EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Osteopathic EPEC Osteopathic EPEC Education for Osteopathic Physicians on End-of-Life Care American Osteopathic Association AOA: Treating Our Family and Yours

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Module 14 Cultural Diversity Issues in End of Life Care Created by the American Osteopathic Association Councils on Minority Health Issues and Palliative Care Issues for educational use.

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC Advance Care Planning Many factors play a role in patients’ preferences for EOL care: Age/Nature of illness Emotions of family/patient Ethnicity Religiosity Gender American Osteopathic Association

EPECEPECEPECEPEC AOA: Treating Our Family and Yours EPECEPECEPECEPEC Advance Care Planning Socioeconomic Status/Education Prior Experience with Illness and Death of Others Culture Journal of Hospice and Palliative Nursing.2008;10(3) & AHRQ –Research in Action, Issue 12 –Preferences for Care at the End of Life American Osteopathic Association

EPECEPECEPECEPEC AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association... W hat Can We D.O.? Research has shown that although many patients would be willing to discuss EOL care and planning, it is a topic often not brought up by physicians. Only 5% of patients felt it was too difficult a topic to discuss. The physician must be the advocate for the patient, especially in patients for whom the health care system is a labyrinth. Emanuel LL, Barry MJ, StoeckleJD, et al. Advance directives for medical care— a case for greater use. N EnglJ Med1991;324(13):889-95

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association Cultural Issues Avoid stereotyping all patients of one culture. Every person is an individual, and each situation is different. Ask each patient whether they wish to discuss advance directives: Alone With family With other decision makers

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC Cultural Issues Do not use family members as translators. Respect the patient’s wishes, even if different than your wishes or desires. American Osteopathic Association

EPECEPECEPECEPEC AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association Patients Who Discussed EOL Care: Had less fear and anxiety. Felt they had more ability to influence and direct their medical care. Believed that their physicians had a better understanding of their wishes. Indicated a greater understanding and comfort level than they had before the discussion.

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC Patients Who Discussed EOL Care SmuckerWD, Ditto PH, et al. Elderly outpatients respond favorably to a physician-initiated advance directive discussion. J Am Board FamPract1993;6(5): Tierney WM, Dexter PR, et al. The effect of discussions about advance directives on patients' satisfaction with primary care. J Gen Intern Med2001;16:32-40 AHRQ Publication Number American Osteopathic Association

EPECEPECEPECEPEC AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association Communicating Bad News Each person is unique. Avoid biases based on previous interactions with members of the same culture. In some cultures, discussing EOL or death directly is taboo. Consider initiating discussions as scenarios that may be affecting other people.

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC Communicating Bad News Then judge the patient’s reaction and proceed based on their willingness to discuss the topic or response. Monitor non-verbal cues as well. Consider the patient’s willingness and ability to receive news. American Osteopathic Association

EPECEPECEPECEPEC AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association Communicating Bad News Ask the patient to confirm their understanding. Don’t assume that they have absorbed the information. CoulehanJ, Block M, The Medical Interview, Mastering Skills for Medical Practice, 5 ed, ch14

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association Talk to Your Patient E: Explanation - What do you think may be the reason you have these symptoms? What do friends, family, others say about these symptoms? Do you know anyone else who has had or who has this kind of problem? Have you heard about/read/seen it on TV/radio/newspaper? (If the patient cannot offer explanation, ask what most concerns them about their problems).

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association Talk to Your Patient T: Treatment - What kinds of medicines, home remedies or other treatments have you tried for this illness? Is there anything you eat, drink, or do (or avoid) on a regular basis to stay healthy? Tell me about it. What kind of treatment are you seeking from me?

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association Talk to Your Patient H: Healers - Have you sought any advice from alternative/folk healers, friends or other people (non-doctors) for help with your problems? Tell me about it. N: Negotiate - Negotiate options that will be mutually acceptable to you and your patient and that do not contradict, but rather incorporate your patient's beliefs.

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association Talk to Your Patient Ask what are the most important results your patient hopes to achieve from this intervention. I: Intervention - Determine an intervention with your patient. It may include incorporation of alternative treatments, spirituality, and healers as well as other cultural practices. (e.g. foods eaten or avoided in general, and when sick)

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association Talk to Your Patient C: Collaboration - Collaborate with the patient, family members, other health care team members, healers and community resources. Levin, S.J., Like, R.C., and Gottlieb, J.E. (2000) ETHNIC: A framework for culturally competent clinical practice. In Appendix: Useful clinical interviewing mnemonics. Patient Care, 34(9):

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association Whole Patient Assessment Includes Assessment of: disease history physical symptoms psychological symptoms decision decision-making capacity information sharing

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association Whole Patient Assessment social circumstances spiritual needs practical needs anticipatory planning for death Emanuel LL, von GuntenCF, Ferris FD. The Education for Physicians on End-of- life Care (EPEC) curriculum, 1999.

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association Cultural Issues Ask your patient: What death means to them Whether any unresolved issues exist Whether any rituals are to be performed Gather input from patient/ family/ decision maker, and respect the role of each

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association LEARN L Listen with sympathy and understanding to the patient's perception of the problem. E Explain your perceptions of the problem. A Acknowledge and discuss the differences and similarities.

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association LEARN R Recommend treatment. N Negotiate agreement. Berlin E.A. and Fowkes, W.C. Jr: A Teaching Framework for Cross-Cultural Health Care, Western Journal of Medicine 1983, 139:

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association Pain Management Cultural differences exist in treatment of pain. Minorities: report more pain increased severity of pain are more likely to be disabled from pain.

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association Pain Management Minorities with cancer pain are < likely to receive treatment for their pain and have < access to specialty care and opioids. Wilner, A, Pain Management Across Cultures. 10/14/2008, Medscape Neurology & Neurosurgery Green CR, Ndao-BrumblaySK, West B, et al Differences in prescription opioid analgesic availability: comparing minority and white pharmacies across Michigan. J Pain.2005;6:

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC American Osteopathic Association Pain Management A: Acknowledge the need for treatment with the patient, and ask about previous treatments utilized. Together determine mutual goals and desired outcomes. D: Discuss potential treatment strategies and options, as well as consequences of non- treatment with the patient (consider issues such as treatment effectiveness, prognosis, use of complementary/ alternative medicine, brand name vs. generics, off label uses, prescription plans, formularies, etc.).

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours EPECEPECEPECEPEC Pain Management H:Handle any questions or concerns the patient may have about treatment (e.g., fears or worries, side effects, costs, dosage, frequency, timing, sequence, duration of treatment, drug or food interactions, proper storage techniques). American Osteopathic Association

EPECEPECEPECEPEC AOA: Treating Our Family and Yours EPECEPECEPECEPEC Pain Management E:Evaluate the patient s functional health literacy and understanding of the purpose/rationale for treatment, and assess barriers and facilitators to adherence ( e.g., environmental, economic, occupational, and sociocultural factors, family situation and supports. American Osteopathic Association

EPECEPECEPECEPEC AOA: Treating Our Family and Yours EPECEPECEPECEPEC Pain Management R: Recommend treatment, and review the therapeutic regimen with the patient. E: Empower by eliciting the patient’s commitment and willingness to follow- through with the therapeutic regimen. The Provider’s Guide to Quality and Culture -Published in: Soto-Greene, M., Salas-Lopez, D., et al, (2004) Antecedents to Effective Treatment of Hypertension in Hispanic Populations. Clinical Cornerstone, 6(3): American Osteopathic Association

EPECEPECEPECEPEC AOA: Treating Our Family and Yours EPECEPECEPECEPEC Cultural Diversity Issues in End of Life Care Summary American Osteopathic Association