Hello, I hope you are excited to listen to this talk and as we go through the slides, a very important discussion relating to the guide to effective culturally sensitive and end of life discussion. My name is Kwame Asante Kwamabwata and I also work with my colleagues, Colin Sprinkler and also Nicole Young. I believe this is a very important talk that we all experience in our various ICUs, especially when it comes to end of life discussion, one that is not easy to be done and it requires a lot of mastery, a lot of exposure. And I really want to appreciate the Society of Critical Care Medicine for taking the time to ensure that we actually having these vital discussions and at least having something in place for us to just start as a guide towards how we can be effective on the bad side when it comes to cultural sensitive end of life discussion. So as we go through these slides, I want to engage all of us to really start thinking about how our own personal culture also plays a lot of role in how we have end of life discussion. All the three authors have no financial disclosure towards this talk. We'll focus our objectives on three key things, the understanding of the role of cultural consideration in end of life care, discussion techniques for assisting families to focus on comfort care discussions, and lastly, discuss current medical advances in end of life situations. So I want us to start this talk with a case presentation, which actually really happened in real life, of a 41-year-old gentleman who was involved in a motor vehicle collision who sustained a devastating traumatic brain injury associated with facial fractures, pelvic and left femur fracture, and bilateral pneumothorax. On arrival to the ICU, the neurosurgery department communicated with the patient's next of kin, who is the wife, that a head CT scan indicated the patient's traumatic brain injury was likely unrecoverable and that the family should withdraw care. So the medical team decided to exhibit the patient. After the patient was exhibited, his wife informed the imam, who is a spiritual leader or advisor when it comes to the Muslim faith, who then instructed the wife that withdrawing care was against their faith and that the patient needed to be re-intubated. The wife then requested that the patient be re-intubated. The two questions here, one is that what cultural issues can be observed in this situation and how should the critical care team address this current situation? So understanding the global concept of culture is an endless pursuit, as the culture of an individual or group can change over time due to the environment domains, such as the socioeconomic influence and exposure to trauma, severe illness, and also the individual self-embracement of their transmitted culture. So I want us to look at what then is end-of-life care. That is the care provided by an interprofessional collaborative healthcare practitioners to an individual or support system that also needs to include such as families, such as the next of kin, such as the community in general, due to the impending death based on the severity of the patient's illness and the anticipation that death may occur within hours, days, weeks, or months. So then the other aspect of it is what then is culture? If we are going to look at culture consideration with end-of-life, what then is truly culture? And it's defined as the individual's way of life encompassing the belief system, behaviors, traits, and values that are shaped over time by transferring knowledge to subsequent generation. So you see that the root of culture is sometimes not on a plain surface and culture may be very different for even people in the same ethnic group or people in the same faith. So there are many different domains that are shaped when we speak about culture. And that's why it's important that as we are going through this discussion, we recognize that there are little pieces of it that we need to make sure we are putting in consideration as we have discussions about the end-of-life of care. So culture is also thought to be served as a protective mechanism and provide reasoning to an individual's choice to create a sense of well-being. I know most of us has probably heard of the word cultural competency and I want us to look at the five stages of cultural competencies. We have to keep in mind that healthcare practitioners own culture beliefs and the health system attitude of embracing a culture and end-of-life issues influence the interaction with patients, their families, and even the overall healthcare team members as well. The level of healthcare providers' culture competency is directly associated with their ability to deliver culturally responsive care to culturally diverse patient population. When we speak of cultural competency, we have to keep in mind that it is a process. It's not just a one-time, you know, check the box and I get it, I got it. It is a process. And like I've made emphasis of earlier as well, culture itself is very diversified. So cultural competency is also likewise diversified and it needs to be appreciated from variation of culture differences, even between individuals within the same ethnic group. So when we speak of cultural awareness, one of the key thing that we need to, you know, look at is relating to our own culture biases towards others' culture. What is our own culture biases? So that self-assessment, that self-evaluation that we as healthcare practitioners need to evaluate to see what are our biases towards others' cultures? How do you respond and act when you have, you know, another ethnic group or another sort of someone, a patient that may be of different sort of like culture, either based on their religion, based on their faith, or based on their language, or based on, you know, their place of origin. There are things that we need to really have that self-assessment to really assess and see what are the biases we have towards one another. And I think when we come to recognize these cultural awareness, it does help us eliminate that biases. And I think when that biases is taken away, then I think really going into looking at the various other components of cultural competencies will then be more intentional and also effective. The next one is looking at cultural knowledge. So what is cultural knowledge? Now keep in mind that I've said this already, that when we speak of culture, it's very diversified. So it's really impossible for one person to say that I know everything about every one culture, right? It's just not possible. But it's really looking at the ecosystem of disease within the ethnic group