1. CULTURAL
COMPETENCY IN END OF
LIFE CARE IN THE ICU:
WHAT STUDENTS
LEARNED IN A PILOT
CURRICULUM
Amy Chi, MD
Elisabeth E. Bennett, PhD
Rebecca D. Blanchard, PhD

2. Background
 Decisions about end of life (EOL) care are
complex and influenced by factors such as:
 Understanding prognosis, preferences in life-
prolonging treatment, family beliefs, patient-
physician communication and culture
 Navigating EOL care discussions can be
challenging with families/patients of different
cultures
 Limited literature describing implementation
and impact of a cultural competencycurriculum
inEOLcare

3. Cultural Competency Pilot
Curriculum in End of Life Care
• Funding from Innovation in Diversity Education
Award (Tufts Medical School)
• Implemented cultural competency in end of life
care curriculum from 2011-2012
• Target: Medical Students during 4th
year ICU
clerkship
• Duration of curriculum: 4 weeks during ICU
clerkship/block
• Total 69 students participated over ten blocks
– 32 completed the curriculum (including pre-/post-tests
and observation form)

4. Observation Tool

5. Outcome Measures:
Quantitative
Survey
(n=32)
Pre-Post Testing
Physician Health Belief
Attitude
(15 items. 6 point Likert
scale)
No Change
Knowledge Assessment
(25 items)
No Change
Level of Comfort with
Cultural Competency
(5 point scale)
Improvement
(pre 3.31 vs post 4.01,
p<0.01)
Dobbie, 2002, Family Physicians Health Conference

6. Results: Qualitative Analysis
Observation Forms
• Observations from reflection tools:
– All observations forms analyzed using general
inductive methods, resulting in 3 categories
• Students learnedthat in navigating cultural
competency:
(1) Level of understanding influenced care
decisions
(2) Conversations must balance information and
feelings
(3) Balance between individual and family
dynamics is important (specifically conflicts and
consensus)

7. (1) Level of understanding
influenced care decisions
 “With the non-English speaking, wife at the
bedside day-in and day-out she was witness to
muchshedidnot understand. Inability to reach
the HCP (patient’s daughter) on a regular
basis meant that her main source of
information on the patient’s status was via her
mother’s interpretationof herhusband’s care.
This situation led to miscommunicationand
frustrationon both sides with the patient stuck
in the middle…I felt very frustrated that our
ability to explain the patient’s condition to him

8. (2) Conversations must balance
information and feelings
 “The care providers did listento the family’s
sufferingandunderstandingof what the
patient’s illness was. The family didnot seem
to fullyunderstandhow ill he was, and how
high the chances of brain death were.”

9. (3) Balance between individual &
family dynamics
 Conflict: “There was conflict between the two
daughters involved in the care. One wanted all
possiblemeasures taken to ‘cure’ their father
and help him live longer and the other wanted
to let naturetakeits coursewhen he was
extubated…[The care team] realized the
complicated family dynamics and were careful
not to take sides but instead deal with the
HCP.”

10. (3) Balance between individual
& family dynamics
 Consensus: “The two sons were able to both
express their concerns and have their
questions answered about their mother’s
current situation. It was vital to hear where
each of them were coming from in order to
provide them with helpful information and
guide the discussion. While oneof thebrothers
[the HCP] seemed at peace with the decision
to pursue hospice, the other was having a
moredifficult timeaccepting her prognosis…
Finally, the HCP made the decision to pursue
hospice, and hewas ableto convincehis

11. Conclusion:
 Communication surrounding EOL care can be
challenging
 Witnessing family meetings allowed students a
deeper understanding of the complexities of
culturally competent care in the ICU
 Family meetings are not simply conveying
information, they must allow for an exchange
for ideas and emotion, and manage complex
individual and group dynamics

12. Questions?
achi@tuftsmedicalcenter.org

13. Curriculum Outline:
 Objectives:
 Integrate how culture influences end of life
decision making
 Improve knowledge and attitudes about how
culture influences end of life decision making
 Teaching Framework:
 LEARN framework
 Components: Lecture, On-line modules,
Observation of family meeting, Reflection
Tool, Small group debriefing

14. The LEARN Model
Be rlin and Fo wke s
Listen to the patient’s perception of the problem
Explain your perception of the problem
Acknowledge and discuss
differences/similarities
Recommend treatment
Negotiate treatment
Berlin EA et al. West J Med 1983: 139: 934 – 938. Helen Fernandez, MD, MPH