Table 1.

Real Cases of Seriously Ill Vietnamese Americans That Illustrate Cultural Beliefs and Behaviors

Learning Points	Care Description
Older Vietnamese may strongly believe in native healing practices. Their beliefs may be in conflict with highly educated younger generations.	H.T. was a 55-year-old Vietnamese woman who immigrated to the U.S. in the 1980s. She had a history of stage IV non–small cell lung cancer and history of venous thromboembolic events on full-dose anticoagulation who presented to the hospital with left-sided weakness and fatigue and had an MRI of the brain that showed extensive bilateral acute infarcts with high-grade occlusion of the proximal right middle cerebral artery. The prognosis was estimated at hours. There was disagreement between the husband and the two adult children over how end-of-life care would proceed. The husband wanted to pursue indigenous therapies, whereas the children wished to have a second opinion at another academic institution. A Vietnamese interpreter who was also a cultural leader was eventually engaged. After multiple family meetings that also included religious and community leaders, it was decided to initiate terminal care in the hospital. When the patient did not pass immediately and the team stated that the anticipated prognosis was in the range of days to week, the husband stated that he wished to bring his wife home. Hospice services in conjunction with a local Vietnamese advocacy group helped arrange care services for the home. The patient was discharged home and died two weeks later.
The patient’s culture can greatly impact the clinical manifestation of their illness(es).	P.N. was a 60-year-old single Vietnamese man with history of hepatitis B and associated cirrhosis with typical complications of end-stage liver disease. He presented to the hospital with severe abdominal pain different from his usual pain associated with tense ascites. CT scan of the abdomen revealed a large necrotic liver mass suspected of being hepatocellular carcinoma. There was also concern that the mass was also bleeding, which resulted in multiple packed red blood cell transfusions. Although the patient was in severe pain, he refused pain medications. Despite multiple meetings during which the care team engaged a Vietnamese interpreter and attempted to convey that the patient was seriously ill with a limited life span, the patient continued to escalate his demands for life-prolonging medical treatments. A palliative care consult was eventually initiated to assist with psychosocial support and symptom management. A junior member of the palliative care team spent time exploring the patient’s life experiences instead of focusing on any medical issues. The clinician discovered a rich history about the patient’s service in the Vietnam War and identified that the patient’s symptoms were likely due to post-traumatic stress disorder. A Vietnamese social worker, who practiced approximately 50 miles from the institution, was recruited to assist the team in exploring the patient’s past. Utilizing telehealth video technology, multiple meetings were held to give the patient an opportunity to do legacy work. After a week, the patient agreed to be transferred to an Asian centric subacute facility with local hospice support. He died a few days later.
Whereas many patients may long for their homeland of origin, others may not.	C.B. was an 82-year-old Vietnamese man who was brought to the emergency department for evaluation of weakness, weight loss, and bloody urine. He lived in an assisted living facility and was largely self-sufficient requiring only minor supervision. His granddaughter who lived locally would visit him weekly and bring him his favorite traditional foods. During the hospitalization, he became septic and required admission to the intensive care unit. Given the lack of significant clinical progress, the palliative care team was consulted to help define the patient’s goals of care. The granddaughter informed the palliative care team that in Vietnam, her grandfather had been famous for fortune telling and had always been an entertainer in social contexts. She explained that her grandfather’s vibrant personality and love of life would not allow him to accept a quality of life that did not include the ability to interact with other people. He had also served in the Vietnam War as an officer and first settled in Texas before eventually moving to California. Given negative experiences that the patient had in Vietnam, the granddaughter shared that her grandfather had instructed her to keep his body in the U.S. as he had vowed never to go back to Vietnam. He also hoped that he would be reborn as an American in his next life. The granddaughter consulted her mother who was living in Australia and together they decided not to escalate care. He eventually died in the hospital.
For some families the preferred place of death may be the hospital.	S.N. was a Vietnamese American man who was born in the U.S. to immigrants who fled after the Vietnam War. He suffered from advanced renal disease, which was originally diagnosed as a young child and depended heavily on his family for support and care. By 31 years of age, he had spent many years on dialysis and had exhausted most of his options for hemodialysis access because of multiple graft infections. When he was admitted to the hospital, he was found to be in heart failure due to a large vegetation on his mitral valve but was deemed not to be an operative candidate. The family was devoted and drove several hours each day to visit him, believing that if they waited long enough, he would get better. Over time, he accepted his prognosis and unilaterally decided his quality of life was very poor and that he wanted to go home to die. As one of his last wishes, he also wanted very much to visit his paternal grandmother before he died to pay his respects. His sister was willing to support his choice and provide primary caregiving for him in the home, but his brother and stepfather would not give permission. After multiple family meetings and extensive discussion, the family conflict could not be resolved and they informed the team that the patient had changed his mind and that he now wanted to die in the hospital. The patient became withdrawn and disengaged emotionally from the care team and died the following day.