Informed Consent
Danny Chuang
Outline
“To tell or not to tell?”
Danny Chuang, Jeremy Rossaak, Prof. John Windsor
Surgical Registrar
Auckland Hospital
Scenario:
Mrs. Wilson, a 54y Pakeha woman with cirrhosis due to Hepatitis B, presented with a RUQ abdominal pain.
Investigations have shown that she has an unrespectable hepatocellular carcinoma
How would you deliver the bad news?
Ethnic population:
Current Population Trend:
Auckland is the most ethnically diverse region in New Zealand
the European: 56 %
the Asian: 18 %
the Pacific islanders: 14%
the Māori: 11%
Estimated Population Trend:
This trend will continue to diversify in the future
NZ European, 5% increase by 2021
NZ Maori, 29% increase by 2021
NZ Pacific, 59% increase by 2021
NZ Asian, 145% increase by 2021
Hospital trend:
In the next 10 years, there will be a increase in number of Asian patients requiring hospital admissions
Health care delivery to these patients can be difficult:
Language barrier
Culture background
Religious beliefs
Breaking bad news:
Breaking bad news to patients is a common routine in hospital
It can be difficult especially if involving life threatening illnesses
Therefore, good communication is the key to avoid frustration, dissatisfaction, and anxiety
Western Model:
Does this model work for patients of Asian background?
Ethnicity and attitudes toward patient autonomy:
To study differences in the attitudes of elderly subjects from different ethnic groups toward disclosure of the diagnosis of a terminal illness and end of life decision making
-Blackhall et al, JAMA, September 13 1995
Methods:
31 senior citizen centres within Los Angeles County, California (n=200)
The interview was conducted by an interviewer of same ethnicity and the language of choice of subject was used.
Results:
African American (89%) and European American (87%) believe that a patient with metastatic cancer should be told the truth compared to Korean American and Mexican American (47%)
Similarly they wanted to be informed of bad prognosis
Korean American and Mexican American believe that the family should make decision about medical treatment and life support (P<0.001)
Interdependence Model:
Potential Issues:
What if the patient's family asks to withhold the truth from the patient?
Should we tell the diagnosis?
Should we respect the family's concerns?
Do all patients want to know the truth about their condition?
What if the truth could be hurtful?
Is it justified to withhold the truth from a patient?
Questions:
What are the differences?
The reasons for these
Potential solutions
Cultural Difference:
Western Culture
Individual
Autonomy
Equality
Eastern Culture
Family
Beneficence and Non-maleficence
Hierarchy
Eastern Culture:
Familial principles:
Amae
Omakase
Filial Piety
Cultural Difference:
Western Culture
Individual
Autonomy
Equality
Eastern Culture
Family
Beneficence and Non-maleficence
Hierarchy
Wallin et al, JOIN, Volume 55(6), September 2006, p 723–735
Culture differences within others:
It’s not an independent, concrete, homogenous variable
It’s important not to categorize culture to specific ethnic origin
There are differences within each culture
World Trend regard Truth telling:
Truth telling is a fundamental principle of Christian Society
Studies have shown that there are countries that routinely withhold information from patients
Italy
France
Eastern Europe
Central and South America
Middle East
Reasons for non-disclosure:
Disrespectful or impolite
Provoke anxiety and depression
Eliminate hope
Some culture believe disclosure of illness makes it real because power of words
Searight et al, AAHPM, September 13 1995
Communication:
Different cultures have different preferences
Culture can be classified into Low and High context
Use of interpreter:
Family
Professional
Medical Professional
Summary:
Patients are different
Western vs. Interdependence
Differences in who receives information and how
Differences in who makes decisions and organise care
Each person = a cultural being
What can we do better?
Cultural competence:
Culturally competent care is no longer a luxury but a necessity (Meleis 1996)
What is it?
Recognize their own personal bias in practice
Understand patients culturally based beliefs, values, and requirements relating to healthcare
Respectful and responsive to these concerns
Find out what model patients belong to!
H.Russell et.al AAHPM bulletin Vol 6 2005
“Some people want to know everything about their medical condition, and others do not. What is your preference?”
“Do you prefer to make medical decisions about future tests or treatments by yourself, or for you?”
If you would like me to discuss your condition with your family, do you want to be present?
Potential future model:
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Ministry
of Health