and treatment practice embraced by that very specific ethnic group. So I think being intentional about focus on that ecosystem approach of a disease does give you some understanding as a clinician to be able to really know what that entails, what treatments are also welcome. In the sense of how we address end of life, I think that will give us a better perception of how we addressed our patients when it comes to gaining that cultural knowledge. The third component is cultural scale. This is about the cultural assessment, behaviors, and practice that are needed to conduct a comprehensive care for ethnic diverse patients. The fourth component is looking at cultural encounters. Cultural encounters allows the healthcare practitioners to learn the beliefs and practice of specific cultures and help to unlearn the possible biases. So the more we are exposed to different cultures and learning the different values and different beliefs and different behaviors associated with that culture, it helps us to unlearn the possible biases that we tend to have based on a small subset population that we may have encountered in the past. The last one is looking at the cultural desires. So cultural desires is one that I really like the most because I believe that as part of the process, this is where the intentionality and really having a sincere pursuit of learning and developing an in-depth knowledge and increased personal awareness and also knowledge, skills, and the encounter to enhance your skill set and your ability to provide comprehensive cultural competent care. So it's really being very intentional about it and engaging yourself with the process to ensure that you're able to provide the best care for your patient and more from the perspective of culturally competent care for your patients. Spirituality, religion, and faith are often used interchangeably, and it really represents a very unique place when it comes to cultural competency. It is one I think most of the time we try as clinicians to really separate ourselves from it, but the reality is that when it comes to end of life, most patients spiritually plays a very vital role. And so what is spirituality? It is really the life force transforming an individual well-being and bringing meaning to their existence. So it carries a huge place in how they decide with end of life. Religion being a very particular case with the case that I presented earlier for us to really think about that, how spiritually plays a role in the decision of when to extubate and when not to extubate in withdrawing care on patients. Now there is a little bit of close match when it comes to spirituality and faith, but there are a little bit of a difference. And faith really is looking at the trusted knowledge based on conviction. So someone may not have any defined spirituality, but their faith may really come from a place of their own conviction, of their own conviction. And to them, that is their faith. Their faith is that trusted knowledge that convicts them or a belief of a divine rooted being that really guides them in their decision making. And so faith is an unwavering conviction that in most contexts, looking at the unwavering conviction that God does exist and that patient's actions are centred on that faith. The Association of American Medical College defines spirituality as the factor contributing to health in many cultures and societies. It is expressed as an individual's search for ultimate meaning through participation in religion and or belief in God, family. And so when we think about all these components, we have to recognise that they are a huge area when it comes to end of life, that we need to look at how best are we addressing the area of spirituality or faith. So looking at culturally sensitive end of life care and spirituality, the question I want to pose is this, does a patient's faith create a barrier to end of life discussion? Now there are multiple studies out there that have demonstrated that patients with an engaged faith system proceed with aggressive care with a decrease in the use of palliative care. However, on the other flip side, recent literature review have also found that when patients end of life care are facilitated by a culturally sensitive team, including a chaplain and the individual's faith was also incorporated into the discussion. It decreased the tendency to pursue aggressive care. So you see, we see how faith can play a huge role in a shift based on how we draw faith into the decision making as health care providers. Looking at a national consensus project for quality palliative care guideline, they made this statement, which I felt like is very important in this discussion, that spirituality, religion and existential aspect of care should be considered fundamental in the end of life of care and spiritual assessment should be included in the history. Now the interprofessional team, including a chaplain, should address the spiritual needs respectfully while not imposing their own individual beliefs on patients and family. This practice can also really enhance the end of life process, bringing strength and comfort to the patients. And so it's very important there is an assessment done relating to spiritual assessment that should be incorporated into the decision making and also the discussion for end of life as well. So I've listed here some key things for us to consider when it comes to spirituality, the source of spiritual strength and the support, the cultural norm and preference that affect beliefs, systems and the spiritual practice, the hope, value, fears, meaning and purposes that relates to the spiritual understanding and how that also plays a role in end of life. The concern that they may have relating to the quality of life, the spiritual practices, what are the things that should be incorporated when it comes to end of life discussions that are spiritual practice that should be part of the norm of that culture. The concerns about relationships, such things as at that very moment, what are the concerns that they may have relating to their relationship with God or their relationship with, you know, whatever the component of their faith may be. So these are things that should be put into consideration as we are going through the assessment and also having that discussion with the family and patient relating to the end of life. So that family and patients can also feel welcome that we are actually here with them, and we are looking at the totality of the very person and not just their diseases, not just the end of life, but really looking at the totality of the patient. So I've