 2015, all military positions are open to women Women Veterans at-risk: chronic conditions, higher mortality Bastian et al.,2016; DoD, 2016; VA, 2014; WHI, 2016

Cultural Demographics: Different Wars World War II: 1941-1945 Enthusiastically supported by Americans Veterans came home as heroes Korean Conflict: 1950-1953 Never officially declared a war “Forgotten war”, Veterans’ trauma minimized/neglected Cold War: “Atomic Veterans” Considered 1945 till 1990s Veterans exposed to radiation VA 2009

Cultural Demographics: Different Wars (continued) Vietnam War Soldiers shamed and dishonored Anti-war protests Tragedy of war: toxic exposures Generational cultural clashes

Cultural Demographics: Different Wars (continued) Gulf War Greeted home as heroes Concerns about toxic agents Research: neurologic diseases Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) – Operation New Dawn (OND) Longer and multiple deployments Environmental and traumatic injuries 17

Civilian challenges that may be intertwined with military culture Homelessness Addictions Discriminations Military Sexual Traumas PTS(D) Poverty

Cultural Demographics: Poor and Homeless Veterans On a single night in January 2013 Estimates of 49 to 58 thousand Veterans are homeless 60% in shelters of transitional housing; 40% unsheltered 8% are female Causes for homelessness Programs to assist Veterans

Providing Palliative Care for Poor and Homeless Goal: stable housing Expect that trust is earned over time Appreciate their unique story Recognize/address maladaptive behaviors Person-centered care is essential Hughes, 2015

Cultural Demographics: Substance Use Disorder (SUD) Substances: alcohol, marijuana, opioids Life-limiting conditions associated with at-risk behaviors Interventions Interdisciplinary care and open dialogue is essential www.ptsd.va.gov/public/problems/ptsd_substance_abuse_veterans.asp

Nurse’s Self-Assessment of Culture Understand our own culture; world-view Cultural diversity of interdisciplinary team members Pre-requisite for culturally competent patient care Spector, 2013

Components of Cultural Assessment Veteran, family & community Country of origin/current residents Ethnic identity Influence of the community Decision-making Language and communication AACN, 2008 & 2011; Douglas & Pacquiao, 2010; Mazanek & Panke, 2015

Components of Cultural Assessment (continued) Religion/Spirituality Nutrition: Food preferences, practices, prohibitions Financial status Health beliefs and practices: Death Grief & bereavement Pain Non-traditional therapies Care of the body Organ donation

Cultural Considerations of Communication Conversation styles Personal space Eye contact Touch View of healthcare professionals Learning styles Language/gestures

Role of the Family Who makes the decisions? Who is included in discussions? Is full disclosure acceptable? Blackford & Street, 2016; Mazanek & Panke, 2015

Cultural Influences on Advance Care Planning Differing perspectives on autonomy and values Disclosure of diagnosis and prognosis: ascertain desire and choice Blackford & Street, 2016; Dahlin & Wittenberg, 2015; Mazanek & Panke, 2015

Language Used at the End of Life “Discontinuation” “DNR” “Withdrawing/withholding” “Organ donation”

When Cultures Clash Clashes occur Assess your reactions, values and bias Never lie Offer information Use cultural guides when indicated Douglas & Pacquiao, 2010; Mazanec & Panke, 2015

Summary Culture is a dynamic and major influence in palliative care There are many components related to culture Necessary to conduct cultural assessment: Veteran, family, community Cultural self-assessment Interdisciplinary care