Instructor Resource ManualModule 2 – Orientation and Opportunity

Table of Contents

Lecture content outline 2Post-lecture knowledge assessment items 8Answer key and rationale for knowledge assessment items 10Observation assessment form and scoring rubric 11Sample Case 15Sample case group debrief questions and instructor guide 16Sample case role-play activity 18Reflective writing assignment and instructor guide 20

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Content Outline for Lecture

I. Introduction to COMFORTa. COMFORT is an acronym that stands for 7 basic principles designed to be taught in

early palliative care communication, care provided for individuals with a life-threatening or serious illness

b. The curriculum is based on empirical research in hospice and palliative care, including observations of interprofessional teams, team meetings, team member collaboration, and interviews with team members across a range of healthcare professions.

c. This lecture will provide an overview of module 2 –Orientation and opportunity, and more specifically team-based practices that address health literacy. This module is an introduction to entry-level communication skills.

II. Objectives overviewa. First, we will define the practice of accommodation with patient/familyb. We then link health literacy with the way that we communicatec. Next, we discuss the connection between literacy and cultured. Finally, we hope you will learn two new communication skills.

III. Framework for Understandinga. We want to begin by sharing two ideas that are essential to patients and families

facing serious, chronic, and terminal illness. You are in possession of unique information---and communicating a patient’s status and options for care can comfort as well as empower a patient/family. This is called orientation.

b. Secondly, committing the communication time and effort to share opportunities for treatment and care supports a patient/family in their illness journey. This clinical communication practice will create a trusting connection between the clinician and patient.

IV. Costs of Limited Health Literacya. Without communicating orientation and opportunity with patients and families, the

research indicates that this results in poorer health outcomes, high costs for burdensome transitions, frequent re-admissions, as well as futile interventions with costly complications.

b. Orienting and sharing opportunity with patients and families is the obvious thing to do. Having some ideas about how to do this might make the process more successful.

V. Health Literacya. Health literacy is different than literacy in that it requires many more communication

skills than reading. For example, collecting and selecting the best and most useful information and then acting on that information introduces much more complexity than simply reading a set of instructions. Family caregivers and patients are both called upon to enact high level health literacy immediately upon entering an illness trajectory.

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b. Family and patient must be able to receive, acquire, understand, and use information to be health literate. Health information seeking behavior is a growing practice for patients and families as result of social media and information access. Worldwide use of the Internet for health information grew 400% between 2000-2008. (Mukherjee & Bawden, 2012)

VI. Added Aspects of Health Literacya. Health literacy also involves the language you use to talk to patients/family, context

of the interaction (are you in the ICU, ER, multiple patient room), culture (do you and the patient/family have the same cultural background), communication skills levels, and technology

b. Health information seeking behavior is a growing practice for patients and families as result of social media and information access. Worldwide use of the Internet for health information grew 400% between 2000-2008. (Mukherjee & Bawden, 2012)

VII. Some things to say to open the health literacy doorsa. Getting to know the patient/family is the pathway to understanding their literacy

level(s). Matching appropriate treatments, choices, and ways to engage the medical world will help you gauge your communication with a particular patient or family.

b. Here are some examples of the types of questions you can ask to begin to understand the patient/family health literacy

VIII. Questiona. Pose this question to the audience. b. Solicit individuals to share their thoughts with the group.

IX. Debriefa. Every patient and family facing emotional trauma, deep grief, worry, or anxiety is

functioning with compromised health literacy levels. b. Despite educational achievement, socioeconomic status, or even a position as a health

care professional, anyone facing a serious illness has low health literacy.

X. Voice of the Lifeworld (Habermas, 1987)a. One of the reasons why health literacy is important in clinical interactions is because

of the words we use when we speak about health. For patient/family, the voice of the life world is used to make sense of how health and illness impact their life. Body parts are identified using plain language and are talked about in terms of how they impact their ability to work, contribute to family, and enjoy social relationships.

b. On the other hand, voice of medicine is what we speak. We engage in medical terms, jargon, acronyms, and medical speak to identify parts of the body, procedures, and tests.

