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Welcome to the End of …. Objectives:. Define Advanced Directives Relate cultural competency to patient self-determination and nursing care Identify the implications of these concepts to the CNL role. Cultural Competency & Advanced Directives. Advanced Healthcare Directives. Instructions on:
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Objectives: Define Advanced Directives Relate cultural competency to patient self-determination and nursing care Identify the implications of these concepts to the CNL role
Advanced Healthcare Directives • Instructions on: • Type of care • Decision-maker: proxy/surrogate/agent • When an individual becomes unable to communicate for himself.
Advanced Healthcare Directives • Types: • Durable Power of Attorney for Health Care • Living Will • Do Not Resuscitate (DNR) order
TRIAD 1: The Realistic Interpretation of Advanced Directives (Mirarchy, Hite, Cooney, Kisiel & Henry, 2006) • N=452, 62% Nurses, 64% Female, • Ave. years as nurse=13.3 • Findings: • Living Wills (LW)/ADs are misunderstood as DNR orders • DNR is misunderstood as Comfort or EOL care
TRIAD 1: The Realistic Interpretation of Advanced Directives • Implications: • Effect on some MDs: Less aggressive critical care procedures, fewer interventions, less documentation. • Effect on some nurses: decreased aggressiveness in nursing care with elderly who are DNR; delays in notifying MD of change in clinical status in DNR pts.
Multicultural & Multi-Ethnic Considerations & Advanced Directives: Developing Cultural Competency (Giger, Davidhizar & Fordham, 2006)
SF Cultural Diversity: • 37% SF pop. is foreign born • 31% Asian • 20% Chinese, 5% Filipino, 1.5% Japanese, 1.5%, 1.5% Vietnamese, 1% Korean • 14% Hispanic or Latino • 6% Mexican • 8% Black or African American • Source: US Census, 2000
Recent end-of-life values practiced in U.S. healthcare system: • Patient maintains autonomous decision-making at all times. • Patient is told the complete truth about diagnosis, prognosis, and treatment options. • Patient is in control over the dying process • But, many individuals in the U.S. do not adhere to this belief system.
Cultural Perspectives- Autonomy and Decision Making • U.S. Health care system- autonomy is regarded as a basic right and informed consent an element of responsible healthcare. • Chinese, Korean, and Mexican individuals believe in a family-centered model of decision making rather than a patient-centered model of decision making. • Filipino- Family will want to be the first informed of a family member’s terminal illness diagnosis. • Jewish law dictates that patients should be informed that death is near which allows the person to put worldly affairs in order. • Hispanics- defer to a physician’s opinion or decisions in regard to end-of-life issues.
Cultural Perspectives- Truth Telling • U.S. Health care system- Patient knows the entire truth about diagnosis. • Full disclosure is considered inappropriate and harmful in some cultures. • Chinese- cancer as an unspeakable disease diagnosis. Speaking of death is unlucky.
Cultural Perspectives- Pain Management • U.S. health care system- pain management in death • The desire for pain avoidance is not a universally shared belief. • Pain may be seen as life-affirming. • Some African-Americans refuse pain meds, seeing illness as a test of one’s faith and valuing longevity over a shorter pain-managed life.
Engaging Culture • http://culturecompetenceadvanceddirectives.wikispaces.com/
Guidelines for a Positive Cultural Interaction • Never approach patients with pre-conceived notions about their culture. • Take cultural knowledge and re-validate it with individual patient beliefs. • Reach mutually acceptable goals through communication.
CNL Roles • Train & educate care teams on cultural competence and ADs • Check & ensure LWs/ADs are not misinterpreted by the care team • For referral, create list of care providers who may be more comfortable with Pt’s beliefs or values • Create protocols for caring for Pt’s family
A 53 year old woman visits her physician monthly for stomach pains. He writes her a different prescription each time, without physically assessing her and sends her out the door. He rejects her suggestion of having cancer. She visits him for the last time and goes to the ER for excruciating pains. After surgery, she is diagnosed with stage IV gastrointestinal cancer. She passes away within 3 days.
Cultural/religious practices that providers should be aware of. • Is there an inappropriate time to ask families about advanced directives? • How would advanced directives affect you as a nurse? • What concerns are there for the family after diagnosis • Something you remembered from a provider that was helpful (gestures/words/temperament) • Negative experiences with care providers? • What has helped you cope? • What is the best thing to do if pt refuses treatment? • Comments on the video?
