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Strategies for Culturally Effective End-of-Life Care

LaVera M. Crawley, MD; Patricia A. Marshall, PhD; Bernard Lo, MD; Barbara A. Koenig, PhD, End-of-Life Care Consensus Panel*
[+] Article, Author, and Disclosure Information

From Stanford University Center for Biomedical Ethics, Palo Alto, California; Loyola University of Chicago, Maywood, Illinois; and University of California, San Francisco, San Francisco, California.

*This paper was written by LaVera M. Crawley, MD; Patricia A. Marshall, PhD; Bernard Lo, MD; and Barbara A. Koenig, PhD, for the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) End-of-Life Care Consensus Panel. Members of the ACP-ASIM End-of-Life Care Consensus Panel were Bernard Lo, MD (Chair); Janet Abrahm, MD; Susan Block, MD; William Breitbart, MD; Ira R. Byock, MD; Kathy Faber-Langendoen, MD; Lloyd W. Kitchens Jr., MD; Paul Lanken, MD; Joanne Lynn, MD; Diane Meier, MD; Timothy E. Quill, MD; George Thibault, MD; and James Tulsky, MD. Primary staff to the Panel were Lois Snyder, JD (Project Director); Jason Karlawish, MD; and David Casarett, MD. This paper was reviewed and approved by the Ethics and Human Rights Committee, although it does not represent official College policy. Members of the Ethics and Human Rights Committee were Risa Lavizzo-Mourey, MD (Chair); Susan Dorr Goold, MD; Joanne Lynn, MD; David A. Fleming, MD; William E. Golden, MD; Jay A. Jacobson, MD; David W. Potts, MD; Daniel P. Sulmasy, OFM, MD, PhD; Vincent Herrin, MD; and Lee J. Dunn Jr., JD, LLM.

Acknowledgments: The authors thank the funding sources for generous support of their work in cultural diversity, end-of-life care, and strengthening the doctor–patient relationship. They also thank the members of the ACP–ASIM End-of-Life Care Consensus Panel and the Annals reviewers for thoughtful and highly valuable comments on multiple drafts of this manuscript.

Grant Support: By the American Foundation for AIDS Research (1772); The Greenwall Foundation; National Institutes of Health (R01 NR029060); Open Society Institute Project on Death in America; the Robert Wood Johnson Foundation; State of California Universitywide AIDS Research Program (R95-ST-188); the University of California, San Francisco, AIDS Clinical Research Center; and the Robert Wood Johnson Foundation Initiative on Strengthening the Doctor–Patient Relationship.

Requests for Single Reprints: Lois Snyder, JD, Center for Ethics and Professionalism, American College of Physicians–American Society of Internal Medicine, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, lsnyder@mail.acponline.org.

Current Author Addresses: Drs. Crawley and Koenig: Stanford University Center for Biomedical Ethics, 701 Welch Road, Suite 1105, Palo Alto, CA 94304.

Dr. Marshall: Medical Humanities Program, Loyola University of Chicago, 2160 South First Avenue, Maywood, IL 60025.

Dr. Lo: Program in Medical Ethics, University of California, San Francisco, Room C 126, 521 Parnassus Avenue, San Francisco, CA 94143-0903.

Ann Intern Med. 2002;136(9):673-679. doi:10.7326/0003-4819-136-9-200205070-00010
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As a result of profound worldwide demographic change, physicians will increasingly care for patients from cultural backgrounds other than their own. Differences in beliefs, values, and traditional health care practices are of particular relevance at the end of life. Health care providers and patients and families may not have shared understandings of the meaning of illness or death and may not agree on the best strategies to plan for the end of life or to alleviate pain and suffering. Good end-of-life care may be complicated by disagreements between physicians and patients, difficult interactions, or decisions the physician does not understand. Challenges may result from cultural differences between the patient's background and traditional medical practice. Values so ingrained in physicians as to be unquestioned may be alien to patients from different backgrounds. Physicians need to be sensitive to cultural differences and to develop the skills necessary to work with patients from diverse backgrounds.

Community and cultural ties provide a source of great comfort as patients and families prepare for death. This paper describes two cases that raise issues about cross-cultural end-of-life practice and suggests strategies for negotiating common problems. Physicians should assess the cultural background of each patient and inquire about values that may affect care at the end of life. They should become aware of the specific beliefs and practices of the populations they serve, always remembering to inquire whether an individual patient adheres to these cultural beliefs. Attention to cultural difference enables the physician to provide comprehensive and compassionate palliative care at the end of life.





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