Cultural Diversity at the End of Life: Issues and Guidelines for Family Physicians - American Family Physician

See page 409 for strength-ofrecommendation labels. E thnic minorities compose an increasingly large proportion of the population of the United States. In the 2000 census, about 65 percent of the U.S. population identified themselves as white, with the remaining percentage representing the following ethnic groups: black (13 percent); Hispanic (13 percent); Asian-Pacific Islander (4.5 percent); and American-Indian/ Alaskan native (1.5 percent). About 2.5 percent of the population identify themselves as bi-ethnic, and this figure is likely to continue to grow.1 The challenge for family physicians in an increasingly diverse society is to learn how cultural factors influence patients’ responses to medical issues such as healing and suffering, as well as the physician-patient relationship. The American Academy of Family Physicians (AAFP) has published cultural proficiency guidelines2 and policy and advocacy statements about diversity in AAFP educational activities.3 In addition, sensitivity to cultural diversity is integrated within the AAFP’s policy statement on ethical principles for end-of-life care.4 Specifically, principle 5 states: “Care at the end of life should recognize, assess, and address the psychological, social, spiritual/religious issues, and cultural taboos realizing that different cultures may require significantly different approaches.” Although cultural proficiency guidelines exist,5 few resources are available to family physicians regarding ways to apply these guidelines to direct patient care. Many physicians are unfamiliar with common cultural variations regarding physician-patient communication, medical decision making, and attitudes about formal documents such as code status guidelines and advance directives. End-of-life discussions are particularly challenging because of their emotional and interpersonal intensity. Physicians also are challenged by the tremendous diversity within specific ethnic minority groups (Table 1).6,7 In fact, research suggests that when compared with whites of European descent, ethnic minorities exhibit greater variability in their preferences.8 ThereEthnic minorities currently compose approximately one third of the population of the United States. The U.S. model of health care, which values autonomy in medical decision making, is not easily applied to members of some racial or ethnic groups. Cultural factors strongly influence patients’ reactions to serious illness and decisions about end-of-life care. Research has identified three basic dimensions in end-of-life treatment that vary culturally: communication of “bad news”; locus of decision making; and attitudes toward advance directives and end-of-life care. In contrast to the emphasis on “truth telling” in the United States, it is not uncommon for health care professionals outside the United States to conceal serious diagnoses from patients, because disclosure of serious illness may be viewed as disrespectful, impolite, or even harmful to the patient. Similarly, with regard to decision making, the U.S. emphasis on patient autonomy may contrast with preferences for more family-based, physician-based, or shared physicianand family-based decision making among some cultures. Finally, survey data suggest lower rates of advance directive completion among patients of specific ethnic backgrounds, which may reflect distrust of the U.S. health care system, current health care disparities, cultural perspectives on death and suffering, and family dynamics. By paying attention to the patient’s values, spirituality, and relationship dynamics, the family physician can elicit and follow cultural preferences. (Am Fam Physician 2005;71:515-22. Copyright© 2005 American Academy of Family Physicians.) Cultural Diversity at the End of Life: Issues and Guidelines for Family Physicians