Henry S. Perkins

Cross-cultural similarities and differences in attitudes about advance care planning

OBJECTIVE: Culture may have an important impact on a patient’s decision whether to perform advance care planning. But the cultural attitudes influencing such decisions are poorly defined. This hypothesis-generating study begins to characterize those attitudes in 3 American ethnic cultures.DESIGN: Structured, open-ended interviews with blinded content analysis.SETTING: Two general medicine wards in San Antonio, Texas.PATIENTS: Purposive sampling of 26 Mexican-American, 18 Euro-American, and 14 African-American inpatients.MEASUREMENTS AND MAIN RESULTS: The 3 groups shared some views, potentially reflecting elements of an American core culture. For example, majorities of all groups believed “the patient deserves a say in treatment,” and “advance directives (ADs) improve the chances a patient’s wishes will be followed.” But the groups differed on other themes, likely reflecting specific ethnic cultures. For example, most Mexican Americans believed “the health system controls treatment,” trusted the system “to serve patients well,” believed ADs “help staff know or implement a patient’s wishes,” and wanted “to die when treatment is futile.” Few Euro Americans believed “the system controls treatment,” but most trusted the system “to serve patients well,” had particular wishes about life support, other care, and acceptable outcomes, and believed ADs “help staff know or implement a patient’s wishes.” Most African Americans believed “the health system controls treatment,” few trusted the system “to serve patients well,” and most believed they should “wait until very sick to express treatment wishes.”CONCLUSION: While grounded in values that may compose part of American core culture, advance care planning may need tailoring to a patient’s specific ethnic views.

Impact of medical ethics consultations on physicians: an exploratory study.

PURPOSE AND METHODS Despite the increasing availability of medical ethics consultations, little research addresses the impact of these consultations on physicians. Therefore, we surveyed physician-requesters and reviewed medical charts to evaluate the 44 ethics consultations concerning individual patients at our university medical center over an 18-month period. RESULTS The physicians who requested these consultations said 14 consultations identified previously unrecognized ethical issues, and 18 changed patient management considerably. The medical charts showed that the most frequently overlooked issue was inappropriate family decisions for incompetent adult patients (five consultations) and the most frequent management changes involved withholding cardiopulmonary resuscitation (12 consultations). CONCLUSIONS Ethics consultations appeared to have considerable impact on physicians in conducting patient care.

Ethics at the end of life

Some of the physician’s most difficult decisions involve whether to give cardiopulmonary resuscitation (CPR). Current research, hospital policies, and case law provide little guidance for these decisions, but medical ethics offers three useful principles. All three are based on patients’ wishes. First, a victim of cardiopulmonary arrest should receive CPR unless compelling reasons indicate he would not want it. Second, a patient has the right to refuse CPR. Finally, if CPR will serve no therapeutic goals defined from the patient’s wishes, it should not be given. Applying these principles requires a sympathetic, directed history which elicits the patient’s wishes relevant to resuscitation. This article uses an actual case and a simple algorithm to show how these principles promote ethically sound resuscitation decisions.

Cultural Beliefs About a Patient’s Right Time to Die: An Exploratory Study

ABSTRACTBACKGROUNDGeneralist physicians must often counsel patients or their families about the right time to die, but feel ill-prepared to do so. Patient beliefs may help guide the discussions.OBJECTIVEBecause little prior research addresses such beliefs, we investigated them in this exploratory, hypothesis-generating study.DESIGN AND SUBJECTSAnticipating culture as a key influence, we interviewed 26 Mexican Americans (MAs), 18 Euro-Americans (EAs), and 14 African Americans (AAs) and content-analyzed their responses.MAIN RESULTSNearly all subjects regardless of ethnic group or gender said God determines (at least partially) a patient’s right time to die, and serious disease signals it. Yet subjects differed by ethnic group over other signals for that time. Patient suffering and dependence on “artificial” life support signaled it for the MAs; patient acceptance of death signaled it for the EAs; and patient suffering and family presence at or before the death signaled it for the AAs. Subjects also differed by gender over other beliefs. In all ethnic groups more men than women said the time of death is unpredictable; but more women than men said the time of death is preset, and family suffering signals it. Furthermore, most MA women—but few others—explicitly declared that family have an important say in determining a patient’s right time to die. No confounding occurred by religion.CONCLUSIONSAmericans may share some beliefs about the right time to die but differ by ethnic group or gender over other beliefs about that time. Quality end-of-life care requires accommodating such differences whenever reasonable.

