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739 Vol. 52, No. 6, 2012 The Gerontologist © The Author 2012. Published by Oxford University Press on behalf of \ The Gerontological Society of America.

doi:10.1093/geront/gns008 1 Forum The population of older adults in the United States is growing in size and diversity, presenting challenges to health care providers and patients in the context of health care decision making (DM), including obtain- ing informed consent for treatment, advance care planning, and deliberations about end-of-life care options. Although existing literature addresses pro- viders ’ need to attend to patients ’ cultural values and beliefs on these issues, less attention has been paid to how the corresponding values and beliefs of pro- viders color the care they deliver and their assess- ments of older adults ’ DM capacity. The provider ’ s challenge is to understand her own unacknowledged anxieties, prejudices, and fears around such charged issues as truth telling, individual agency, capacity, death and dying, and the value of life itself and address their impact on the delivery of care. A social constructivist perspective and the clinical concept of cultural countertransference are proposed as aides in achieving this awareness and improving care. Key Words: Cultural proﬁ ciency , Informed consent , Capacity Turning the Lens Inward: Cultural Competence and Providers’ Values in Health Care Decision Making Mindy Chettih , LMSW, JD * Silver School of Social Work, New York University . * Address correspondence to Mindy Chettih , LMSW, JD, 32 Fenwick Road, Hastings on Hudson, NY 10706. E-mail: [email protected] Received October 17 , 2011 ; Accepted January 12 , 2012 Decision Editor: Rachel Pruchno, PhD The number of older adults in the United States is growing, as is their diversity ( Allen-Meares, 2007 ).

The increasing number of older adults translates into an increasing number of patients with some level of cognitive impairment ( Foster, Cornwell, Kisley, & Davis, 2007 ). These facts present chal- lenges in the context of health care decision mak- ing (DM), including obtaining informed consent (IC) for treatment , advance care planning, and deliberations about end-of-life care options. Interest in ensuring access to and delivery of competent care for this population has generated a substan- tial literature on health care DM by and for older adults. As in so many other practice areas, cultural competence is recognized as a critical skill in work- ing with these patients ( Allen-Meares, 2007 ; Kwak & Haley, 2005 ; Panos & Panos, 2000 ; Stein, Sherman, & Bullock, 2009 ). However, providers may not adequately consider the subtle and often unconscious impact of their own cultural ﬁ lters, and those of their organizations, on their ability to deliver competent care in working with older The Gerontologist © The Author 2012. Published by Oxford University Press on behalf of \ The Gerontological Society of America.

Cite jour nal as: The Gerontologist Vol. 52, No. 6, 739–747 All rights reser ved. For permissions, please e-mail: [email protected].

doi:10.1093/geront/gns008 Advance Access publication on March 8, 2012 at Towson University on September 18, 2015 http://gerontologist.oxfordjournals.org/ Downloaded from 740 The Gerontologist The Gerontologist 2 adults. The purpose of this paper is to bring that challenge front and center. First , the concepts of DM capacity, cultural competence , and cultural countertransference are described , and the literature on existing models for cultural competence in health care DM is brieﬂ y reviewed. The importance for providers of identifying their cultural ﬁ lters and evaluating the impact on care is then discussed. Key Concepts DM Capacity DM capacity in health care settings pertains to the patient ’ s ability to provide IC to, or to refuse, treatment. The Western bioethical framework for health care treatment rests on the fundamental principle that individuals have the right to autonomy to determine what happens to their own bodies ( Berg, Appelbaum, Lidz, & Parker, 2001 ). The com- mon law has long recognized that nonconsensual touching of the body violates this right and there- fore has honored the patient ’ s right to refuse treat- ment ( Grisso & Appelbaum, 1998 ). Over the years, this basic right has been augmented by the provider ’ s afﬁ rmative duty to disclose relevant information (including risks, beneﬁ ts, and alternatives to treat- ment) , a recognition that any decision must be informed to be meaningful. The legal requirements of valid IC are that it be voluntarily obtained , based on disclosure of ade- quate material information , by a patient with DM capacity ( Berg et al., 2001 ; Kapp, 2010 ). Thus , obtaining IC requires an evaluation of the patient ’ s capacity to consent, even if only done informally in conversation with the provider. Although some question whether assessing DM capacity and eval- uating the patient ’ s competence are equivalent, the American Bar Association and American Psycho- logical Association (2008) Handbook, Assessment of older adults with diminished capacity , does not make any distinction between these terms , nor will this paper. DM capacity in any patient involves four core abilities: to communicate a choice, to understand the disclosure, to appreciate the nature of the decision , and to reason (to manipulate the information in order to make the decision ; Farrelly, 2010 ; Grisso & Appelbaum, 1998 ; Smyer, 2007 ). Karlawish & Pearlman (2003) add a ﬁ fth functional area of evaluation: the ability to make a reasonable choice.

