Cultural Competencies for the Palliative Care Provider Caring for the Latino Patient

Jennifer Garrison, MSN, APN, AGPCNP-C

Latinos are the largest ethnic minority in the USA, and they are expected to make up 30% of the country’s population by 2060 (Alvarez et. al, 2019). There will be more patient encounters as this ethnic group grows, making it imperative that we as healthcare providers understand the population’s cultural norms and differences. Many Latinos are undocumented and without health insurance, which creates a barrier to receiving healthcare. Other barriers Latinos face are language differences and different values and beliefs. This article will outline some key concepts that will help us to understand the Latino culture so that we as healthcare providers can better meet the needs of Latino patients. This will be especially true when offering palliative care/pain management services from Always Think Comfort.

• Familismo: Latino patients value family. Families are often large, and extended family members are typically involved in care. There may be numerous family members at the bedside, and it is important to note that extended family members are likely to be involved in decision-making with regard to treatment options. As healthcare providers we must encourage family involvement and it is crucial that the right family members are present for advanced care planning discussions. There is often a spokesperson who has the most respect and power in the family. Without this person present, certain decisions and conversations can be nearly impossible.

• Personalismo: When caring for Latino patients, it’s important to establish personalismo, or personalized care. Latino patients appreciate greetings prior to receiving care, and they typically develop loyalty to their primary caregivers and routine nursing assignments. Continuity of care is important and the same nurse should be assigned to Latino patients whenever possible. At Always Think Comfort, we focus on this continuity of care by assigning one nurse practitioner to each facility that the company covers. Additionally, healthcare providers should know that Latino patients prefer close personal space during encounters. Traditional distances of about 2 feet may make the healthcare provider seem detached or uncaring. Simply leaning in or patting the patient’s hand shows that the healthcare provider takes a special interest in the patient as a human being (Dayer-Berenson, 2014).

• Respeto and Simpatía: Latino patients are known to highly respect nurses, but there are ways we as healthcare providers can lose this respect. Maintaining eye contact and not strictly focusing on the translator is critical to maintaining respect. Additionally, it’s important to be sensitive and respectful when collecting data. There’s certain information that Latinos may feel is too personal and should be kept within the family. It may be necessary to ask certain questions in a non-direct manner. Some additional pearls for healthcare providers to follow to maintain respect from Latino patients are as follows:

1. If you the healthcare provider are younger than the patient, you should use formal titles when addressing the patient and communicating. The Spanish terms are señor (Mister), don (Sir), señora (Missus), or doña (Madam).

2. Try to speak some Spanish in the encounter. Learn basic greetings such as “Buenos dias” (good morning), “adios” (goodbye) etc. I have been expanding my Spanish vocabulary with every Latino patient encounter I have, and I find it means a lot to patients when you try to speak their native language. A translator should always be used though if there is any question of whether the information is being delivered appropriately or if the patient understands your Spanish. For non-native speakers, it is best to use a translator for complex discussions on advanced care planning and goals of care.

3. Encourage asking questions. According to Dayer- Berenson (2014) Latino patients may avoid asking questions as a sign of respect. We need to make sure that we keep the lines of communication open so that patients remain compliant with treatment plans.

• Pain response and machismo: To most Latinos pain is a routine part of life, a fate that they are supposed to experience. Many Latinos will accept pain without complaint in an attempt to appear strong and courageous (Dayer-Berenson, 2014). Men attempting to achieve machismo may be reluctant to admit they are in pain and they may not accept pain medication. As healthcare providers we need to reinforce that even if medication or treatment is needed they are still strong courageous men (Dayer-Berenson, 2014).

• Fatalismo and Espiritualismo: The majority of Latino patients are Catholic. According to Dayer-Berenson (2014), “The Catholic Church teaches that the soul is eternal and continues on after the physical body has died. The faith also holds that all life is sacred. Pain and illness may be viewed as a ‘test.’ This faith may interfere with the patient agreeing to the use of comfort measures, such as the use of pain medication (p. 220).” This is a critical concept for us at Always Think Comfort, and we plan to be sensitive when working with Latino patients who may be resistant to certain therapies. It is also important to note that often Latino patients won’t have advanced directives or living wills due to the belief that it is God’s decision as to when it is one’s time to die. Through their spirituality, Latinos typically feel they have little control over their destiny and health status. Dayer- Berenson (2014) states, “Many [Latinos] believe that illness is a result of God’s will and that fate controls life and health” (p. 221).