provided here an example of one spiritual assessment tool, which is the FICRE spiritual assessment tool, looking at faith or belief or what brings meaning to them, the influence, the community, and also the address or actions in care. So when it speaks of faith, the question is as simple as, do you consider yourself spiritual or religious? You know, if the patient says no, the healthcare provider can say, what gives you life meaning? So these are things that could help guide you as a practitioner to really understand exactly where faith or religion plays a role into, or spirituality plays a role in their decision making when it comes to end of life. Influence is one of the questions that I actually think is very powerful here, is that what importance does your faith or belief have in your life? Have your belief influenced you in how you handle stress? Do you have civic belief that might influence your healthcare decision? And again, that is a very bigger question, which I think will give you enough feedback and enough responses to really be able to guide and how you shape and helping the family and the patient address end of life discussion as well. Community really looks at, are you part of a spiritual or religious community? And so in this case, one of the things we can think about is that if we have this assessment in place, the family could, I mean, the healthcare team could have probably quickly incorporate the imam into the discussion as well as the family, if the family did approve of that, if the family was okay with that. So these are things that sometimes in our discussion with the end of life, we could really bring up and ask the family, do you want us to bring anyone to this discussion, especially someone relating from the spiritual or the religion community? And I think those are questions that sometimes we do neglect, but they are patients that are very connected to their pastors or their spiritual leaders. And looking at how we incorporate them into these discussions tend to sometimes ease the concerns or the barriers that sometimes we end up seeing at the end. And lastly, how we address this, how should the healthcare provider address these issues in your healthcare? And so being very honest about that and really seeing what the patient also then has to say, this can lead to you either referring a chaplain or a clergy or other spiritual care providers into the decision-making as well. So who should incorporate the entire team? It should be obviously our physician team, our advanced practice providers, the nurses, the social workers, the respiratory therapists, the dietician. I think the entire multidisciplinary team, our chaplains, needs to also be incorporated into these discussions as well. And as a collective team, really have the goal of looking at the ethics and the palliative care needs that a patient may have, and the goal of also reducing ICU days and resolving conflicts and improving communication and decreasing the use of resources. So if that becomes our primary goal of how we address these things, I think that will help alleviate a lot of the barriers that we, or the challenges that we face when it comes to end-of-life discussion. What are some of the key considerations that a multidisciplinary team or the interdisciplinary team should be thinking about when it comes to end-of-life discussion? Now it is well studied that patients that may come from different cultural backgrounds that we have all not been, you know, is not well exposed to us, tend to feel less supported by the staff during times such as end-of-life, and they feel like there is more challenges and barriers that also does resonate during those times as well. So during that death process, it is important that the interdisciplinary team or the interdisciplinary team to provide support and understand how involved family members or caregivers want to be involved with the entire end-of-life as well. So this is where I believe that the chaplains also bring a lot to the table of looking at things such as the community resources that are made available for them. This is where our social work and our care coordination team looks at the finance and the health insurance issues and the burden that sometimes family may be resistant to really come into that agreement of saying that maybe the time has come that they have to, you know, not be that aggressive in the care. And so these are things that there are a lot of barriers and a lot of gaps that that is why coming together as an interdisciplinary team is very critical in how we help our families be able to go through the process of end-of-life. What are the family beliefs and behaviors? And also really having that, you know, system assessment of looking at what is the health system barriers when it comes to end-of-life? What is the culture and the religious barriers as well that we may also have as individual clinicians? And also looking at, you know, the concept of what we've already talked about, faith and the culture leaders that should be open to the family desires as well. The other consideration is looking at the relationship and effectiveness of our communication with the patients and the family and ensuring that it is everything that we do talk. One, we are speaking of the same message, but also we are respecting the cultural component of our communication, right? So even our facial expression, you know, our tone of voice, you know, all these things does go in place with that effectiveness of communication, you know. And so as we communicate with the family, we need to be very mindful of this approach. We also have to recognize that even in the point of the patient getting ready to transition to death, how much do we as a team, we still need to be very involved in that as well. I've listed here multiple other considerations that we need to factor into when it comes to what is necessary for the family for end of life. One other key thing I want to just draw your attention to here is asking the patient and their family what they consider good end of life care can help address a lot of the expectation. It could be as simple as maybe I want to be kept clean, or maybe I want to be awake. I want to be able to participate in a conversation with my family. And so looking at those factors that are important to the family and incorporating that into the end of life is extremely very important. In an effort to really look at how best we communicate with our patients and our family when it comes to the process of end of life or palliative care, we have to look at this model, which I think is extremely very helpful. It