The Influence Of Cultural Diversity On Medical, Legal And Financial Decision-Making

Published in Families of Loved Ones (FOLO magazine)

By Stephanie L. Schneider

Health care professionals and elder law attorneys provide information to caregivers and people with disabilities regarding long term care planning, options and advance directives. It is important to communicate and understand different cultural beliefs and practices in the medical decision-making process for all parties involved. This article explains different cultural approaches toward medical decision-making and suggests how we all can raise our awareness and improve the communications process.

Culture plays a significant role in the way in which an individual approaches care planning and end-of-life choices. The U.S. is a melting pot of many cultures, religions and races, with more than 300 languages spoken. While some of the older generation were not born in this country but immigrated here, other individuals may be the first or later generation born in this country. Subsequent generations may or may not adopt what some consider a Western attitude of ‘individualism’ and ‘autonomy’.

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The Patient Self Determination Act PSDA* (see box at right) was intended to promote education of surrogate decision making and end-of-life care as well as the principle of self-determination. There are inherent assumptions that may act as a barrier to the PSDA being useful for some ethnic groups.

* Patient Self-Determination Act (PSDA)

On November 5, 1990, Congress passed this measure as an amendment to the Omnibus Budget Reconciliation Act of 1990. It became effective on December 1, 1991. The PSDA requires many Medicare and Medicaid providers (hospitals, nursing homes, hospice programs, home health agencies, and HMO’s) to give adult individuals, at the time of inpatient admission or enrollment, certain information about their rights under state laws governing advance directives, including: (1) the right to participate in and direct their own health care decisions; (2) the right to accept or refuse medical or surgical treatment; (3) the right to prepare an advance directive; (4) information on the provider’s policies that govern the utilization of these rights. The act also prohibits institutions from discriminating against a patient who does not have an advance directive. The PSDA further requires institutions to document patient information and provide ongoing community education on advance directives.

FOR EXAMPLE, THE PSDA:

• Promotes written advance directives and assumes all Americans can read and write.
• Presumes that people will trust the medial profession and that every reasonable effort to preserve life is desired before “the plug is pulled.”
• Assumes that every culture has an autonomous approach to medical decision-making as opposed to family, group decision-making, or community decisions via spiritual leaders or others.

By being aware of these inherent assumptions and not expecting that all individuals hold the same values and belief systems, we can assist people to make medical decisions that best serve them.

ASIAN CULTURE

Traditional Asian culture values the group (family and society) ideals over the individual. For example, ‘courtesy’ and ‘thoughtfulness’ are highly valued in the Japanese culture. A suggested approach for providing legal & medical counseling is to be respectful, thoughtful, and empathetic but not direct or blunt.

If the traditional hierarchy is maintained in a Japanese family, the husband fulfills the role as the decision-maker. The alternate decision-maker is the eldest son who would attempt to make a decision that is compatible with the wife’s preferences.

A traditional family will not openly discuss or argue in front of a physician because this would be seen as shameful and reflect negatively on the family name.

The degree of acculturation** will determine the extent to which an open discussion on death and dying can take place. An elder may defer completely to the children to make a decision. The view called “ShiKata ga nai” may be observed when a person has a terminal illness. It means “it can not be helped.” This approach removes blame, responsibility or failure from the ill person and embodies acceptance of the illness. Japanese families are likely to pursue traditional remedies while simultaneously receiving Western medical treatment.

AFRICAN-AMERICAN CULTURE

Studies show that there is a preference for life-sustaining treatment despite the state of the disease and the educational level of the patient. Key concepts about end of life, medical care preferences and decision-making were observed:

• Not wanting to be a burden and death as an avoided issue
• Need for hope and faith
• Fear of pain and suffering
• Skeptical of the health care system; wanting to stay at home
• Need for resources i.e. information on finances, access to care, family and extended family and community support

HISPANIC CULTURE

The Hispanic culture values the importance of family and the expectation that family members will care for each other. Like African Americans, there is a preference for life-sustaining treatment. Studies indicate that Mexican-Americans are more likely to hold a family-centered model of medical decision making. This finding suggests that professionals should ask the person if they wish to receive information and make decisions or, if they prefer that their families handle such matters.

One study looked at ethnicity and care of people with dementia. They studied female Caucasian and Latino care-givers. Non Hispanic white care-givers placed their relatives with dementia in an institution sooner than Hispanic care-givers. Latinos reported greater benefits and a more positive outlook toward care-giving.

These observations may indicate that Hispanics who have not fully assimilated may not reach out for services available in the community. It may take a lot of time and encouragement to help them overcome their feelings of isolation, both culturally and emotionally, before they are comfortable seeking help.

BUDDHISM AND THAI CULTURE

Buddhists believe in the interdependence of all phenomena and a correlation between mutually conditioning causes and effects. The mind and body are viewed as interdependent and life is not limited to a single existence on earth but goes beyond space and time. Buddhism has a belief called “karma” that is the correlation between a deed/action and its subsequent consequences. Nothing is completely predetermined so there is always the opportunity to fulfill and complete the karma and thereby end one’s suffering.

A Buddhist takes a holistic view toward health as an outward manifestation of the balance (harmony) or imbalance that exists within and the world around them. Buddhism promotes taking personal responsibility for one’s health by bringing one’s actions and words into alignment; health may be gained by good efforts.

Being aware of the Buddhist practice of compassion and forgiveness can assist us by practicing compassion toward the individual who is ill. Compassion comes in many forms: setting aside adequate time to serve a patient’s mental as well as physical needs; doing what is within one’s power to relieve suffering.

**Acculturation-The degree to which a person and their family maintain the traditional beliefs of the ethnic group.

Stephanie L. Schneider is a Board Certified Elder Law Attorney practicing in Fort Lauderdale, Florida. She can be contacted at 954-382-1997 or www.fl-elderlaw.com.