Cultural Awareness Training and Education in Palliative and End-of-Life Care

Many racial/ethnic minority patient groups have unequal access to health care as compared to their white counterparts. Not surprisingly, these well-documented disparities persist through the end of life care as well. Health care disparities in end-of-life care among minority patients are influenced by multiple factors. These include economic inequities, such as lower household income; lack of health insurance; inability to afford preventive or maintenance care, which leads people to seek treatment later in their disease; and social inequities, including neighborhood pharmacies that don't stock pain medication. Other challenges are the cultural and spiritual belief systems about end-of-life care. For example, how families care for and take leave of their loved ones is often influenced by their cultural backgrounds, the spiritual beliefs or religious practices they use to cope and find meaning and comfort. In addition, family roles, gender roles, and religious rituals also affect utility of the health care services. Palliative and end-of-life care at the most basic and personal level touches on access to services, disparities in health care delivery systems, cross-cultural communication, cultural competencies, spirituality, religion, beliefs, rituals, community care giving resources, economics, and family dynamics.

There is a noticeable gap in the training of physicians and other health care providers in the understanding of how these disparities and cultural beliefs impact on patients and their families facing the end of life care needs. There are three core areas of health care disparities in palliative care identified in the literature which includes pain assessment and management, discussion of advanced care planning and access to hospice and palliative care. For example, research shows that African-Americans and Latinos fail to adequately use hospice care and palliative-care services, both of which could vastly improve their pain management and overall quality of life in their final days. Also, many Latino and African American patients and families may not be as aware of options for end-of-life care planning, such as living wills and advance directives. Many Latino and Asian Americans patients and families make health care decisions as a family unit rather than as individuals, a deviation from the mainstream American concept of autonomy. Other studies have shown that patients of ethnic minorities receive sub-optimal pain treatment compared to Whites patients.

In the Spring, 2006, AETNA awarded a grant to Mount Sinai for our "Palliative Care Across the Cultures" Project. The aim of this project was to develop, implement and evaluate a curriculum for third-year medical students in their Medicine-Geriatrics Clerkship along with Geriatrics and Palliative Medicine Integrated fellows, and faculty. The Project is a joint collaboration between the Lilian and Benjamin Hertzberg Palliative Care Institute, Brookdale Department of Geriatrics and Adult Development, and the Center for Multicultural and Community Affairs.

We wish to thank AETNA for its vision and support in the training of healthcare professionals. As we see this addressing our ultimate goal of providing optimal healthcare delivery to the diverse patient communities we are privileged to serve.