has been taught in many health institutions. I think it brings a very holistic approach in how we go about addressing the various issues and how we provide effective communication. The other thing that this model also does help with is really addressing the health literacy that most of the time family members may not always understand. We may say we have actually had a conversation, but it may not really understand exactly what has been communicated. So they have seven domains that they look at. The first one is connect. Connect is really basically sharing difficult information with the patient and the family. Really being mindful to understand that it is clear, it is well-structured, it gets straight to the point for them to truly understand and also getting feedback to ensure that they really understand what has been communicated to them. So prioritizing also the person's self-message. What did they hear from you as a clinician? And seeking understanding when communicating with their patient and also their caregiver as well. So that feedback is extremely very important. The next one is the orientation or options, which look at integrating the culture and the spiritual awareness into the practice. And so what are the cultural things that they would like for us to incorporate into the care of the patient? And so that helps us secure effective communication to also enhance the relationship between the patient and also the caregivers as well. Making meaning is really about examining the meaning of suffering or the meaning of death to the patient and the caregiver in the sense of culturally, you know, competence as well. And so seeking to deliver a communication that is responsive to meeting the patient care goals. What are their goals when it comes to how death means to them? What does death means to them? Family caregiver looks at the practice of the family-centered care to serve as a caregiver for the care recipients, right? So gain an understanding of how the family wants to be communicated, how involved they want to be part of the care that we delivered for the patient for the end of life. Opening is really looking at understanding the importance of navigating privacy boundaries for the patients and their families, friends, and also their caregivers as well. How extent do we need to welcome into that conversation? Again, this is where we have the discussions of looking at, do we engage the spiritual leaders into the discussions as well? The second component is looking at relating, you know, and engaging the uncertainty and the certainty as patients and families advance in disease and plans of care change, you know, the goals of care discussions that we will have that, or that needs to be, to be have with between the family and also the care providers as well. It also relates to, you know, engaging with the family to, for feedback and receiving feedback from them and also evaluating how best we are communicating with them relating to the palliative care or end of life care. The last component looks at teamwork. And so how do we best collaborate as a multidisciplinary team? You know, what does our partnership look like? You know, we need to avoid groupthink. We need to try to really share information together and have one set bank of really how best we share resources and information to ensure that the team needs are also met. And so I think those are, you know, seven key components that we should be looking at in the sense of how best we can ensure that we have effective communication with our patients and family during end of life. Going back again to the case that I presented earlier, it's really looking at the communication aspect of the team and also being respectful to the approach that an individual faith does matter when it comes to the end of life and how the relationship with also the creator is also viewed into the discussion when it comes to end of life. So we, you know, sort of like dissect through this and also look at our own individual practice. We should put that into consideration, factor these things into consideration. And how do a patient recognize pain and suffering as even part of their faith and with end of life as well? And so in a nutshell, with that very particular case, what we should have drawn out of is that effective communication and incorporating the cultural competency or the holistic care looking at the spiritual belief of the patient would have probably prevented a lot of the barriers that was seen in this dynamic of issue that was presented and became very complicated. But I think those are things that sometimes we take for granted. But in situations like that, I know most of us, we not want to be part of such a very complex situation after extubating the patient, being asked to reintubate the patient. So in a nutshell, really to take away from this talk is and this area is effective communication is vital, very vital, understanding the culture and the spiritual factors that are important to the patient and the end of life can also be a starting point for our conversations and also having an open discussions about the prognosis and deferring life sustaining treatment must also occur early in the patient's care in order to establish expectations and meet the patient's desires. I also addressing the psychological changes that occur when it comes to end of life and helping families to really understand this to help mitigate the anxiety, the stress that goes with end of life care. And lastly, addressing the spiritual beliefs of the patient, incorporating the faith influence community and also the actions and also ensuring that there is a multidisciplinary team that really deals with these cases. We work together as a multidisciplinary team and that should include all the disciplines, including especially what I always want to address is our respiratory therapists, especially when a patient is ventilated, you know, really they are key players in really helping the families to alleviate the stress because some patients may want to be obviously after extubation, may want to at least have conversation with their family and their loved ones. So these are all key things and key disciplines that we need to ensure that we have our social workers also playing a role, our care coordination team, our chaplain playing a role with the entire multidisciplinary team. So I want to say thank you so much for your time, for listening to us, and I hope you enjoyed this talk and enjoy the Congress. Thank you.

end-of-life discussions

cultural considerations

ICUs

comfort care discussions

cultural competency

holistic care