Diversity of patients' beliefs about the soul after death and their importance in end-of-life care

Background Because beliefs about the soul after death affect the dying experience, patients and survivors may want to discuss those beliefs with their healthcare provider; however, almost no medical research describes such beliefs, leaving healthcare professionals ill prepared to respond. This exploratory study begins the descriptive process. Methods Assuming that culture is key, we asked older adult Mexican American (MA), European American (EA), and African American (AA) inpatients their beliefs about whether the soul lives on after physical death; if so, where; and what the “afterlife” is like. Results Some beliefs varied little across the sample. For example, most participants said that the soul lives on after physical death, leaves the body immediately at death, and eventually reaches heaven. Many participants also said death ends physical suffering; however, other beliefs varied distinctly by ethnic group or sex. More AAs than MAs or EAs said that they believed that the soul after physical death exists in the world (57% vs 35% and 33%) or interacts with the living (43% vs 31% and 28%). Furthermore, in every ethnic group more women than men said they believed that the soul exists in the world (42% vs 29% for MAs, 45% vs 14% for EAs, and 71% vs 43% for AAs). Conclusions As death nears, patients or survivors may want to discuss beliefs about the soul after death with their healthcare provider. This preliminary study characterizes some of those beliefs. By suggesting questions to ask and responses to give, the study provides healthcare professionals a supportive, knowledgeable way to participate in such discussions.

Culture as a Useful Conceptual Tool in Clinical Ethics Consultation

The shared values, beliefs, and behaviors by which people interpret life events are what we call culture. More than medical science, culture determines how people react to illness and death. Science may determine which drug or surgery best treats the disease, but culture often determines how the health professional best treats a patient with the disease. Culture influences when the patient believes he is ill, which treatments he accepts, and which results he prefers. Because culture surely affects illness outcomes, health professionals must not ignore it. This project received financial support from the Mexican American Medical Treatment Effectiveness Research Center and the Aging Research and Education Center at The University of Texas Health Science Center and from the Ecumenical Center for Religion and Health, San Antonio. Presented in an earlier version at the Seventh Annual David C. Thomasma, Ph.D., Memorial International Bioethics Retreat, Medical Faculty, University of Padova, and Fundazione Lanza, Padova, Italy, 26 June 2004; presented at the Second International Conference on Clinical Ethics Consultation, Basel, Switzerland, 19 March 2005; and accepted for presentation at the national meeting of the Society of General Internal Medicine, New Orleans, Louisiana, 13 May 2005. Erika Blacksher, John Stone, Susan Bagby, and David J. Doukas thoughtfully critiqued earlier drafts of this article. Andrew K. Diehl and Helen P. Hazuda critiqued a research abstract of the material. I thank all these people for their many helpful suggestions.

Exploring Chronically Ill Seniors' Attitudes About Discussing Death and Postmortem Medical Procedures

Proxy decisions about postmortem medical procedures must consider the dead patients likely preferences. Ethnic‐and sex‐based attitudes surely underlie such preferences but lack sufficient characterization to guide decisions. Therefore, this exploratory study interviewed Mexican‐American, Euroamerican, and African‐American seniors in San Antonio, Texas, for their attitudes about discussing death before it occurs and about organ donation, autopsy, and practice on cadavers. A rigorous content analysis identified themes. Majority attitudes of an ethnic group or sex subgroup here may characterize the group generally.