The cultural concepts and tips for success when caring for Latino patients listed above are just a few key components of Latino culture that we will encounter as healthcare providers in palliative care and pain management. Providing culturally competent care goes beyond using a translator. We must adjust our views and understand the core values and beliefs of our Latino patients. With the Latino population growing in the communities Always Think Comfort serves, we look forward to incorporating these concepts and techniques with the hope of better patient outcomes and experiences.

References

Alvarez, S. I., Muñoz-Blanco, S, Sanchez, M.E., Macip, P.M., Fernandez, J.M., Berroa-Garcia, L. (2019) Tear down the wall and build a bridge: Understanding latino culture and spiritual values to enhance the delivery of palliative care in the latino population [PowerPoint Slides]. Retrieved from The Annual Assembly iOS application.

Dayer-Berenson, L. (2014). Cultural competencies for nurses: Impact on health and illness. Burlington, MA: Jones & Bartlett Learning.

How To Give Your Parent​ A Peaceful Passage: 9 Pieces Of Bedside Wisdom


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Death is the last taboo, and we learn about it in sterile hospital corridors from doctors who are trained to help us heal, not to help us die. And yet, theirs will be the only voice many of us will hear when we make end-of-life decisions with our parents. After helping my mother through her own passing, and then writing a novel inspired by the experience, here are nine pieces of wisdom I learned along the way.

  1. Recognize the signs. It takes nine months to be ready to come into the world, and it often takes that long to be ready to leave it. There is a pathway to a natural death, and it may start up to a year in advance. You may see signs that Dad is disinterested, resigned or depressed. He might withdraw and stop participating. Understand this is natural, and is his way of preparing to say goodbye.
  2. Talk. You might find that Mom wants to talk about the end of her life, and no matter how uncomfortable it is for you, let her. Ask her how she feels about dying. Talk about what kind of passage she imagines. Many people don't imagine dying in the hospital intensive care unit, tied to machines, but over 60 percent of us will because no one asks.
  3. Remember to ask yourself: Whose life is it, anyway? Sometime in the last few centuries, Americans turned death over to medical institutions. In doing so, we give up our personal and spiritual freedom at a time when we most need it. When I wrote Finding Frances, I realized how strong the pull is to take medical treatment at all costs, right up until the end, regardless of religious or personal beliefs. In the book, William, one of the main characters, struggles to help his mother die in accordance with her own beliefs, even though they are in conflict with his own. But here is what my own experience taught me: If we believe our parents are entitled to their own choices, their dying becomes easier.
  4. Consider Mom's quality of life. In our litigious, high-tech society, doctors offer increasingly improbable solutions when the most obvious solutions prove ineffective. When one method doesn't work, it's often followed by the words, "But we can try ___." Help Mom make the best decisions for herself by understanding the probabilities of success, the amount of damage the solution will cause and the probable quality of life if the new treatment is successful. Let her know it's her choice whether or not to proceed. Her answer might surprise you.
  5. Help Dad communicate his wishes. Everyone knows they should have a will, but between 40 and 60 percent of us do not have advance care directives, which are legal documents that spell out our wishes for the end-of-life experience. You can get a valid one for your state online or from your lawyer. There are organizations like Project Grace (www.projectgrace.org) that offer innovative, easy ways to capture those last requests. Help Dad fill his out and give copies to family members and doctors.
  6. When they can't speak for themselves, honor the surrogate. Advance care directives makes the job of being a health care surrogate is much easier. A health care surrogate is the person who will make decisions for Mom if she's unable to speak for herself. In my book, Frances asks her son, William, to play this role. The choice should always be for the person who best knows and is willing to adhere to the parent's own wishes without bringing a personal agenda. They may or may not have a limited power of attorney for the parent.
  7. Explore hospice. Hospice care does not prolong life, but offers comfort treatment for a dying parent at the end stages. Most people say they don't want to live their last days in a hospital, yet most people don't get into hospice care soon enough to allow for a truly peaceful ending.
  8. Know your limits, and do your best. All families have their histories and complications. It isn't always a Hallmark moment when they gather around a sickbed. There will be plenty of time to live the family drama when the parent is gone. If your emotional limit is ten minutes, stay ten minutes, and then leave. If you're exhausted, take time out for yourself. Your responsibility is for your parent's peace and for your own physical and mental health. All you can give is your best effort.
  9. Try to find closure. In the last days when it seems there is nothing left to do but grieve, ask yourself, "What will I always wish I said but won't be able to?" and "What do I need to ask before it's too late?" When your parent is dying on his own terms, death can be a beautiful time of bonding and mending


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