Negotiating cross-cultural issues at the end of life: "You got to go where he lives".

Culture fundamentally shapes how individuals make meaning out of illness, suffering, and dying. With increasing diversity in the United States, encounters between patients and physicians of different backgrounds are becoming more common. Thus the risk for cross-cultural misunderstandings surrounding care at the end of life is also increasing. Studies have shown cultural differences in attitudes toward truth telling, life-prolonging technology, and decision-making styles at the end of life. Using 2 case studies of patients, one of an African American couple in the southern United States and the other of a Chinese-American family in Hawaii, we outline some of the major issues involved in cross-cultural care and indicate how the patient, family, and clinician can navigate among differing cultural beliefs, values, and practices. Skilled use of cross-cultural understanding and communication techniques increases the likelihood that both the process and outcomes of care are satisfactory for all involved.

Bioethics in a different tongue: the case of truth-telling.

After a survey of 800 seniors from four different ethnic groups showed that Korean-American and Mexican-American subjects were much less likely than their European-American and African-American counterparts to believe that a patient should be told the truth about the diagnosis and prognosis of a terminal illness, we undertook an ethnographic study to look more deeply at attitudes and experiences of these respondents. European-American and African-American respondents were more likely to view truth-telling as empowering, enabling the patient to make choices, while the Korean-American and Mexican-American respondents were more likely to see the truth-telling as cruel, and even harmful, to the patients. Further differences were noted in how the truth should be told and even in definitions of what constitutes "truth" and "telling." Clinical and bioethics professionals should be aware of how their cultural and economic backgrounds influence the way they perceive ethical dilemmas and remember to make room for the diverse views of the populations they serve.

Ethnicity and attitudes towards life sustaining technology.

The ethical and legal implications of decisions to withhold and withdraw life support have been widely debated. Making end-of-life decisions is never easy, and when the cultural background of doctor and patient differ, communication about these issues may become even more difficult. In this study, we examined the attitudes of people aged 65 and older from different ethnic groups toward foregoing life support. To this end, we conducted a survey of 200 respondents from each of four ethnic groups: European-American, African-American, Korean-American and Mexican-American (800 total), followed by in-depth ethnographic interviews with 80 respondents. European-Americans were the least likely to both accept and want life-support (p < 0.001). Mexican-Americans were generally more positive about the use of life-support and were more likely to personally want such treatments (p < 0.001). Ethnographic interviews revealed that this was due to their belief that life-support would not be suggested if a case was truly hopeless. Compared to European-Americans, Korean-Americans were very positive regarding life-support (RR = 6.7, p < 0.0001); however, they did not want such technology personally (RR = 1.2, p = 0.45). Ethnographic interviews revealed that the decision of life support would be made by their family. Compared to European-Americans, African-Americans felt that it was generally acceptable to withhold or withdraw life-support (RR = 1.6, p = 0.06), but were the most likely to want to be kept alive on life-support (RR = 2.1, p = 0.002). Ethnographic interviews documented a deep distrust towards the health care system and a fear that health care was based on one's ability to pay. We concluded that (a) ethnicity is strongly related to attitudes toward and personal wishes for the use of life support in the event of coma or terminal illness, and (b) this relationship was complex and in some cases, contradictory.

Traditional alternatives as complementary sciences: the case of Indo-Tibetan medicine.

Traditional medical systems, like those preserved in Asia, pose a challenge because they involve theories and practices that strike many conventionally trained physicians and researchers as incomprehensible, even nonsensical. Should modern medicine continue to dismiss these systems as unscientific, therefore worthy of debunking rather than serious study; view them as sources of alternatives, possibly effective but hidden in a matrix of prescientific custom and belief; or do they represent something like a complementary science of medicine? We make the latter argument using the example of Indo-Tibetan medicine. Indo-Tibetan medicine is based on analytic models and methods that are rationally defined, internally coherent, and make testable predictions, therefore meeting current definitions of "science." The possibility of multiple, complementary sciences is a consequence of certain findings in physics that have led to a view of science as a set of tools-instruments of social activity that depend on learned agreement in aims and methods-rather than as a monolith of absolute objective truth. Implications of this pluralistic view of science for medical research and practice are discussed.

A discourse of relationships in bioethics: patient autonomy and end-of-life decision making among elderly Korean Americans.