Conflicting Duties to Patients: The Case of a Sexually Active Hepatitis B Carrier

Abstract A hemodialysis nurse who is a hepatitis B carrier insists on continuing dialysis nursing and sexual relationships but refuses to inform her lovers. The implications of her stance pose an e...

Cross-cultural medical ethics

To the Editor:—We welcomed the recent contribution of Feldman, Zhang, and Cummings 1 to the growing literature about cross-cultural medical ethics. The authors surveyed Chinese and American internists and found significantly different beliefs about professional ethics. American internists were more likely to disclose to patients a cancer diagnosis; Chinese internists, to honor family wishes over patient wishes about care.

Commentary on "providing guidance to patients: physicians' views about the relative responsibilities of doctors and religious communities".

My mother and I joined a grief support group at her retirement center shortly after my father died. Mr S., a recent widower, joined the group at approximately the same time. He was depressed and withdrawn. His rare comments during discussions revealed how his wife’s death had devastated him. Despite successful military and business careers, an attentive daughter, and comfortable surroundings at the retirement center, Mr S. believed his life had no further purpose. Doctors then diagnosed Mr S. as having metastatic prostate cancer. They offered treatments to lengthen his life and improve its quality, which he stubbornly refused, baffling the doctors. Untreated during the ensuing months, Mr S. increasingly became debilitated and angry, and he was soon confined to a wheelchair and spoke in the center’s dining room only to complain loudly about the food. Nevertheless, I greeted Mr S. whenever possible. He usually said nothing and only pointed skyward, although once he did say in a low, flat voice that he just wanted to join his wife. He died days later. What can Mr S’s troubling case teach us doctors? The study by Sheppe and colleagues in this issue of the Southern Medical Journal provides a hint. The doctors surveyed in this study indicated that doctors and spiritual advisors alike bear responsibility for guiding patients who face diagnoses that frighten them, death, anxiety or depression, or morally complex medical decisions. In other words, both bioscientific and nonbioscientific considerations are important in such situations. Admittedly, Mr S’s treatment refusal dismayed me as a doctor, and I wondered whether my view was too narrow. Medical training had taught me to ground patient care decisions in quantitative laboratory tests, quality-of-life scales, and survival timesVmeasures of the objective, physical dimension of illness; however, Mr S’s case focused my attention on another dimension that I had neglected: the spiritual. I now believe the human body has two dimensionsVone physical and one spiritual. (I purposefully do not use the word ‘‘religious’’ here because it refers strictly to a system of beliefs, practices, and symbols facilitating a particular community’s search for transcendent meaning through relationship with a supreme deity. I use instead the word ‘‘spiritual’’ because it refers to a potentially wide-ranging, individualistic search for that meaning. For many people, of course, religion informs spirituality.) Although this bodily ambiguity may bother some doctors, it is not unique. Life presents many ambiguities: light behaves as both particle and wave, humor emerges from tragedy, peoplemay act from simultaneously good and evil motives. I also see the two bodily dimensions as inseparable, like the anatomical brain and the metaphysical mind. Philosophical and theological traditions centuries old support this point. Aristotle understood all objectsVundoubtedly including the human bodyVas having four dimensions, or ‘‘causes’’: the material, the efficient, the formal, and the final. The first three causes belong squarely to the physical world. The material cause refers to an object’s constituent raw ingredients; the efficient, to the techniques necessary to create the object; and the formal, to the shape or form the created object takes. The basic sciences focus on these three causes. The fourth, or final, cause is qualitatively different. It concerns the object’s meaning or purposeVthat is, why the object exists. This cause belongs largely to the extrascientific ‘‘spiritual’’ world. Christian theology, for example, incorporates Aristotle’s idea of final cause when espousing a duty to sustain the body only so long as it fulfills its God-given purpose: having a relationship with God. Theologian John Paris cited this duty when he defended the Invited Commentary