Towards Cultural Competency in End-of-Life Communication Training

Abstract

To meet the needs of a more diverse population, a culturally sensitive approach to end-of-life communication is critical. This paper describes a unique communication workshop that introduces future physicians to the delivery of culturally responsive care for patients in palliative and end-of-life treatment. The workshop is embedded within the required fourth year medical student rotation in Geriatrics and Palliative Care. Using case-vignettes, role playing, and small group discussions, content areas include: breaking bad news, discussing advanced directives, and decisions regarding withdrawal or withholding of treatment. Post workshop student evaluations reveal an overwhelmingly favorable response to the curriculum, with high scores for overall quality of the workshop, practical value, and appropriateness for level of training. This workshop meets the goal for all graduating medical students to engage in culturally competent palliative and end of life patient care.

Background

In an increasingly diverse society, a culturally sensitive, patient-centered approach to end-of-life communication is critical. According to the US Census, only 65% of the US population was non-Hispanic White in 2010, and that proportion is expected to decrease to 46% by 2050. Due to its unique history, Hawai‘i's non-Hispanic White population has been small, and about 70% of Hawai‘i residents are of Asian and/or Pacific Islander (API) heritage. The API group is itself diverse, including more than 30 distinct ethno-cultural groups from the Asia-Pacific region.¹

Ethnic heritage is just one factor that influences health behaviors. Others include cultural norms, socioeconomic status, generational influences, and community of residence. Physicians need to understand how these factors influence health care seeking practices, medical decision making, and ultimately health outcomes. This constitutes the general premise driving the delivery of culturally competent health care.

In 2009, the Joint Commission on Accreditation for Health Organizations (JCAHO)² adopted standards for patient-centered care, requiring the training of all staff in the area of cultural sensitivity. The US Department of Health and Human Services, Office of Minority Health, developed national standards called “Culturally and Linguistically Appropriate Services” (CLAS, 2009), which proposed integrating cultural competency training at all levels of health professional education.³

These standards mandate that health care providers be trained to recognize and respect patients' cultural beliefs and practices. Thus, training often contains information on historical events and cultural values that have shaped groups of immigrant Americans. However, even though historical patterns and shared values have been described in books and other scholarly literature, providers are cautioned not to generalize these descriptions to all members of an ethnic group. Generalizations and stereotyping are not acceptable and can be detrimental to the establishment of therapeutic relationships.⁴

US health care policy further underscores the need for cultural understanding with the 1990 Congressional enactment of the Patient Self Determination Act, which advocates discussion of advanced directives and end-of-life decision making with patients. These practices may cause conflict between physicians and patients/families with culturally specific beliefs about death and terminal medical conditions. Physicians must learn to balance the assumptions of Western medicine regarding medical decision making, which include autonomy and championing individualism, with cultures that view collectivism (family centeredness) as a core principle for major decision making.⁵ Revelation of medical futility may directly affront certain ethnic groups who perceive beneficence as a physician's responsibility to extend life at all costs.⁵ Additionally, the interpretation of non-maleficence (do no harm) may have different cultural interpretations regarding revealing a terminal condition or the use of morphine or other comfort measures. Observational studies about cultural influences reveal the commonly held belief in the power of negative words, so that after words are spoken, they become reality or are harmful to the patient.⁴

Physicians need to know how to truly assess the beliefs and needs of individual patients. Thus, sensitivity training should take a crosscultural approach, focusing on culturally humble communication skills to recognize and respect individual variability. Learning to take a patient-centered approach is more valuable than just learning “facts” about an ethnic group. The patient-centered approach is more effective than using cultural stereotypes, whether discussing common medical conditions or more complex problems such as end-of-life preferences.⁶

The purpose of this paper is to describe a communication workshop developed and tested at the University of Hawai‘i John A. Burns School of Medicine, Department of Geriatric Medicine, that helps prepare future physicians to use a culturally sensitive approach to palliative and end-of-life patient-centered care.

Description of Curriculum

This communication workshop is part of the required fourth year medical student rotation in Geriatrics and Palliative Care at the John A. Burns School of Medicine. During this rotation, students are instructed to view the faculty as role models of expert communication and become active listeners for “words that work.” Students also attend weekly seminars that teach core geriatric principles, and incorporate the skills and attitudes requisite in the delivery of patient-centered care. In addition, they write a journal entry to refl ect on their development as a physician. This exercise is intended to promote humility, empathy, curiosity, sensitivity, and awareness towards their patients. Recognizing that communication skills are critical in the care of frail and complex patients, seminars were modified in the academic year 2010–11 to be more interactive and case-based than in previous years. This has expanded opportunities for role play and discussion, which allows students to apply core concepts and practice communication skills.

Embedded within the rotation is an interactive 3-session workshop, with faculty coaching students with role playing and providing feedback on key skills for end-of-life discussions. The workshop is divided into three one-hour sessions: (1) breaking bad news, (2) discussing advanced directives, and (3) discussing withdrawal or withholding of treatment.

Session 1 focuses on breaking bad news. This session begins with an overview of techniques and teaching points on strategies about breaking bad news, followed by a discussion of teaching points regarding communication strategies in a culturally sensitive manner. The problem-based learning case involves a Chinese-speaking widow and her eldest son, who are waiting in the Emergency Room and need to be told about the progression of her cancer. The main teaching points include the appropriate use of medical interpreters, and clarifying who the decision makers are given cultural norms and expectations.⁷ After rules for feedback are reviewed, the students are divided into groups of four. Each person in the group is assigned a role (patient, son, physician, and observer) and given a script. The observer's role is to write down specific observations for feedback. The session concludes with debriefing in the large group, providing feedback and helpful tips.