A two-year, multidisciplinary study (N = 800) was conducted on attitudes about end-of-life decision making among elderly individuals in four ethnic groups (African American, European American, Korean American, and Mexican American). On a quantitative survey, Korean Americans reported negative attitudes about the use of life-sustaining technology for themselves but positive attitudes about its use in general. This article reports on an interview with a 79-year-old typical Korean American respondent to explain the contradiction in the survey data. Expectations among elderly Korean Americans include protecting family members with a life-threatening illness from being informed of their diagnosis and prognosis, and doing everything to keep them alive. Two conclusions, one substantive and the other methodological, are drawn: First, the bioethics discourse on individual rights (patient autonomy) is insufficient to explain the preferences of many Korean Americans and must be supplemented with a discourse on relationships. Second, the rigorous use of qualitative, narrative methods clarifies quantitative data and should not be dismissed as "anecdotal."

Ethnicity and attitudes toward patient autonomy.

OBJECTIVE: To study differences in the attitudes of elderly subjects from different ethnic groups toward disclosure of the diagnosis and prognosis of a terminal illness and toward end-of-life decision making. DESIGN: Survey. SETTING: Thirty-one senior citizen centers within Los Angeles County, California. RESPONDENTS: A stratified quota sample of 200 subjects aged 65 years and older self-identified as being from each of four ethnic groups: European American, African American, Korean American, or Mexican American (N = 800). MAIN OUTCOME MEASURES AND RESULTS: Korean Americans (47%) and Mexican Americans (65%) were significantly less likely than European Americans (87%) and African Americans (88%) to believe that a patient should be told the diagnosis of metastatic cancer. Korean Americans (35%) and Mexican Americans (48%) were less likely than African Americans (63%) and European Americans (69%) to believe that a patient should be told of a terminal prognosis and less likely to believe that the patient should make decisions about the use of life-supporting technology (28% and 41% vs 60% and 65%). Instead, Korean Americans and Mexican Americans tended to believe that the family should make decisions about the use of life support. On stepwise multiple logistic regression, ethnicity was the primary factor related to attitudes toward truth telling and patient decision making. CONCLUSIONS: Korean-American and Mexican-American subjects were more likely to hold a family-centered model of medical decision making rather than the patient autonomy model favored by most of the African-American and European-American subjects. This finding suggests that physicians should ask their patients if they wish to receive information and make decisions or if they prefer that their families handle such matters.

Low survival rate after cardiopulmonary resuscitation in a county hospital.

BACKGROUND: The standard of practice in hospitals in the United States is to perform cardiopulmonary resuscitation on all patients who suffer a cardiac arrest unless a specific order has been written to the contrary. In recent decades, however, data showing a low rate of survival to discharge under certain conditions have accumulated, leading some to question this policy. The objective of this study was to examine variables predictive of patient survival following cardiopulmonary resuscitation using standardized methods of measuring severity of illness. METHODS: All patients were identified who underwent cardiopulmonary resuscitation on the medicine service at Los Angeles County (California) Hospital from August 15, 1990, to February 15, 1991. Severity of illness was evaluated by examining diagnosis, Acute Physiology and Chronic Health Evaluation II score, and organ system failure. Cases were followed up prospectively until death or hospital discharge, and data concerning post-arrest mental status, utilization of resources, and disposition were gathered. RESULTS: Of the 131 patients identified, 22 patients (16.8%) survived for 24 hours but died before discharge; only four patients (3.1%) survived to discharge. CONCLUSIONS: This study suggests that in some settings (eg, institutions that are for sick patients under conditions where monitoring is limited because of scarcity of resources), survival after full cardiopulmonary arrest may be even lower than previously documented.

Discussions regarding aggressive care with critically ill patients.

Protocols concerning orders not to resuscitate have come into existence recently in order to facilitate decisions regarding resuscitation and to ensure that patient's rights to participate in such decisions are preserved. Prior to the do-not-resuscitate (DNR) decision is the decision whether to discuss the issue of resuscitation with the patient at all. To determine how frequently physicians discuss this issue with their patients, the authors gathered information on all 611 patients admitted to the medical intensive care unit (MICU) or the cardiac care unit (CCU) at a tertiary care teaching hospital over a nine-month period. They found that the issue was discussed with only 10.8% of patients or their families on admission of the patients to these units. Such discussions occurred more frequently with older patients, those who were more severely ill or were estimated to have worse prognoses, those with poor intellectual function, and those admitted to the MICU rather than the CCU.