不同文化的處理與處置

授課教師：李菁蓉
案例一

大衛是一位英國人的 45 歲男性，於
一年前因解血便，故到醫院求診，經檢查
發現為 Anal cancer with bone, lymph nod
es and liver metastasis ，已經接受過手
術，化學治療，但效果不佳，這次因在家
意識昏迷而送入醫院，醫師告知他，現在
他約只剩三個月的生命。
案例二

阿桃是從泰國來台灣工作的 30 歲
泰國人，最近一個月有不明原因發燒情
形，他有自行服用退燒藥及去診所求治
，但仍經常高燒不退，故到某醫學中心
檢查，經抽血檢查發現： WBC: 240000
/ul, blast: 99% ，醫師診斷為 AML ，建
議馬上住院並對病患發出 “ Critical” 通
知。
案例三

黃太太是一位不會將英文的澳洲的華
人，最近幾個月因咳嗽不止，故去醫院求
診，診斷為肺癌，目前已做完化學治療，
但腫瘤大小經追蹤後並無明顯變化，醫師
建議他接受緩和治療，但病人卻不想住在
一個 “等死的地方”。
人人人人人人人
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文化

 是一種經過長時間發展的行為反應型態
 受到同一文化群體成員所共享的價值、信
念、常模和活動塑造而成
 包含多各向度，如性別年齡、性向、宗教
、經濟、居住、職業
Complexities of Culture
 Individual embedded in multiple layers of
social systems, each with its own culture
or subculture
 Different parts of culture are expressed at
different times
 Some parts of culture or unrecognized
 Continuum of acculturation
 Health care has its own culture
 Challenges

 Different cultures
 Different values
Complications
 Disagreements between physicians and
patients
 Difficult interactions
 Decisions the physician does not understand
 Cross-cultural
Misunderstandings

is risky.
文化的影響
 塑造個人價值、信念、常模和活動
 引導個人思考、決定和行動的模式
 需提供個人及家庭化的健康照護
Locus of decision making

•Group  decision  making  is  preferred

•Deferring  to  family
Differing Attitudes : Filipinos

 Wanted  to  die  in  their  homelands

 Attitudes  towards  advance  directives  w
as  positive
 Prior  knowledge  and  completion  rate  
was  low
Differing Attitudes: Chinese

 Attitudes  towards  death : Filial  piety,  cent

rality  of  the  family,  andemphasis  of  hier
archy    
 Respondents  rejected  advance  directives
 Not  mention  the  word  “death”
 Not  say   the  word  “cancer”
文化能力

 一種動力、流動、持續覺知的過程
 包括知識、技巧、互動和文化敏感
 覺察文化的差異
 適當、有效的介入能力
 四大要素：文化覺察、文化知識、文化技
能、文化體驗
文化覺察

 檢視自己的遺產、家庭生活、經驗和宗教
或靈性信念
 確認並接納個人價值系統與人互動中扮演
的角色
 檢視對文化刻板印象對信念、價值和臨床
執業的影響
文化知識

 對不同族群的文化知識
 運用各種資源以瞭解特定文化知識
 認同個體的獨特性
 接受存在團體差異性
文化技能

 文化評估
 跨文化溝通
 解釋
 適當介入
Importance
 Culture and ethnicity determine thoughts about death.
 Culture is a group’s worldview and values.
 Ethnicity is one’s self-identified group and may include subgroups
that share common values.
 Culture shapes choices for life support and preferences: to know
a terminal diagnosis; to die at home, in the hospital, or in a
hospice; and to promote quality during the last days.
 Talking of death may be taboo.
 Having different values about using treatment or artificial nutrition
with a feeding tube, trusting physicians, and participating in
decisions.
 Cultural traditions that involve karma may be at odds
Attitudes toward ...

 Truth telling
 Life-prolonging technology
 Decision-making styles

are different.
文化評估

 生於何處？住在這個國家多久？
 所認同自己種族為何？其種族認同有多強
烈？
 主要支持者為誰？住在使用其族群中社區
嗎？
*Some cultures may believe caring is the community’s duty and obligation.

 母語和第二語言的聽說讀寫能力？
 語言溝通風格？
THE ROLE OF FAMILY

 Providing care pain management, and

protect the patient
 Making sacrifices to care for relatives
文化評估
 宗教？其對日常生活和現在的言行舉止重
要嗎？
 飲食偏好和禁忌？
 經濟狀況？收入能滿足家人需求嗎？
 對健康和及應的信念和實踐？
 對於生病和死亡有哪些風俗習慣的信念？
Keys cross cultural dimensions

 Attitudes toward advance directives

and end-of-life care
 Locus of decisions making
 Cross cultural communication
Points of Cultural Diversity
in Health Care
 Emphasis on individualism versus collectivism
 Definition of family (extended, nuclear, non blood kinship)
 Common views of gender roles, child-rearing practices, and care
of older adults
 Views of marriage and relationships
 Communication patterns (direct versus indirect; relative emphasis
on nonverbal communication; meanings of nonverbal gestures)
 Common religious and spiritual-belief systems
 Views of physicians
 Views of suffering
 Views of afterlife
 LEARN model
 L: Listen with sympathy and understanding to t
he patient's perception of the problem
 E: Explain your perceptions of the problem
 A: Acknowledge and discuss the differences
and similarities
 R: Recommend treatment
 N: Negotiate agreement
Cross-Cultural Interview Questions

 “Some people want to know everything a

bout their medical condition, and others d
o not. What is your preference?”