Session 2continues with the same patient and family in the previous scenario, but moves the discussion forward to discuss goals of care and advanced directives. The session starts off by explaining to the students that cultural factors often govern medical decision making. Students are taught the importance of investing time early in the encounter in order to understand the patient and family perspectives regarding the social, emotional, relational, and cultural factors that may influence their decisions. The main teaching point emphasizes that while it is important to understand and take cultural norms into consideration, one must not make any assumptions regarding cultural expectations, and it is important to listen carefully to each particular patient/family scenario. Finally, the Physician Orders for Life-Sustaining Treatment (POLST) form is introduced, and students are provided suggestions and examples that may help them discuss advanced directives and correctly complete the form. As in the previous session, the class breaks into groups of four, with each student choosing a role (patient, son, physician, and observer) and using a prepared script. The observer records comments, and the session concludes with time to debrief as a whole group, providing feedback and helpful tips for improving communication skills.

Session 3 addresses the withdrawal of invasive treatments. This session begins with a discussion regarding assessing capacity for medical decision making, and the role of health care surrogates (designated or non-designated), the hierarchy of decision making, and understanding the definition of futility of treatment. The case involves discussing the withdrawal of artificial nutrition and mechanical ventilation in a terminal cancer patient with multi-system organ failure, whose family has expressed their specific cultural and religious beliefs, and whose husband is an attorney. The main teaching points include students' awareness that ethnic minority populations may feel discriminated against and may require careful attention to these sensitivities. It is also important to understand how a family may embrace “hope” from their cultural and religious perspectives, in order to help the patient and family develop more realistic goals of care (ie, from “hope for cure” to “hope for a peaceful and dignifi ed death”). Next the class engages in role play which includes the physician, the husband, and observer. Students practice presenting realistic options to the family and help them come to acceptance of the poor prognosis in the context of culturally sensitive issues. The observer documents the interactions, and the session concludes with a time to debrief as a whole group, providing feedback and helpful tips.

Program Evaluation

At the conclusion of the Palliative Care communication workshops, trainees completed a mandatory seminar evaluation. The results of this survey from the first 5 months (N=36) of curriculum implementation reveals an overwhelmingly favorable response to the curriculum. Using a Likert scale (1= poor to 5=excellent), the average rating of the overall quality of the seminar was 4.6, content of practical value 4.6, and content appropriate for level of training 4.6. Comments from students included the following statements: “very helpful”; “role playing was very helpful, provided a safe learning environment”; “great topics”; “engaging and informative.” Faculty feedback was also positive, and included suggestions of providing additional resources to medical students.

Discussion

The curriculum meets the current goals and standards of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO),² the Liaison Committee of Medical Education (LCME)⁸ and Accreditation Council for Graduate Medical Education (ACGME),⁹ with the latter two having established core competencies in communication and professionalism for working with increasingly diverse patient populations.

In the authors' review of the literature, while many academic medical institutions have recognized the need for cultural competency training, with successful integration into the first two years of their curriculum, the incorporation and application of such training during the clinical clerkship years is rare.^10,11

The curriculum incorporates the recommendations regarding training in cultural competence using an approach that fosters cultural sensitivity and humility. Frequently, medical schools apply “categorical” teaching methods about race and ethnicity, providing information on common practices and beliefs of distinct cultural groups, eg, Asians, Hispanics, or African Americans. However, this factual knowledge is not adequate, and may ultimately result in delivery of disparate health care unless individual preferences are taken into account. Thus the new standard of cultural competence education is that training should focus on cultural sensitivity and humility in patient communication.^12–14

This newly designed curriculum also utilizes strategies found to be most effective for teaching regarding communication and end-of-life care. Improving communication skills among medical students should exceed the measurement of knowledge and attitudes, and move towards the behavioral assessment of end-of-life communication skills.¹⁵ The Institute of Medicine (IOM) has called for practical case-based curricula to be continually developed and evaluated, and focused on process oriented instruction in medical interviewing and communication. The use of case vignettes, roleplaying in small groups, and the opportunity to practice skills and time to debrief are strategies found to be effective in the training of communication skills in end-of-life care.^16,17

This is the first such curriculum described in the literature that explicitly teaches about both culturally sensitivity and effective communication techniques for advance care planning and end-oflife discussions during their clinical clerkships.

Future Directions

The feedback obtained from the initial sessions from both faculty and students will promote increased opportunities for developing culturally appropriate communication tools and skills. Specifically, future sessions will incorporate the use of video vignettes to facilitate discussion regarding the delivery of bad news. Checklists to provide structured feedback to participants and to target desired behaviors during communication exercises are being developed. This curriculum will undergo annual evaluation with modifications based on cumulative workshop feedback. Additionally, outcomes research is planned to compare pre/post curriculum implementation effect on Palliative Care communication skills, using the required Palliative Observed Structured Clinical Exams (OSCE) scores. The goal is for all graduating medical students to be able to provide culturally competent health care to all patient populations, especially those most vulnerable at the end of life.