Advanced cultural competency in caring for geriatric patients

Upon completion of this chapter, the reader will be able to:

• Describe the core attitudes/skills/knowledge of advanced cultural competency (ACC).

• Consider how the experience of dementia is shaped by each subculture’s concept of what makes a person a person.

• Recognize that acknowledging and exploring the nature of health care disparities is necessary to achieve ACC, and that seeking to understand one’s own internal biases is an integral part of this effort.

• Discuss the model of offering truth, and possible scripts for sharing end-of-life information respectfully.

• Realize that health beliefs may shed some light on but are never sufficient to explain patient preferences and behavior, and that it is critical to consider the patient and his or her community’s personal and historical experience and perception of health care.

Defining cultural competency

CASE 1 Dr. Thaddeus Overman

Dr. Overman is a white male gay doctor, born, raised, and trained in Alabama. He moved to California for his residency in internal medicine. While caring for a patient with end-stage chronic obstructive pulmonary disease (COPD), he walked into the intensive care unit waiting room to discuss code status with the patient’s family and discovered more than 20 family members. When Dr. Overman asked who was the patient’s next of kin, he was told, “We are all kin.” He asked who had power of attorney and was met with silence. When he clarified, all the women in the room identified themselves as the patient’s sisters, and all the men as his brothers, and he started to feel that he needed to identify the patient’s cultural group; “I had been taught that if only I could figure out what culture the patient was, then I could find the right article or textbook chapter to read,” Dr. Overman explained later. Upon further discussion he realized that the patient was a Gypsy and he learned that the Gypsy definition of family centered around clan; this was not the same type of family or clan Dr. Overman had grown up with in Alabama. Many years have passed, but Dr. Overman vividly recalls the intensity of what he feels was his seminal clinical encounter with the necessity of understanding a patient’s cultural context.

What patient encounters come to mind in your own experience that have made you feel that you were out of your cultural element?

Special Thanks to Sharon Kaufman, Mary Jo Del Vecchio Good, Lawrence Cohen and Paul Farmer, who have been tremendous mentors and allies throughout my journey as a clinician-anthropologist.

The importance of cultural competency is widely accepted as fundamental to quality care ¹^,² and increasingly is seen as essential to combating health care disparities and in providing high-quality health care to all.^3–7 However, at the same time, there are few rigorous studies regarding the efficacy of cultural competency training,⁸^,⁹ and there are many critiques of cultural competency as it is often defined and taught.^10–15

Conventional cultural competency training implies that one can master a body of knowledge to become culturally competent.¹⁶^,¹⁷ However, competency as a goal is inherently flawed because cultures are complex and varied. Assuming that a clinician can be competent in understanding other cultures is naive and implicitly leads to oversimplification and stereotyping, objectification of the patient, and failure to develop valuable, generalizable skills.

Conventional cultural competency has often led to oversimplification and stereotyping, objectification of the patient, and failure to develop valuable, generalizable skills.

Advanced cultural competency involves learning and applying Attitudes, Skills, and Knowledge that will allow the clinician to function empathically and therapeutically. Note that this turns around the traditional medical hierarchy (Knowledge, Skills, and Attitudes), and thereby acknowledges that Attitude is the key to developing Skills, which then allow you to gain Knowledge of the individual patient and his or her cultural contexts. The resulting acronym—ASK—indicates the primary posture of advanced cultural competency.

Advanced cultural competency acknowledges that attitude is the key to developing skills, which then enables you to gain knowledge of the individual patient and his or her cultural contexts.

Table 5-1 identifies the key attitudes, skills, and knowledge of advanced cultural competency. The remainder of this chapter presents case scenarios that demonstrate how these factors interact and can be applied in common geriatric situations.

TABLE 5-1

Key Elements of Advanced Cultural Competency

Dementia, personhood, and culture

CASE 2 Ms. Nettie Mae (Part 1)

Ms. Nettie Mae is 78 years old. She lives with her grandson and his wife and their three small children. Her own children live nearby and join for meals on a weekly basis. The family knows that Ms. Nettie Mae is forgetful, and they do not like to leave her alone. She started a small fire in the kitchen last year, and her family no longer lets her cook. In a joking but firm way they took her car keys and stopped allowing her to drive. For the past 3 years she has helped out when the children come home from elementary school. She sits with them while they watch TV or do their homework. She helps out with dinner by cutting things up, setting the table, and mixing things together under the direction of her granddaughter-in-law.