OPTIONAL: Encourage the audience to identify pairs of medical jargon and plain language. For example, medical term: vomit; plain language: throw up. Alternatively, have students create a group list of three to five medical terms that are difficult for patient/family to understand. Then have individuals work independently to create

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plain language for these terms. Then ask for a few volunteers to share their alternative plain language terms.

OPTIONAL: If the audience is comprised of interprofessional healthcare providers, then have the audience compile three medical terms per discipline and then ask audience members to choose a discipline other then their own and create plain language for those terms. Ask for volunteers to share their alternative plain language terms.

XI. Prompts to illicit feedbacka. Getting to know your patient/family is the pathway to understanding their literacy

level(s). Matching appropriate treatments, choices, and ways to engage the medical world will help you gauge your communication with a particular patient or family.

b. Here are some questions that you can use to encourage feedback. Especially important is the form in which it is shared.

c. When working with team members, think about the form for sharing information. Is some information better shared written or spoken?

d. When working with team members, don’t assume that another person understands. Elicit feedback to receive clarification, especially when working with new interprofessional team members.

XII. Communication Accommodation (Giles, 2008)a. A primary tool for orientation and opportunity is communication accommodation.

Each person you deal with is considered unique---in terms of their cultural specificity as well as their illness experience.

b. Two things to remember about communication accommodation: i. In every setting, people share aspects of their communication, but also employ

very different communication.ii. Your behavior influences the perception of others. For example, if you are

explaining/educating about only one treatment plan, the family and patient might be influenced not to ask or seek out information on another treatment plan that might better suit who they are and what they want.

XIII. Accommodation in Clinical Practicea. Let’s be more specific about accommodation in your day-to-day work. The

accommodation you are striving for is CONVERGENCE. This is communication that adapts and aligns with the communication of your patient or family. The best way to align and adapt is to ask about things you are unsure of---like culture, interest, worries, needs, questions, and more.

b. DIVERGENCE is communication that will increase the differences between you and patient/family. For instance, if you don’t speak the language of the patient and use a translator, but only look at the translator during the interaction, you are increasing the differences in language between yourself and the patient.

c. OVERACCOMMODATION can occur when a health professional uses extreme modification or regulation in an interaction, and can end up creating more distance between himself and the patient or family. An example of this might be social worker

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interacting with an 80-year old couple, both determining place of care as they face dual cancer cases. While the social worker talks with them, he uses an exaggeratedly slow rate of speech that is very loud, as well as high in pitch. This social worker needed to interact with the couple and first gauge their ability to process speech before assuming they were hard of hearing as well as slow in thought processing.

XIV. Strategiesa. We present some strategies for helping to accommodate health literacy levels of

patient/family.b. Message accommodation includes living room language. Try to speak in plain

language by avoiding medical terms/jargon and using lay language and repetition. c. When teaching patient/family, allow them to ask questions, ask them to demonstrate

with you, ask them to demonstrate to another family member or the patient.d. Have two team members work together with the patient/family. Be sure to think about

all aspects of the health care system when considering team members.e. Provide written material or directions when possible. Ask patient/caregiver to repeat

directions.

XV. Communication Impairment (Lambert, 2012; Salt & Robertson, 1998)a. Communication impairment is common among seriously and terminally ill patients,

stemming from motor compromise, neurological compromise, weakening, aphasia, delirium, and/or confusion.

XVI. Communication Impairment (Lambert, 2012; Salt & Robertson, 1998)a. Speech language therapists (SLPs) and occupational therapists (OTs) are instrumental

in helping patients and families identify goal of care and make care plansb. Treatments to be addressed in planning: resuscitation, ventilation, non oral feeding,

artificial hydration, narcotic pain control, dialysis, modified dietsc. Communicating about goals of care and advance planning can be facilitated through

Print Material, Video, and a Combination of Methodsd. All seriously ill patients are compromised in their motor productivity and energye. Take care not to exclude or diminish patient cognitive capacity

XVII. Cultural Considerations (Gunaratnam, 2007)a. Closely inter-related with accommodation is the work of considering culture. Culture

cannot be separated from any aspect of communication. It plays a role in how families operate, how treatment decisions are made, and the patterns of communication that you encounter.

b. Culture also suggests a hierarchical structure for people, or who yields power, or what yields power. So, assumptions of hierarchy and power impact communication assumptions and certainly decision-making.

