Transcript Module 1 - American Osteopathic Association

E
P
E
C
Osteopathic EPEC
Education for Osteopathic Physicians on End-of-Life Care
American
Osteopathic
Association
American
Osteopathic
Association
AOA:Treating
Treating
Our
Family
and
Yours
AOA:
Our
Family
and
Yours
E
P
E
C
Module 14
Cultural Diversity
Issues in End of Life
Care
Created by the American Osteopathic Association Councils on Minority Health
Issues and Palliative Care Issues for educational use.
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Advance Care Planning
Many factors play a role in patients’
preferences for EOL care:
•
Age/Nature of illness
•
Emotions of family/patient
•
Ethnicity
•
Religiosity
•
Gender
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Advance Care Planning
•
Socioeconomic Status/Education
•
Prior Experience with Illness and
Death of Others
•
Culture
Journal of Hospice and Palliative Nursing.2008;10(3) & AHRQ –Research
in Action, Issue 12 –Preferences for Care at the End of Life
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
. . . What Can We D.O.?
Research has shown that although many
patients would be willing to discuss EOL care
and planning, it is a topic often not brought
up by physicians. Only 5% of patients felt it
was too difficult a topic to discuss.
The physician must be the advocate for
the patient, especially in patients for whom
the health care system is a labyrinth.
Emanuel LL, Barry MJ, StoeckleJD, et al. Advance directives for medical care—
a case for greater use. N EnglJ Med1991;324(13):889-95
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Cultural Issues
Avoid stereotyping all patients of one
culture. Every person is an individual, and
each situation is different. Ask each patient
whether they wish to discuss advance
directives:
• Alone
• With family
• With other decision makers
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Cultural Issues
•
•
Do not use family members as
translators.
Respect the patient’s wishes, even if
different than your wishes or desires.
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Patients Who Discussed
EOL Care:
•
Had less fear and anxiety.
•
Felt they had more ability to influence
and direct their medical care.
•
Believed that their physicians had a
better understanding of their wishes.
•
Indicated a greater understanding and
comfort level than they had before the
discussion.
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Patients Who Discussed
EOL Care
SmuckerWD, Ditto PH, et al. Elderly outpatients respond favorably to a
physician-initiated advance directive discussion. J Am Board
FamPract1993;6(5):473-82.
Tierney WM, Dexter PR, et al. The effect of discussions about advance
directives on patients' satisfaction with primary care. J Gen Intern
Med2001;16:32-40
AHRQ Publication Number 03-0018
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Communicating Bad News
Each person is unique.
• Avoid biases based on previous
interactions with members of the same
culture.
In some cultures, discussing EOL or death
directly is taboo.
• Consider initiating discussions as
scenarios that may be affecting other
people.
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Communicating Bad News
•
Then judge the patient’s reaction and
proceed based on their willingness to
discuss the topic or response.
•
Monitor non-verbal cues as well.
•
Consider the patient’s willingness and
ability to receive news.
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Communicating Bad News
•
Ask the patient to confirm their
understanding.
•
Don’t assume that they have absorbed
the information.
CoulehanJ, Block M, The Medical Interview, Mastering Skills for Medical
Practice, 5 ed, ch14
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Talk to Your Patient
E:
Explanation - What do you think may be the
reason you have these symptoms?
What do friends, family, others say about these
symptoms?
Do you know anyone else who has had or who
has this kind of problem?
Have you heard about/read/seen it on
TV/radio/newspaper? (If the patient cannot offer
explanation, ask what most concerns them
about their problems).
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Talk to Your Patient
T:
Treatment - What kinds of medicines, home
remedies or other treatments have you tried for
this illness?
Is there anything you eat, drink, or do (or avoid)
on a regular basis to stay healthy?
Tell me about it. What kind of treatment are
you seeking from me?
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Talk to Your Patient
H: Healers - Have you sought any advice from
alternative/folk healers, friends or other people
(non-doctors) for help with your problems? Tell
me about it.
