Understanding Cultural Considerations in Palliative Care for Veterans

1. Module 4:Cultural and Spiritual 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 Honor Courage Commitment to comrades, unit and nation Good of the unit and mission above the good of the individual • Duty • Valor • Loyalty

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)

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: 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

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

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) • Demographics • 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

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 in Spirituality and Religion • Spirituality • Meaning-making • Need for purpose, forgiveness, love, hope, relatedness and religious faith • Religion • “Organized” • Institutional beliefs Taylor, 2015

26. FICA: An Example of a Spiritual Assessment • F = Faith • I = Important • C = Community • A = Address Puchalski, 2014

27. Spiritual Care Interventions • Providing presence • Deep listening • Bearing witness • Putting compassion into action Baird, 2015

28. Cultural Considerations of Communication • Conversation styles • Personal space • Eye contact • Touch • View of healthcareprofessionals • Learning styles • Language/gestures

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

30. 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

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

32. 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

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