Although she has lost the ability to converse, dress herself, and toilet herself, Ms. Nettie Mae has remained a part of the family. She is often honored at family occasions, as the matriarch. For example, at the church and community center events, when prizes are given away with doorway raffle tickets, several are always reserved and given to the elders in the room. The stories of days gone by that Ms. Nettie Mae has told for decades are now told by others on her behalf, while she sits and politely smiles. It is not clear that she follows or understands the stories, nor is it clear that she does not understand them. She smiles and laughs at the socially appropriate times.

As her disease progresses, she loses the ability to dress herself and toilet herself, causing increased physical stress on her caregivers. One day the granddaughter-in-law sees you for a back strain she got helping Ms. Nettie Mae off the commode. Seeing this stress, you encourage her family to visit assisted living and nursing home settings, to explore the possibility of placing her. The family politely and repeatedly declines the need for any assistance.

If you had a parent or grandparent who needed assistance at the level of Ms. Nettie Mae, what criteria would you use to determine whether you could maintain her in your home or whether you would begin to look for a long-term care facility? To what extent do these criteria reflect your culture and/or family of origin?

The dominant U.S. cultural definition of personhood in terms of independence and achievement leads to excess disability and suffering.

The dominant cultural approach to dementia in the United States reflects the cultural definition of an intact person as a person with value; the focus of achieving full personhood is on independence and achievement.18–21 In contrast, other cultures may value more highly such qualities as interdependence, spiritual connection, embodied activity, or social relationships and role.^22–25 In the above case, we see that Ms. Nettie Mae is still valued as a full person because she still is the family matriarch. The role as a surviving elder is honored as an embodiment of the community’s history and the community’s ability to survive in a fairly hostile environment (e.g., slavery, Jim Crow, Civil Rights struggles, ongoing structural and institutional racism in the contemporary United States). Finally, her personhood endures because she still is able to participate interpersonally and emotionally with family and community members. Indeed, we increasingly recognize that emotional and relational abilities persist far into the progression of Alzheimer’s disease and other dementias. Therefore, when personhood is defined as the ability to relate to others appropriately, dementia is less of a threat to the patient’s personhood. In contrast, by narrowly defining full personhood as independence and cognitive achievement, the dominant U.S. cultural approach to personhood leads to excess disability and suffering.²⁶

It is a valuable moment when a physician realizes what a truly odd subculture we belong to. In this respect, almost every clinical encounter is cross-cultural.

CASE 2 Ms. Nettie Mae (Part 2)

Ms. Nettie Mae has fallen, breaking her hip. Before the fracture she was not walking more than a few steps at a time, and it was not uncommon for family members to carry her about. When the orthopedist suggests that a reasonable option is to not do surgery, given her minimal preinjury ambulatory status, the family disagrees. The choice to not have surgical repair is not considered a real option. “Of course we want the surgery,” the grandson says. “Just like I would have it, if I broke that bone!”

Do you agree with Ms. Nettie Mae’s grandson? Why or why not?

Discussion

As already discussed, Ms. Nettie Mae is considered by the family to be a full person, just like everyone else in the community, with the same value as everyone else in the family/community. Her dementia and its increasingly significant deficits have not diminished her value and status as a full person.

Health care disparities

CASE 2 Ms. Nettie Mae (Part 3)

During her hospitalization, the family is quite concerned that Ms. Nettie Mae’s pain is not well controlled. They frequently complain that the nurse won’t bring enough medication and that she does not answer the call button soon enough.

Which do you feel is more likely: (a) that Ms. Nettie Mae is being treated differently from other patients, or (b) that these complaints reflect differential family expectations?

Disparities are a significant and persistent issue in our health care world. The evidence base documenting the pervasive reality of health care disparity is voluminous and spans every organ system and medical subspecialty.²⁷ For example, the undertreatment of pain in patients of color is well documented. Latinos with long bone fractures in a Los Angeles emergency department, for example, did not receive the same pain medication given to Caucasians with the same fractures.²⁸ A similar study in Atlanta confirmed that African Americans with long bone fractures received less pain medication than Caucasians.²⁹

Increasingly, we recognize that clinical thinking and decision making are influenced by clinical biases.30–33 When studies control for insurance, economic class, socioeconomic status, and education, a stubborn persistence of health care disparities remains, most strikingly along axes of race and ethnicity, but also along axes of gender and age.²⁷ Advanced cultural competency, by recognizing equity as essential to quality care, always seeks to address the complex processes that lead to health care disparities.