XVIII. Cultural Humilitya. We can’t memorize a list of preferences or differences that accompany traits or

affiliations of people. In a many instances, trying to type a person based on their

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religious affiliation, ethnicity, or country of origin will put you in the position of diverging in your communication.

b. For this reason, practicing cultural humility goes a long way in attending to the uniqueness of a person and their needs, and makes room for the diverse and specific desires people have concerning their own rituals, preferences, and beliefs.

c. This means asking questions in order to learn about the patient and family, their experience, and demonstrating an interest in what makes them unique.

XIX. Cultural Humilitya. Cultural identity is not static, or general, or understood by memorizing a chart. People

are complicated. Families are even more complicated. Multiple perspectives and rituals can coexist within one generation as result of travel, marriage, and education.

b. Treating each person as an original is the best practice of cultural humility.

XX. Practicing Cultural Humilitya. Some specific questions that can help you learn about the needs and preferences of a

patient or family member might include questions about origin, language, caregiver, and food.

b. Elicit examples of the need to practice cultural humility.

XXI. Team-based health literacya. Here are some specific team-based practices for ensuring health literacy is addressed

in care planning and clinical visits.b. Elicit examples of team practice that positively impacted patient/family health

literacy.

References

Giles, H. (2008). Communication accomdation theory. In L. A. Baxter & D. O. Braithwaite (Eds.), Engaging theories in interpersonal communication (pp. 161-174). Los Angeles: Sage.

Gunaratnam, Y. (2007). Intercultural palliative care: do we need cultural competence? International Journal of palliative Nursing, 13, 470-477.

Habermas, J. (1987). The theory of communicative action: Lifeworld and system. A critique of functionalism and reason (T. McCarthy, Trans. Vol. Two). Boston, MA: Beacon Press.

Lambert, H. (2012). The allied care professional’s role in assisting medical decision making at the end of life. Topics in Language Disorders, 32, 119-136.

Mukherjee, A., & Bawden, D. (2012). Health information seeking in the information society. Health Information & Libraries Journal, 29, 242-246.

Salt, N., & Robertson, S. J. (1998). A hidden client group: Communication impairment in hosptice patients. International Journal of Language & Communication Disorders, 33(S1), 96-101. Vernon, J. A., Trujillo, A., Rosenbaum, S., & DeBuono, B. (2007). Low health literacy: Implications for national policy. Retrieved November 30, 2008, from http://www.gwumc.edu/sphhs/departments/healthpolicy/chsrp/downloads/LowHealthLiteracyReport10_4_07.pdf

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Wittenberg-Lyles, E., Goldsmith, J., Ferrell, B., & Ragan, S. (2012). Communication and palliative nursing. New York: Oxford.

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Post-Lecture Knowledge Assessment Items

1. A single father learns he is no longer able to drive as a result of ALS and is highly concerned that he will no longer be able to drive his sons to school. This is an example of how the patient’s ___________ affects his understanding of his illness.

a) Lifeworldb) Cultural competencyc) Health literacyd) Social power

2. Providing patients/families with orientation and opportunity means_______________.a) Sharing information with the family.b) Telling the patient/family which treatment option is best.c) Providing patients/families with all of the information available.d) Sharing the appropriate treatment options in an understandable way.

