On Our Own Terms: Moyers on Dying

Making broad assumptions based upon ethnicity, race and socio-economic class can lead to unfair prejudices and unequal treatment. At the same time, however, it is important to understand that culture and class make a difference. While more study of diversity issues is needed when approaching decisions about health care in general and end-of-life care especially; the following guidelines can help care-givers be more sensitive to cultural and economic nuances:

Be patient and sympathetic:
Recognize that distrust and suspicion may color the responses and decisions patients and their families make about advanced directives, Do Not Resuscitate options, and/or any decisions about continuing or foregoing life sustaining therapies. Some patients, especially those from poor communities or traditionally under served populations, may have come from circumstances where physical and psychological deprivation are the norm, and many may be suspicious and distrustful of the health care system.

Be aware of economic concerns:
Financial limitations and constraints play a significant role in the decisions patients and their families make about hospice care or nursing home placements. There may also be cultural traditions that may make families reluctant to allow care outside of the home. Work with these families as much as possible to offer in-home care alternatives.

Religion matters:
Spirituality and religious beliefs may feature significantly in attitudes toward the dying process and the determination of what treatments are appropriate.

Remember there are life long conflicts at play:
Be aware that life long feelings of deprivation and oppression may become a factor when patients and families confront end-of-life care. Some people may be passive in the extreme, while others will be very hostile and demanding.

Be careful when discussing limiting certain treatments:
Concerns about limiting care can often be perceived as denial of care along racial or economic lines, rather than because the treatments are medically futile.

Language matters:
Be aware that language and styles of communication make a huge difference in determining the content and types of responses you get from patients and families. Poverty, lack of education, and literacy levels may cause barriers in communicating effectively. Caregivers must work hard to overcome communications barriers and make sure patients and their families fully understand what is happening and what is being offered.

Listen to the illness:
Recall what you know about the illness and be cognizant that persons from lower socio-economic groups and diverse racial and ethnic backgrounds will exhibit behavior consistent with their disease, even if it is in another language. Remember that all sick people will feel a degree of powerlessness, and vulnerability. Caregivers must work hard to reassure and comfort patients any way that they can.

Don't lump everyone together:
Keep in mind that people from diverse racial and ethnic backgrounds are not necessarily from lower socio-economic groups. Also be aware that there are wide variations in common populations. For example, African American communities may identify with vastly different cultures, from native North American, to Caribbean, African continental, and South American.

Don't go on appearances:
Notwithstanding all of the above, you must clearly identify the value orientations of your individual patients and their families by keeping an open mind and ruling out certain assumptions.

Be more self aware:
Remember that your experiences will color your reaction to others. Things that you take for granted may not even occur to people from different backgrounds.

Making sure that the best care available is offered to all is a complex challenge. There are no simplistic explanations or easy solutions. Medical workers, caregivers and neighbors must be sensitive and willing to be creative in their approach to offering care and supporting patients of all races and classes at the end-of-life.

Marian Gray Secundy, Ph.D. is a social worker and bioethicist with a specialization in Medical Humanities. She is the Director of the National Center for Bioethics in Research and Health Care at Tuskegee University. Dr. Secundy also served as Director of the Clinical Ethics Program at Howard University Health Sciences Center.