End-of-life communication hard for discharge planners

Tailor discharge planning around cultural beliefs

Medical City Dallas Hospital staff tailor their discharge planning and education around the patient and family’s cultural beliefs, particularly when end-of-life issues are involved. The hospital treats a significant number of Hispanic patients along with increasing numbers of Asian and Russian patients, reports Pat Wilson, RN, BSN, manager of case management. "The strongest and hardest obstacle we have to overcome with our patients from diverse cultures is death and dying," Wilson says.

For instance, many Hispanic families reject hospice care for terminally ill patients because they feel as though it is giving up, she notes. "In these cases, we work more toward teaching the family how to care for those going home with an end-of-life disease. The physicians and other staff are very careful with their wording so the hospital can provide the palliative care the patient needs without creating the impression that it’s hospice care," she says.

Most Hispanic patients have very strong family ties and have caregivers at home who are willing and able to do whatever is necessary to provide care for the patient, rather than hiring someone else to provide care or considering a skilled nursing facility, she adds.

When this is the case, a lot of time is spent educating family members about how to care for the patient at home, the medications they need, and when they should receive it. The hospital works closely with home care agencies that have Hispanic caregivers so the patient and family will feel comfortable with at-home care.

The hospital staff have learned to pick up cues from family members about the direction they should take in caring for the family members. When they are assigned a patient from another culture, the staff identify a family member who is the spokesperson and, with the help of an interpreter, gives that person the discharge instructions. The staff typically use both a medical translator and a family member to make sure what they are saying is being translated correctly. They ask the family member translator to repeat what he or she understood.

"The staff does an excellent job of identifying a person in the family who can be the spokesperson and can help us understand the cultural beliefs and how to address them," Wilson points out.

For instance, many elderly patients have grandchildren who have become Americanized and are a great resource for helping the case managers understand what medical care is like in the family’s country of origin as well as its cultural practices and beliefs surrounding health care.

Enlist help from family and friends

Staff enlist the aid of the grandchild to compare what would be happening if the patient were in their native country with what is going on in the hospital. "We discuss what our traditional treatment plan is here and ask them to help us determine what will work best for the grandparent. We want to incorporate the family’s cultural beliefs whenever possible, as long as it isn’t anything that will interfere with healing," Wilson says.

When staff members have trouble accepting that their patients’ cultural beliefs don’t allow certain medical procedures that are routine in western medicine, Wilson and other department heads refer them to the hospital’s ethics committee to help them work through the issues. "[The hospital staff] may think the treatment that has been proposed will be beneficial to the patient. If the family says they don’t want the treatment and the staff truly believes it is beneficial, that’s an ethical conflict between the health care worker and the family," she says.

The ethics committee does not make any decisions in these cases, but can help the health care workers resolve the issues for themselves, Wilson points out.

Staff at Medical City Dallas attend annual diversity seminars designed to help them understand the cultural beliefs and practices of the hospital’s diverse patient population. The hospital’s diversity program gives staff basic information about patients from other cultures, tips on contacting appropriate health lines and community organizations, and instruction on how to use the translator line. "We give our staff a good overall view of the cultures we see in our hospital, their values, beliefs, and practices, and how we can respect them and provide the best treatment for our patients," Wilson says.

The hospital has translated its discharge instructions and other pertinent documents into Spanish. The hospital maintains a list of bilingual staff members who can be called on to help the rest of the staff build bridges with the patients. For instance, one case manager is from Iran and speaks Farsi. There are several Spanish-speaking social workers who are called by their co-workers and other people in the hospital to translate.

"When we’re talking about the Asian community, it’s harder to find staff who can communicate with them. We do have some physicians who speak Chinese, or Vietnamese, or Korean, but we also tend to use the translator line," she says.

The hospital established a mentoring program that pairs new hires with nurses from their same country who acts as a mentor. "It not only gives them a bond with someone who shares their background, but it gives them a mentor to help them learn about the hospital. It’s one of the best things we’ve done to acknowledge and respect different cultures and to recognize that there is a difference and that we need them," she says.


For more information about tailoring end-of-life care or issues for different cultures, contact: