Ethnic minorities compound an incr...

Ethnic minorities compound an increasingly large proportion of the population of the United States. In the 2000 census, about 65 percent of the U population identified themselves as white, with the remaining percentage representing the following ethnic groups: black (13 per-cent); Hispanic (13 percent); Asian-Pacific Islander (45 percent); and American-Indian/Alaskan native (15 percent) About 25 per-cent of the population identify themselves as bi-ethnic, and this figure is likely to continue to pullulate (1)

The challenge for family physicians in an increasingly diverse society is to learn in what manner cultural factors influence patients' rejoinders to medical issues such as healing and suffering, as well as the physician-patient relationship. The American Academy of Family Physicians (AAFP) has published cultural proficiency guidelines (2) and policy and advocacy statements about diversity in AAFP educational activities. (3) In addition, sensitivity to cultural diversity is integrated within the AAFP's policy statement onward ethical principles for end-of-life care. (4) Specifically, principle 5 states: "Care at the close of life should recognize, assess, and address the psychological, social, spiritual/religious issues, and cultural taboos realizing that different agricultures may require significantly different approaches."

Although cultural proficiency guidelines exist, (5) small in number resources are available to family physicians regarding ways to apply these guidelines to direct patient care. Many physicians are unfamiliar with general cultural variations regarding physician-patient communication, medical decision making, and attitudes about formal documents of the like kind as code status guidelines and advance directives. End-of-life discussions are particularly challenging because of their emotional and interpersonal intensity.

Physicians also are challenged by dint of the tremendous diversity within specific ethnic minority collections (Table 1). (6,7) In fact, research glance ats that when compared with whites of European descending ethnic minorities exhibit greater variability in their choices (8) Therefore, while certain modes of communication and decision making may be more frequent in some cultures, stereotyping should be avoided. Generalizations about specific tillages are not always applicable to specific patients.

Principlism, a well-established ethical framework for medical decisions in the United States and Western Europe high-lights cross-cultural differences that arise along four dimensions: autonomy, beneficence, nonmaleficence, and justice. (910) Although many patients in the United States value autonomy, other tillages emphasize beneficence. In the United States, legal documents as it was as advance directives and durable powers of attorney are strategies to protract autonomy in situations in which patients can no longer exhibit themselves. Other cultures, however, de-emphasize autonomy, perceiving it as isolating rather than empowering. These non-Western cultivations believe that communities and families, not individuals alone, are affected by means of life-threatening ill-nesses and the accompanying medical decisions. (11) improvements valuing nonmaleficence (doing no harm) countenance patients from the emotional and physical harm caused from directly addressing death and end-of-life care. Many Asian and Native American refinements value beneficence (physicians' obligation to advance patient welfare) by encouraging patient faith even in the face of terminal illness.

Cultural influences in late-life care became particularly evident with the passing of the 1990 Federal Patient Self Determination Act (PSDA). (12) Case studies appeared that highlighted unforeseen dilemmas in the PSDA's implementation among a certain ethnic and cultural groups. (1314) after research and case studies identified three basic dimensions in end-of-life treatment that may vary culturally: communication of "bad news" locus of decision making, and attitudes toward advance directives and end-of-life care.

Communicating Bad News

The consumer change legal requirements, an emphasis forward patient informed consent, and reduc physician authority have contributed to health-related "truth telling" in the United States. Outside the United States, health care professionals frequently conceal serious diagnoses from patients. Physician strategies commonly useed to minimize direct disclosure include using terminology that lurids the seriousness of a condition or communicating diagnostic and treatment information single to the patient's family members. Many African and Japanese physicians, when discussing cancer with patients or family members, make choice of terms such as "growth," "mass," "blood disease," or "unclean tissue," (15) rather than specifically describing a potentially terminal condition. In Hispanic, Chinese, and Pakistani communities, family members actively harbor terminally ill patients from knowledge of their condition. In the United States, this protection may include deliberately not translating diagnosis and treatment information to patients, (16) a situation that is les likely to arise with appropriate use of a translator (Table 2) (1718)