3. What percentage of patients facing serious illness has low health literacy:a) 100%b) 75%c) 50%d) 25%

4. Accomodating to patients/families means:a) going out of your way to help the patient and family by changing your

communicationb) neglecting other patients in order to care for one specific patient/familyc) moving toward a patient/family by changing your communicationd) exaggerating the differences in communication between you and a patient/family

5. If you were to communicate with a young pediatric patient and started to simplify your word choice you would be engaging in:

a) convergenceb) divergencec) overaccommodationd) maintenance

6. What are some components of health literacy?a) A-using Web MD to get health informationb) receiving, understanding, and using health informationc) being able to readd) being able to write

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7. A young Korean boy, his parents and grandmother are a new patient/family. Identify which of the following is the best way to practice cultural humility.

a) Upon meeting them, ask if they have a preference for the language they speakb) Before meeting them arrange for an interpreterc) Feel fortunate that you took Korean I and II during colleged) Treat them like any other patient/family

8. The best way to learn about the cultural preferences of your patient/family is to:a) Read in the patient chartb) Reference your textbooks concerning cultural competenciesc) Ask themd) Base your approach on prior experiences with that cultural group

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ANSWER KEY - Post-Lecture Knowledge Assessment Items

1. Answer: ARationale: Patients and families speak the Voice of the Lifeworld and relate illness to ways in which this will affect their day-to-day life. Patients cite feelings more often than precise empirical data, and experience the global impact of illness on their life instead of identifying specific and measured segments of poor health impact.

2. Answer: DRationale: Communicating the entire story of the patient’s status and options for care---and ensuring this happens in an understandable way---is the essence of orientation to life-limiting illness. Health care professionals are central to making true orientation possible, as well as appreciating and articulating what opportunities for treatment and care exist for a patient/family. Without this information, far fewer desirable decisions, choices, and ultimately outcomes will happen for a patient and family in the face of serious illness.

3. Answer: ARationale: The general assumption in the literature is that patients and families with language barriers and social determinants are likely candidates for low health literacy. What is unique to serious illness is that all patients and families experience compromise in health literacy. Impeded communication, emotional stability, thought processing, listening, and information processing all serve to lower health literacy. Though we recognize studied and proven populations operating in below basic and basic health literacy levels, we also propose that any patient and family receiving care---despite their ethnicity, background, and appearance---be cared for as though they are operating with lower levels of health literacy until the contrary is demonstrated.

4. Answer: CRationale: Accommodating communication establishes that all people communicate in similar and dissimilar ways and that the way in which we understand the speech and behavior of another will determine what we think of the interaction. Accommodations made to identify with another person’s similarities can decrease the dissimilarities.

5. Answer: ARationale: Convergence involves adapting and aligning with another person’s communication, while divergence increases the differences between people, and overaccommodation overperforms efforts to regulate, modify, or respond to others.

6. Answer: BRationale: Health literacy is about receiving or acquiring information, understanding that information, and then using that information in decision making about health-related issues.

7. Answer: ARationale: Cultural humility asks health professionals to adopt a “clean slate and assess the patient regardless of their cultural orientation” in order to determine patient/family needs and preferences. This approach to cultural sensitivity and communication asks the professional to

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mindfully respect each patient/family member, their dignity, and their need---regardless of an ethnic origin, religious belief, or personal attribute that might label them.

8. Answer: CRationale: Cultural humility does not suggest disposing of valuable knowledge about the health care practices of particular communities, rather it adds flexibility to the mix that will allow for humbleness: an opportunity for clinicians to seek out and locate the best resources for their patients and families. This begins by talking to them and asking about what is important in terms of patient/family needs and preferences.

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The COMFORT Communication Assessment ScaleModule 2 - O/O-Orientation and Opportunity

Student:_______________________

Element Unacceptable(1)

Poor(2)

Acceptable(3)

Good(4)

Identify patient/family health literacy barriers

Ignores health literacy barriers

Recognizes patient health literacy barriers

Recognizes patient and health literacy barriers

Recognizes and then engages patient and family health literacy barriers (e.g., language, context, culture, communication skills levels, technology) and attends to communication barriers

Communicates with patient/family in a culturally sensitive manner

Communicates with patient/family in a way that does not reflect a sense of cultural humility

Communicates with patient/family in a manner that reflects preconceived cultural competency and predefined cultural knowledge

