Conclusion
In addition to receiving care from western medical providers, many Navajo, like Ms. X, also seek care from traditional healers, who have been part of Navajo culture for centuries. The healing powers, healing songs, and prayers have been passed down through the generations to the “chosen” ones. No one knows exactly how they are selected, and the Navajo are taught not to question the “chosen” ones.
This case must be viewed from the perspectives of both Western medicine and traditional Indian medicine. The provider's treatment plan was clear and straightforward from a Western approach. The patient also held traditional beliefs that needed to be respected. Two specific factors may have influenced the patient to challenge the treatment plan. First, the provider was of a different background, and the patient may have seen this as negative or threatening. She repeatedly told the provider, “You don't understand because you are not a native, and you don't believe in my beliefs.” The provider's only response was again to explain the results of the ultrasound and what they meant. This is normal conduct for a provider when considering issues of informed consent, truth-telling, and advance care planning.5 Second, the patient's lack of education could have contributed to her level of understanding. Her reaction might have been partly due to denial.
This case also led to some concern on the part of the PA student (Becenti) assigned to the facility. A Navajo herself, this student could not understand why the traditional healer told the patient that the baby was alive. The student began to question the practices of the traditional healer and whether the healer who had been consulted was authentic. This question could not be resolved.
The PA student, who takes advantage of both Western and traditional medicine, intervened by discussing the case with the patient and her mother. They were surprised when the student explained her use of both approaches. This provided the patient and mother with a sense of connection. The student explained that the provider who was caring for the patient most certainly had the patient's best interests in mind. She reminded them that they had presented to the clinic because they were concerned about the bloody discharge, which indicated that they must have known something could possibly be wrong. The student gave them time to consider the question: “Where do you think the blood is coming from?”
The provider then suggested performing another ultrasound. The provider described in detail what the ultrasound should look like if the fetus were viable. The provider repeated the ultrasound and took the time to explain exactly what she was doing and seeing. She welcomed questions and comments. The mother and daughter finally accepted the reality of the situation. They embraced in tears and were now willing to hear the treatment options.
Any difference in cultural beliefs and practices between provider and patient can present an ethical dilemma. It is beneficial for providers to educate themselves about the practices, beliefs, and traditions of various groups of people. This is especially important if a patient panel is composed largely of a particular cultural group.3 Translators and others with knowledge of and ability to communicate in the context of the patient's beliefs should also be utilized when possible.3
Carrese and Rhodes' suggestions for delivering negative news to Navajo patients include using positive language and discussing an illness in a way that does not focus on the patient.4 Campinha-Bacote developed a model to aid health care providers working with diverse populations.6 The mnemonic ASKED (awareness, skill, knowledge, encounters, desire) provides a framework for building cultural awareness in clinical practice:
• Awareness: Am I aware of my personal biases and prejudices toward cultural groups that are different from mine?
• Skill: Do I have the skill to conduct a cultural assessment and perform a culturally based physical assessment in a sensitive manner?
• Knowledge: Do I have knowledge of the patient's world view and the field of biocultural ecology?
• Encounters: How many face-to-face encounters have I had with patients from diverse cultural backgrounds?
• Desire: What is my genuine desire to “want to be” culturally competent?6 JAAPA
Joycelyn Becenti is a student and Keren Wick is Director of Research and Graduate Programs, both at MEDEX Northwest Division of Physician Assistant Studies, Physician Assistant Training Program, University of Washington School of Medicine, Seattle.
F.J. Gianola, PA, DEPARTMENT EDITOR is a member of the MEDEX faculty.
REFERENCES
1. Kliman HJ. Intrauterine fetal death. UpToDate Online. 2005 [update 14.1, 2005]. Available at: http://www.uptodateonline.com. Accessed November 27, 2006.
2. Conway SC. Early pregnancy loss. In: Lemke D, Pattison J, Marshal LA, Cowley DS. Current Care of Women: Diagnosis and Treatment. New York, NY: Lange Medical/ McGraw-Hill; 2004:605-612.
3. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 5th ed. New York, NY: McGraw-Hill; 2002.
4. Carrese JA, Rhodes LA. Bridging cultural differences in medical practice. The case of discussing negative information with Navajo patients. J Gen Intern Med. 2000: 15:92-96.
5. Carrese JA, Rhodes LA. Western bioethics on the Navajo reservation. Benefit or harm? JAMA. 1995;274:826-829.
6. Campinha-Bacote J. Many faces: addressing diversity in health care. Online J Issues Nursing [serial online]. 2003;8(1):[manuscript 2]. Available at: http://nursingworld.org/ojin. Accessed November 27, 2006.