N: Negotiate - Negotiate options that will be
mutually acceptable to you and your patient and
that do not contradict, but rather incorporate
your patient's beliefs.
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Talk to Your Patient
Ask what are the most important results your
patient hopes to achieve from this intervention.
I:
Intervention - Determine an intervention with
your patient. It may include incorporation of
alternative treatments, spirituality, and healers
as well as other cultural practices. (e.g. foods
eaten or avoided in general, and when sick)
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Talk to Your Patient
C: Collaboration - Collaborate with the
patient, family members, other health
care team members, healers and
community resources.
Levin, S.J., Like, R.C., and Gottlieb, J.E. (2000) ETHNIC: A framework for
culturally competent clinical practice. In Appendix: Useful clinical
interviewing mnemonics. Patient Care, 34(9): 188-189
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Whole Patient Assessment
Includes Assessment of:
• disease history
• physical symptoms
• psychological symptoms
• decision decision-making capacity
• information sharing
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Whole Patient Assessment
• social circumstances
• spiritual needs
• practical needs
• anticipatory planning for death
Emanuel LL, von GuntenCF, Ferris FD. The Education for Physicians on End-oflife Care (EPEC) curriculum, 1999.
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Cultural Issues
Ask your patient:
•
What death means to them
•
Whether any unresolved issues exist
•
Whether any rituals are to be performed
•
Gather input from patient/ family/
decision maker, and respect the role of
each
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
LEARN
L Listen with sympathy and understanding
to the patient's perception of the
problem.
E
Explain your perceptions of the problem.
A
Acknowledge and discuss the differences
and similarities.
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
LEARN
R
Recommend treatment.
N
Negotiate agreement.
Berlin E.A. and Fowkes, W.C. Jr: A Teaching Framework for Cross-Cultural
Health Care, Western Journal of Medicine 1983, 139:934-938
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Pain Management
Cultural differences exist in treatment of
pain.
Minorities:
• report more pain
• increased severity of pain
• are more likely to be disabled from pain.
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Pain Management
Minorities with cancer pain are < likely to
receive treatment for their pain and have <
access to specialty care and opioids.
Wilner, A, Pain Management Across Cultures. 10/14/2008, Medscape Neurology
& Neurosurgery
Green CR, Ndao-BrumblaySK, West B, et al Differences in prescription opioid
analgesic availability: comparing minority and white pharmacies across
Michigan. J Pain.2005;6:689-699
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Pain Management
A: Acknowledge the need for treatment with the
patient, and ask about previous treatments
utilized. Together determine mutual goals and
desired outcomes.
D: Discuss potential treatment strategies and
options, as well as consequences of nontreatment with the patient (consider issues such
as treatment effectiveness, prognosis, use of
complementary/ alternative medicine, brand
name vs. generics, off label uses, prescription
plans, formularies, etc.).
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Pain Management
H: Handle any questions or concerns the
patient may have about treatment (e.g.,
fears or worries, side effects, costs,
dosage, frequency, timing , sequence,
duration of treatment, drug or food
interactions, proper storage techniques).
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Pain Management
E: Evaluate the patient s functional health
literacy and understanding of the
purpose/rationale for treatment, and
assess barriers and facilitators to
adherence ( e.g., environmental,
economic, occupational, and
sociocultural factors, family situation and
supports.
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Pain Management
R: Recommend treatment, and review the
therapeutic regimen with the patient.
E: Empower by eliciting the patient’s
commitment and willingness to followthrough with the therapeutic regimen.
The Provider’s Guide to Quality and Culture -Published in:
Soto-Greene, M., Salas-Lopez, D., et al, (2004) Antecedents to Effective
Treatment of Hypertension in Hispanic Populations. Clinical Cornerstone, 6(3):
30-36
American Osteopathic Association
AOA: Treating Our Family and Yours
E
P
E
C
Cultural Diversity Issues in
End of Life Care
Summary
American Osteopathic Association
AOA: Treating Our Family and Yours