1. Module 4: Cultural Considerations in Palliative Care

2. 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

3. 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

4. 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

5. 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

6. 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

7. Military Culture

8. 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

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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

15. Cultural Demographics: Different Wars
World War II:
Enthusiastically supported by Americans
Veterans came home as heroes
Korean Conflict:
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

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

17. 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

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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

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

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

27. 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

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

29. 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

30. 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