As the cultural diversity of older adults in the United States grows, clinicians are very likely to encounter older patients from a wide range of ethnic groups. The purpose of the Geriatrics Cultural Navigator is to provide cross-cultural assistance to clinicians with older patients from minority groups. The Geriatrics Cultural Navigator outlines factors for the practitioner to reflect upon before interacting with a patient.
Doorway Thoughts
- Communicate attitude of respect
- Be aware that you are in the presence of a high-status individual
- Listen to “purpose of visit” without interruption
- Interpreter needed if English is not preferred language
- Past experience with Indian Health Service may be negative
Preferred Cultural Terms
- American Indian, Alaska Native. It is better to use the specific tribe that person is from (ie, “Cherokee” “Eastern Band Cherokee”). Also “Indian” is not used unless people are referring to themselves; it is used more as slang like “NDN”
- Be aware of tribal affiliation
- Try to use an alternative term than “Native American”- though some AIAN find this term acceptable, it is impossible to predict who finds this term to be inappropriate
- Don’t make or express any value or care preference assumptions based on their status as an AIAN
Formality of Address
- Initially formal: Dr., Rev., Mr., Mrs., etc., + surname
- First name only with patient’s permission
- Informality may develop later
- Humor is valued, mostly after trust/relationship established
Effective Communication
- Avoid attitudes of physical dominance
- Delay personal touching until trust is established
- Do not bring up your own family indigenous roots unless asked
- Do not make assumptions about cultural practices you have learned about/heard of
- Do not generalize and use information you have heard about another tribe; tribal communities are heterogeneous
Tradition and Health Beliefs
- Balance is believed to be of utmost importance and may involve health as it relates to the environment, time of year/season, social factors, family
- Different ideas about disease and its origins: a community may have a story detailing the origin of disease and it may result from outside forces, colonization, trauma, lack of balance
- Treatments: rituals, herbal remedies, statements of intent, consulting with traditional healer
Culture-Specific Health Risks
- Type 2 diabetes, CAD, blindness, renal failure, amputation are of higher risk than other populations
- Dementia is a newly-known disease process; many tribes do not have a term in their language describing memory loss. Tribes have differing ideas on the causes of dementia and how to approach the disease process. Loss of cognitive ability is not always associated with loss of self.
- Patient may not feel comfortable sharing use of traditional practices, and often those practices cannot be shared as it could cause damage or eliminate benefit. Do not ask for details about cultural practices for healing.
Practices and Health
- Plant-based medicine may be important
- Use of traditional foods/food sovereignty often crucial for health
- Tribes vary in traditions and ceremonies – do not generalize a concept or tradition from one tribe to another
Approaches to Health Decision-Making
- Close or distant relatives or kinsmen may be decision-makers
- Preferred decision-makers may live elsewhere
- Some indigenous groups are matrilineal and there may be hesitancy in directing decision-making for the matriarch of a family
- Kinship may be related to clans or other connection rather than blood relatives
Informed Consent
- Seek consent with honesty, care
- Stress hope while acknowledging concern and always express intent to do well for them
- The patient may not want to know full information and may ask that a family member be given full disclosure
Gender Issues
- Variable: tribes may be matrilineal or patrilineal
- Some tribes have historically supported two-spirit beings and may have complicated views of transgender health issues
End-of-Life Care
- Keep care consistent with patient’s overall view of life and death
- Difficulties:
- Absence of recognized decision-maker or family
- Desire for unfettered struggle with death
- Suggestion of providing less than full spectrum of care may arouse suspicions of assumption that patient and family matter less than other non-AIANs, due to history of provision of paternalistic health care to AIANs
- Desire to stay with family on homeland
- Desire to maintain hopeful, maintain positive attitude
- AIAN practices and beliefs surrounding death may be unfamiliar to the clinician, and therefore misunderstood. There are some practices that AIAN patients cannot discuss with non-AIANs, including clinicians.
- Be open to and try to accommodate requests to use ceremonies involving smoke. Ask if there are specific traditions/expectations about death. Questions to ask may include:
- Can you talk about death directly? If not, how should issues around death and dying be discussed? (Such as using third person or theoretical situations, for example)
- What words/phrases are not used in that tribe/area to discuss death?
- Are there certain plans for using the body after death that affect notification of funeral home, etc.?
- If in a healthcare facility, are there accommodations that need to be made during the dying process in terms of visitation times/duration?
- Who are the traditional decision-makers in families and does your state accommodate those wishes?