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Beyond Age Discrimination

Religion and National Origin

Comments from Barbara Greene, a Multicultural Care Consultant

From the Rights Stuff Newsletter, July 2009

In a series of interviews, Minnesotans offer their perspectives and experiences on issues facing older Americans seeking care with dignity and respect for their individuality, cultural identity and human rights.

Comments from Barbara Greene

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Question: You have worked extensively with the Somali community in hospice and other settings. Do you find that the needs of that community, and their experience with health care, may be different than for other groups?

Barbara GreeneOften the needs of Somalis may be quite different than other populations in terms of how to discuss end of life care, and who to include in those conversations. And how to respect the Muslim faith, and belief that Allah ultimately will make the decisions about not only if someone will pass away, but when and how. Sometimes there are conflicts between a physician who may determine that a person is terminally ill and may have only a couple of months to live, and the belief that a physician does not govern the universe, and does not determine when someone will live or die. That goes to a much greater power. Calling someone terminally ill can also be seen as a sign that providers have given up on care, that they will not serve this person to the best of their ability—that they are letting this person die. One problem is, there are not many hospice or end-of-life-care communications in the Somali language. So we have been trying to create materials in the Somali language, in partnership with the Somali community, so that they are appropriate.

Question: I understand there is a cultural reluctance among some Muslims to turn to an institution, such as a nursing home, rather than keeping an older person home with the family. Is there a similar reluctance to seek hospice care?

Somewhat, but I think it’s from a different viewpoint. For Somali families as well as others, not giving up—and going on to additional treatments and sometimes invasive or other kinds of care—is a sign of your love for that person. Giving up, or saying, "there is nothing more I can do for you, father or mother or brother," can be perceived as a lack of love.

I think that sometimes the western model, even though it tries to be very compassionate and caring, underestimates the strength of those concerns. The family does not want to be seen as not caring for their grandfather, because they are giving up, or giving up too early. Sometimes, as health care providers, we forget the power of those bonds.

Question: When we talk about "family" in terms of Somali and Muslim culture, who is included? Who might be present at "family visiting hours?"

There really aren’t family hours in a lot of cultures. The family is integral, and the family should always be there, or should always be permitted to be there. They are part of this individual. So having hours is really foreign and not welcoming.

What is family? Often hospitals and clinical settings have a very narrow range, and it’s a very limited view of family compared to most of the world. So those are things that we try to really work with hospital systems and providers in recognizing, along with things about having food available for family members, having more chairs, or a little bit bigger space. There are probably going to be a lot more people in a room—young children, many generations, being there for long periods of time, reading the Koran, praying and talking. When there are a lot of people there, it’s a sign that they are really loved.

The family decides how they want to care for their loved one, what kind of care they want, in what kind of environment, and the hospice team follows their lead. It takes time to determine who the family spokespeople, or decision-makers, are. With some Somali families here, for example, elders may be still in Somalia or Mogadishu, or maybe in Germany. So sometimes long-distance conference calls with the hospice team and the physician are really needed, so that all parties are included.

Question: You have talked about the need to provide culturally appropriate care. What would be inappropriate care? What have you seen happening, that shouldn’t be?

There are some mismanaged or unfortunate experiences with Somalis in the health system—there are some great breaches of trust, because of language and other differences. Being available timewise is important—focusing on the family, really listening, being present goes a long way. In a health care system where someone is watching the door, or they’re speaking to the patient or an interpreter, but one hand is on the doorknob and they are ready to leave—that’s really a strong indication that your provider has other priorities, and you’re really not being cared for well, or listened to.

Question: What would be an example of culturally appropriate care?

Culturally appropriate care would include the Imam in the care—recognizing that the Imam is a very holy person, and that your role as a physician or nurse, while important, may be secondary. It would also be having a medical interpreter there. It would be not using children or family members as interpreters—any family member—no matter how good their English is. It is a very poor practice, and is not reliable, and often has very serious implications for the child or the family member. Family members may find it very difficult to tell their loved ones some bad news, and often people don’t even know the words—hospice is a word that doesn’t exist in Somali. So new words are being created.

Culturally appropriate care would also include things like having prayer rugs available, having copies of the Koran available. Being aware of diet, and gender issues—generally women need to be cared for, if possible, by women. Being aware of the importance and the respect that go to elders. Those are some key examples.

Question: How widespread are those practices that are not culturally sensitive and should not be happening? How far are we along recognizing the needs of this community?

Different people are going to answer that very differently. I guess my response is, we are really fortunate in the Twin Cities and the state of Minnesota to have a health care community that is extremely committed to cultural competency. Not all health care systems place this as their highest priority, but there are true leaders, internationally and nationally, in this state, that have broken ground in their practices, that continue to change large systems to be respectful and appropriate.

Cultural competency is not an initiative, it’s not a program. It’s a way of delivering care that’s responsible for all the care that you give. It’s a slow, steady, commitment that health care systems take on—a long term commitment to training, and to being involved with the community, because the community are our teachers.

We’ve made great steps. And we’ve got still a long way to go.

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