Communicates respect for patient and family regardless of ethnicity, religious beliefs, or personal attributes

Communicates respect for patient and family regardless of ethnicity, religious beliefs, or personal attributes and practices humility by keeping an open mind, engaging in continuous reflection, flexibility, and sensitive communication in order to create shared meaning

Assess patient/family ability to process information

Information processing ability is never considered

Acknowledges deficits in information processing but fails to explore further

Explores patient/family understanding of prognosis and treatment options

Asks targeted questions to learn how patient/family process medical information, the environment, and various treatment options and listens to answers

Accommodates patient/family communication preferences

Neglects to accommodate to patient/family communication in any way

Engages patient/family by communicating in ways that increase differences between them

Attempts to engage patient/family but over- adjusts communication style

Communicates with patient/family by adapting and aligning to their communicative behaviors

Orients patient/family to life-limiting illness and presents opportunities for treatment and care

Neglects to discuss patient status and care options

Patient status is discussed but care options are not discussed

Patient status and care options are mentioned but not discussed

Appreciates and communicates the patient’s entire story including status and care options in a clear understandable manner

Integrates patient/family life when considering patient status and care options

Discussion of patient status and care options remains biomedical in focus

Minimal acknowledgement of patient/family illness experience

Demonstrates knowledge of patient/family illness experience and related concerns

Demonstrates mindfulness for the patient/family illness experience and related concerns when making assessments and discussing patient status and care options

Uses gathered information to identify best plan for securing orientation and opportunity

Selects care plan based on previous experience rather than understanding of unique patient attributes

Utilizes a checklist of traits rather than observations and inquiry

Patient/family observation and communication is used to develop the best plan

Integrates acquired knowledge (e.g., patient/family narrative, observation, inquiry) with biomedical knowledge to identify the best plan for securing orientation and opportunity for the patient/family

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Engages in person-centered interviewing and care

No recognition of patient/family emotion during interview

Attempts to recognize direct expressions of emotion during interview

During interview, acknowledges direct and indirect emotional expression

Engages direct and indirect emotional expressions (i.e., verbal, nonverbal) and encourages patient to discuss distress

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Comments to be filled out by students following viewing of videotaped encounter:1. Regarding (orientation and opportunity) communication skills, what do you think went well?

2. Regarding communication with this patient/family member (role play), what, if anything, would you do differently?

3. What are the barriers and pathways you see in communicating with this patient/family?

4. Any other observations or comments about this particular patient/family encounter?

NOTE: Feel free to refer to O/O Orientation and Opportunity of COMFORT when reflecting on which tasks you accomplished, as well as the way in which you accomplished them.

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Sample Case

In January 2007, Marco Rodriguez, a man in his mid-70s, fell during a daily walk. He and his wife maintained their own home in South Texas and enjoyed their four children, who all lived within 3 hours of them. Marco experienced pain for a few days, went to his local physician, and received a clean bill of health. By July, he was still complaining of pain and a general practitioner referred him to a “cancer doctor.” He proceeded on to an oncologist, not understanding that he had been diagnosed with advanced cancer. He told his daughters he had a hole in his leg bone.

With Marco’s oncologist, the family discovered that he was suffering from advanced stage multiple myeloma. The four children quickly identified roles in the caregiving process and moved into action to assist their parents. The eldest daughter, Guadalupe, became researcher and planner. The youngest daughter, Melissa, became a researcher. Sons Gabe and Manuel were the hands-on caregivers and comforters to their parents. By early fall of 2008, Marco was incapacitated and bedridden. His sons provided all of the day-to-day care for their parents. The family became frustrated with the oncologist as Marco’s pain was never alleviated, and they felt they were not taken seriously on this matter. In the midst of his excruciating pain, he underwent intensive chemotherapy treatments that were far more aggressive in their side effects than the family knew they would be. Marco deteriorated substantially and was referred to a regional health care center for a stem cell transplant.

