Work around beliefs to solve treatment problems

Be flexible, keep the lines of communication open

To serve people of other cultures, you have to have the patience to keep the lines of communication open and know that you will have to work at accommodating their beliefs and values, says Claire Creech, CRC, CCM, CDMS, CLCP, senior case manager for the Center for Diagnostics and Evaluation at Shepherd Center in Atlanta. "As case managers, we are the ones who have to be flexible and do things differently. The family members have to adapt to the illness or injury, and we have to help them learn to do it in a context that is meaningful to them," Creech adds.

Creech has encountered families from a variety of cultures and worked to solve problems for badly injured patients. Here are some examples of how Creech worked with families from other cultures to help meet their medical needs and at the same time not violate cultural values: Only one Hispanic worker’s family ever was willing to discuss the option of care in a skilled nursing facility. The family of the worker, who was in a persistent vegetative state, wanted to get him back to Mexico but allowed him to stay in a nursing facility when they weren’t able to do so. "The care needs of these patients are very demanding, and many non-Hispanic families choose a skilled nursing facility. But the Hispanic families often choose to bring in female family members to provide care at home," Creech says.

A similar issue arose in the case of a brain-injured Korean man whose young adult daughters lived nearby. He was not comfortable with his daughters in a caregiving role because of cultural modesty. Instead, Creech arranged for his sister to move from Korea to Atlanta to assist in his care. "We had to solve the problem in a way that he could tolerate," Creech says.

Creech was working with a Native American brain injury patient who lived with his tribe on a reservation that was six hours from the nearest city. The family adamantly opposed the idea of moving to be near the medical care he needed. "Their heritage and their life was on that reservation with that tribe," Creech says. When she designed the life care plan for the patient, Creech built in the cost of transportation to the city for scheduled medical follow-up care.

Often when Hispanic patients were treated at Shepherd Center, the entire extended family came from Mexico to be at the bedside. "There is a belief that the family needs to always be vigilant," Creech says.

When large groups are in the room with a brain injury patient, the patient often is overstimulated and becomes anxious, Creech points out. In that case, she often calls a multigenerational family conference, sometimes with as many as 25 to 30 people. She explains what happens with brain injury patients and how they get overwhelmed when there is a lot of confusion. She suggests drawing up a schedule so one or two family members can be in the room for a while. "Sometimes it may take dropping in and pointing out that the patient is agitated, then suggesting that the family step out for a few minutes," she says.

In some Hispanic cultures, illness is seen as an imbalance between hot and cold in the body. Sometimes family members bring food to counteract the imbalance. "While I encourage and support that, I make sure it’s OK for the patient medically. For instance, there may be swallowing issues," she says.

Creech cautions other case managers to be aware that even though the wife is the legal next-of-kin, in some cultures, she may not be the formal decision-maker in the family. Often, it’s going to be the patient’s father or another male relative. "You have to work through confidentiality issues and have the decision-makers participate in the treatment and discharge planning," she says. "If I don’t take time to find out who is the decision-maker in the family and include [him or her], the discharge plans get wrecked pretty quickly."

Sometimes patients have beliefs in alternative health methods and want to have alternative healers present. This often creates a conflict between clinicians trained in Western medicine and the family. Creech recommends devising a way to honor family beliefs if it doesn’t harm the patient.