CULTURAL COMPETENCY IN END OF LIFE CARE IN THE ICU:WHAT STUDENTS LEARNED IN A PILOT CURRICULUM

Amy Chi, MD

Elisabeth E. Bennett, PhD

Rebecca D. Blanchard, PhD

Background Decisions about end of life (EOL) care are

complex and influenced by factors such as: Understanding prognosis, preferences in life-

prolonging treatment, family beliefs, patient-physician communication and culture

Navigating EOL care discussions can be challenging with families/patients of different cultures

Limited literature describing implementation and impact of a cultural competency curriculum in EOL care

Cultural Competency Pilot Curriculum in End of Life Care• Funding from Innovation in Diversity

Education Award (Tufts Medical School)• Implemented cultural competency in end of

life care curriculum from 2011-2012• Target: Medical Students during 4th year ICU

clerkship• Duration of curriculum: 4 weeks during ICU

clerkship/block• Total 69 students participated over ten blocks

– 32 completed the curriculum (including pre-/post-tests and observation form)

Observation Tool

Outcome Measures: Quantitative

Survey(n=32)

Pre-Post Testing

Physician Health Belief Attitude (15 items. 6 point Likert scale)

No Change

Knowledge Assessment (25 items)

No Change

Level of Comfort with Cultural Competency (5 point scale)

Improvement(pre 3.31 vs post 4.01, p<0.01)

Dobbie, 2002, Family Physicians Health Conference

Results: Qualitative AnalysisObservation Forms• Observations from reflection tools:

– All observations forms analyzed using general inductive methods, resulting in 3 categories

• Students learned that in navigating cultural competency:(1) Level of understanding influenced care

decisions(2) Conversations must balance information

and feelings(3) Balance between individual and family

dynamics is important (specifically conflicts and consensus)

(1) Level of understanding influenced care decisions “With the non-English speaking, wife at the

bedside day-in and day-out she was witness to much she did not understand. Inability to reach the HCP (patient’s daughter) on a regular basis meant that her main source of information on the patient’s status was via her mother’s interpretation of her husband’s care. This situation led to miscommunication and frustration on both sides with the patient stuck in the middle…I felt very frustrated that our ability to explain the patient’s condition to him and his wife was limited to the words of our interpreter.”

(2) Conversations must balance information and feelings

“The care providers did listen to the family’s suffering and understanding of what the patient’s illness was. The family did not seem to fully understand how ill he was, and how high the chances of brain death were.”

(3) Balance between individual & family dynamics Conflict: “There was conflict between

the two daughters involved in the care. One wanted all possible measures taken to ‘cure’ their father and help him live longer and the other wanted to let nature take its course when he was extubated…[The care team] realized the complicated family dynamics and were careful not to take sides but instead deal with the HCP.”

(3) Balance between individual & family dynamics Consensus: “The two sons were able to both

express their concerns and have their questions answered about their mother’s current situation. It was vital to hear where each of them were coming from in order to provide them with helpful information and guide the discussion. While one of the brothers [the HCP] seemed at peace with the decision to pursue hospice, the other was having a more difficult time accepting her prognosis…Finally, the HCP made the decision to pursue hospice, and he was able to convince his brother that it was the right decision.”

Conclusion:

Communication surrounding EOL care can be challenging

Witnessing family meetings allowed students a deeper understanding of the complexities of culturally competent care in the ICU

Family meetings are not simply conveying information, they must allow for an exchange for ideas and emotion, and manage complex individual and group dynamics

Questions? achi@tuftsmedicalcenter.org

Curriculum Outline:

Objectives: Integrate how culture influences end of life

decision making Improve knowledge and attitudes about how

culture influences end of life decision making Teaching Framework:

LEARN framework Components: Lecture, On-line modules,

Observation of family meeting, Reflection Tool, Small group debriefing

The LEARN ModelBerlin and Fowkes

Listen to the patient’s perception of the problem

Explain your perception of the problemAcknowledge and discuss

differences/similaritiesRecommend treatmentNegotiate treatment

Berlin EA et al. West J Med 1983: 139: 934 – 938. Helen Fernandez, MD, MPH