At the regional health care center, the family complained about Marco’s unrelenting pain. They were referred to Dr. Mendoza and a full palliative care team. The stem cell transplant was put on hold until his quality of life could be improved. In the spring of 2009, due to pain relief, nutrition care, therapies, and effective communication with his medical care team, Marco moved from a wheelchair, to a walker, to a cane in his ambulation, and experienced complete pain relief. Marco and his wife became fully independent in their own home once again. Their children remain concerned and realistic about their Dad’s prognosis. Most recently they have noticed that Marco is having difficulty expressing himself, often using words that are confusing to the listener. Marco himself does not understand his childrens’ concern over this matter.

Guadalupe’s Profile: The eldest daughter of Marco, Guadalupe identifies herself as a primary caregiver of her dad, but in her descriptions of the family effort to improve Marco’s quality of life, the roles played by her three other siblings become very important. None of the siblings have equivalent skill sets or gifts, but each of them self-identify with labors that will contribute to the family effort. They all share in their anxiety about the communication Marco has with clinicians outside of their presence, as information has been previously amended or edited. In different geographic locations, they have coordinated their communication about his and their mother’s care.

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Sample Case Group Debrief Activity

1. When meeting and working with a new patient/family, how do you negotiate expectations of cultural competencies with the idea of cultural humility?

Instructor Guide: Health professionals are trained to make discerning communication choices in light of cultural competencies. This curriculum challenges some of those competency assumptions and pushes team members to investigate each person as a unique individual. Discuss some of the challenges and benefits in practicing cultural humility. Example:

What are some implications for the use of time when working with patients and families? What could be some of the long-term benefits of practicing cultural humility? What might be some pitfalls in using cultural competency assumptions about a certain religious/ethnic/cultural group?

2. After seeing Mr. Rodriguez and his children, how would you demonstrate cultural humility?

Instructor Guide: Cultural humility asks that we treat each patient/family as a unique entity. With converging and blurring lines demarcating cultural groups and preferences, there is no standard or set practice that quickly gets at the cultural specifics of a patient/family. Example:

“Tell me/us how your family would like to learn about treatment options? Mr. Rodriguez, can you describe what you and your family would prefer. We want to work with your family in the way that best suits their needs and expectations. (Using a Spanish translator until you learn if needed or not).

3. How would you deal with the varying levels of health literacy between the patient and family in this case?

Instructor Guide: Each team member has varying skills and a role to play in orienting a patient/family unit to illness and treatment options. Since the patient and family represent varying cultural and literacy needs, these should be recognized and met. Accomodating to the needs of the patient and the family is essential in building trust and relationship. Example:

“Can we talk about what needs you (patient and family) have in understanding Mr. Rodriguez’s illness? We are particularly interested in knowing how the children can be supported in his care and what we can do to facilitate that.”

4. How would you handle a situation in which a team member feels strongly that Mr.

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Rodriguez should make his own decisions about care despite the fact he has stated several times he would like his children to communicate with staff and make the decisions?

Instructor Guide: It is important to fully listen to each team member’s point of view and how their role can inform the team-care process. Your role on the team is to remind all to support the care needs of the patient and family by privileging their cultural and literacy needs. Example:

“Has anyone had the experience of seeing Mr. Rodriguez’s relief knowing his daughters are fielding the care decisions? This seems like the way in which their family as well as their larger culture works. Once he knew they were his champions in the health care setting, he seemed to be much more at ease.”

5. Does Marco’s recently appearing aphasia need to be addressed by members of the care team?

Instructor Guide: Team member will have perspectives on this new development in Marco’s status. It is important that the team gain awareness about the aphasia, but also that this matter is explored with Marco and his family.

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Role Play Activity

Objectives:

1. Practice identifying health literacy opportunities.2. Practice identifying cultural humility opportunities.3. Engage in role-play activities informed by health literacy and cultural diversity.4. Extend O and O module learning for practical communication application.

How to Proceed-Introduction & Discussion: (20 minutes)

Review objectives for group activity and facilitate introductions of group members to one another.

Ask group participants to read case. Facilitate discussion of caregiver type and indicators.