 “Do you prefer to make medical decisions

about future tests or treatments for yours
elf, or would you prefer that someone els
e make them for you?”
 To patients who request that the physician disc
uss their condition with family members: “Woul
d you be more comfortable if I spoke with your
(brother, son, daughter) alone, or would you lik
e to be present?” If the patient chooses not to b
e present: “If you change your mind at any poin
t and would like more information, please let m
e know. I will answer any questions you have.”
(This exchange should be documented in the
medical record.)
 When discussing medical issues with family me
mbers, particularly through a translator, it is oft
en helpful to confirm their understanding: “I wa
nt to be sure that I am explaining your mother’s
treatment options accurately. Could you explai
n to me what you understand about your mothe
r’s condition and the treatment that we are reco
mmending?” “Is there anything that would be h
elpful for me to know about how your family/co
mmunity/religious faith views serious illness an
d treatment?”
 “Sometimes people are uncomfortable di
scussing these issues with a doctor who i
s of a different race or cultural backgroun
d. Are you comfortable with me treating y
ou? Will you please let me know if there i
s anything about your background that w
ould be helpful for me to know in working
with you or your (mother, father, sister, br
other)?”
Communication issues
•Low  hanging  fruit

•Harvard  Negotiation  Project

1. Don’t Bargain Over Positions
2. Separate the People From the Problem

3. Focus on Interests
4. Invent Options for Mutual Gain
5. Insist on Using Objective Criteria
BARRIERS of OMMUNICATION

 Critical messages may be lost in translation or in unfamiliar terms.

 Translations and culturally sensitive written information in native
languages are lacking.
 Physicians typically talk too briefly about end-of-life options and
neglect culture or values.
 Speaking another language or having limited skills may
complicate interactions and speaking up.
 Minority cultural groups often believe that the health care staff
have negative attitudes toward them, use unclear technical terms,
and treat them differently.
“What happened” conversation?

•What  are  we discussing?

•What  was  said  and  by  who?
•Who  is  right  and  who  is  wrong?
•Who  is  to  blame?  

and  here  is  why  I  am  right…..

Goals of the “What
happened”
conversation?
•Make them understand that they are a “a l
ittle different”
•Get them to admit that their actions/ reque
sts are unusual
•Persuade them that our way is the right w
ay
Feelings conversation

•How  this  discussion  making  me feel?

•How  the  power  balance  is  affecting  me
?
•Should  I bring  up  my feelings  or  not?
“Feelings conversation”: Goal
s
•Avoid  talking  about  feelings  that  make  
me vulnerable
•Avoid  letting  their feelings  cloud  the  sit
uation

 What was NOT said is more important

Identity conversation

•What  does  this  interaction  say  about  m

e  and  mycultural   competence?
•What  am  I  learning  about  mycultural  ef
fectiveness  (  or  the  lack  thereof)?
•Do  I  like  this  “new  me”?
Identity  conversation
•CategoricalAssumptions:
–I  am  good  or  bad
–I  am  competent  or  incompetent
–Its  either  “you  listen  to  me” or  “I  list
en  to  you”

•Goals:
–Protect  my  self‐image
From certainty to curiosity

•Learning  conversation
•The  real  truth  =  a  hybrid  of  (  your  ver
sion  +  my  version  )
Exploratory Phrases that work

•“Please help me understand…”

•“I guess, I am not asking the right question
…”
•“You are the world’s expert on yourself !”
•“If you had to complain about 3 things, wh
at would they be?”
•“I don’t expect you to remember any of thi
s. I am happy to go over it again…”
So…

Open and culturally

sensitive discussion is
needed.
Culture fundamentally
shapes how individuals
make meaning out of
illness, suffering, and
dying.
WHAT NEEDS TO BE
DONE?
 Need to research about culture, communication, and
dying to prevent unwanted, treatments .
 Need to be quality assurance
 Need to understand how culture and socioeconomics
influence quality care.
 Need to explore what the family wants.
 Need to educate on about culturally competent
strategies for communication and end of life care is
needed
 Need to revise policies to offer AD options and
palliative care centers that honor rich cultural traditions.
Conclusion

 To respect
 To aware
 To appreciate
 To communicate
 To learn
 To develop
 To understand