How to Proceed-Role Play: (20 minutes)

Roles: There are several roles to be played in this case; remaining participants can observe

Facilitator: Keep time (20 minutes MAX for this part of group activity, as divided below): 5 minutes for role players to read roles and arrange seating for conversation 10 minutes for role play 5 minutes for de-brief and discussion.

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Rodriguez Family – Part TwoFamily Meeting Role Play

Situation: Marco is well. He is walking, eating, and enjoying life. The family is embracing a period of good health and stasis after months of fear, exhaustion, intense caregiving, and worry. The Rodriguez parents have told the children they would like to discontinue palliative care therapies, which include nutrition, physical therapy, occupational therapy, and pain control. The appointments required to maintain palliative care therapies are too time consuming for the couple and they want to enjoy time together outside of the clinic. Guadalupe and her siblings have contacted the palliative care team to withdraw from their care.

Present: Guadalupe (lead caregiver child), Nikki (caregiver child), Dr. Reilly (palliative care physician), Ms. Miner-Rane (palliative care nurse specialist), Mr. Todd (nutritionist)

Guadalupe: Is curious to see what the team thinks about her parents’ proposal. She is charged with sending and receiving all face-to-face communication about her Dad’s care.

Nikki: Serves as a driver for her parents and would be eager to find some relief from the frequent commutes in obtaining this specialized care for her Dad, especially. Nikki also has two high-school aged sons and is a single parent.

Dr. Reilly: Has seen Marco return to a state of high quality of life as a result of rigorous palliative care. She is very anxious about Marco’s desire to end palliative care and wants to find a solution to the family’s concerns so that they might continue to benefit from their Dad’s current good health.

Ms. Miner-Rane: Has only dealt with Guadalupe in the past. She has a good sense of this family and their deep commitment to their Dad’s wellness and happiness. She wonders if there is a simple fix to this current challenge.

Mr. Todd: Shares a connection with Marco himself, unlike most of the clinicians on Marco’s team. Mr. Todd is also fluent in Spanish and worked hard to identify food preparations that would be interesting to Marco. Mr. Todd has seen Marco regain 60 pounds during his time with the palliative care service and knows that food and nutrition support has been an important component in Marco’s improvement.

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Reflective Writing Activity

David Calica is a 42 year old, Philippine, gay man seen in the oncology clinic who has AIDS and

associated malignancy. David had been estranged from his family for many years, and only

recently reconnected with his sister Nannette. At the clinic, a nurse (Laura) explains a new

protocol and potential side effects to David and Nannette. The treatment will not be curative but

the hope is that it may palliate his symptoms and decrease the tumor bulk to slow the metastasis.

When Laura leaves the room to prepare the infusion, Nannette tells her brother that she thinks he

should consider declining the treatment, as it just sounds “too risky”. Nanette believes an

herbalist and local Philippine doctor can offer alternative treatments. As Laura, the clinic nurse

re-enters the room to start the infusion, she detects the tension and change in the room and

decides to sit and visit with David and Nannette to determine what has happened and how she

can address their concerns.

Questions:

1. How should Laura start this conversation with David and Nannette?

2. What information will be important for Laura to learn about David?

3. Identify 2-3 medical terms that will be important for David to understand. Write

explanations for these terms in plain language.

Instructor Debrief

Accommodating the infinite range of ritual practice, treatment beliefs, and family

disclosure preferences requires determined attention and intention on the part of health care

professionals. The case of David and Nannette brings to light the overwhelming influence of

culture in cancer care. This brief scenario emphasizes the force of cultural beliefs, relationships,

family history, family disclosure, and the fragility of recent reconciliation between a brother and

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sister. Laura, the nurse, has done the first thing exceedingly well; she has paused to listen and is

thus practicing convergence. Accommodating patients and families is a conscious choice.

Convergence describes communication that aligns with differences or seeks to understand

tensions while not alienating a patient or family by altercasting, stetereotyping, or assuming

cultural knowledge or competency. Using plain language to explain terms such as malignancy

and metastasis will be important to the process of convergence.

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