This is a judgment about the outcome of the deci- sion and as such is rejected by many ( Berg et al., 2001 ; Farrelly, 2010 ; Grisso & Appelbaum, 1998 ; Kobylarz, Heath, & Spike, 2005 ). Although juris- dictions that are “ rationality dependent ” versus “ appreciation dependent ” favor the approach of Karlawish and Pearlman ( Smyer, 2007 ), it is prob- lematic in the context of culturally competent practice ( Karel, 2007 ): whose view of rationality or correctness would apply? Age-related changes in cognitive functioning and diseases that are more common among older patients will have a differential impact on, at min- imum, the ability to understand the information disclosed, including the risks and beneﬁ ts of alter- natives, and to communicate a consistent preference among those alternatives ( Smyer, 2007 ). Cognitive deﬁ cits can be caused by a variety of conditions, but among the aging , dementia has the most dev- astating impact on cognition, due to its irreversible and progressive nature and its prevalence in this population ( Segal, Qualls, & Smyer, 2011 ). The risk of a diagnosis of dementia doubles approxi- mately every 5 years after the age of 65. Given the rate at which our society is aging, it can be expected that the prevalence of dementias will double within less than 30 years, increasing the need for DM capacity assessments ( Segal et al., 2011 ). DM capacity must be assessed in the context of the event that triggers the assessment, both the domain-speciﬁ c (life area) and the decision-speciﬁ c (level of potential harm or complexity) nature of the decision at hand ( Farrelly, 2010 ; Grisso & Appelbaum, 1998 ). Capacity in one domain, say ﬁ nancial management, may be affected without impairing capacity in another realm. Pertinent questions include the following : is it an emergency or related to a chronic condition ( Hsaio-Rei Hicks & Sau-Ching Lam, 1999 ); what are the relative risks at stake in the decision ( Karlawish & Pearlman, 2003 ) and the level of cognitive impairment, mental illness , or mental retardation of the patient ( Grisso & Appelbaum, 1998 ); what is the need for an imme- diate decision, the complexity of the information to be understood and appreciated in making the decision; and are there observable ﬂ uctuations in the patient ’ s abilities over any period of time ( Farrelly, 2010 )? Another potential factor is cultural disparity between the provider and the patient. Cultural Competence The NASW standards for cultural competence in social work practice ( National Association of Social Workers, 2001 ) deﬁ ne cultural competence as a process of improving individuals ’ and systems ’ 3 ability to respond to “ people of all cultures, lan- guages, classes, races, ethnic backgrounds, religions, and other diversity factors in a manner that recog- nizes, afﬁ rms, and values the worth of individuals, families, and communities and protects and preserves the dignity of each ” (p. 11). This deﬁ nition fails to address the inﬂ uence of the provider ’ s own belief and value systems, as well as the institutional and societal factors at play. These issues will be explored subsequently , but a good beginning might be the observation provided by Kohli, Huber, and Faul (2010) :

Cultural competence . . . involves awareness of one ’ s own biases or prejudices and is rooted in respect, validation, and openness toward differ- ences among people. Cultural competence begins with an awareness of one ’ s own cultural beliefs and practices, and the recognition that others believe in different truths/realities than one ’ s own.

It also implies that there is more than one way of doing the same thing in a right manner. (p. 257) Cultural Countertransference The clinical concept of countertransference captures the emotional responses a client stirs up in a therapist, responses that are transferred from earlier relationships in the therapist ’ s own life, that is, the therapist ’ s own transference ( Kernberg, 1965 ). Although the concept may seem far aﬁ eld from cultural competency, thinking about cultural countertransference invites health care providers to confront their own intercultural anxiety, which left unaddressed risks affecting both the quality of care they provide and the stress they experience ( Ulrey & Amason, 2001 ). The cultural component of transference consists of the cognitive and affec- tive elements of the clinician ’ s “ culturally derived personal life values , academically based theoreti- cal/practice beliefs , emotionally driven biases about ethnic groups , and feelings about their own ethnic self - identity ” ( Perez Foster, 1998 , p. 256).

These elements are activated in work with a client who is a cultural “ other ” and in the clinician ’ s use of theoretical constructs based on them. Values and beliefs shape the therapist ’ s perceptions, clinical judgments, treatment expectations , and all their interactions with the client ( Perez Foster, 1999 ).

In addition to these cognitive elements , Perez Foster describes the affective elements of the counter- transference: the biases/prejudices/anxieties/fears the clinician experiences about her clients ’ ethnic identities and her own. These elements, even if disavowed, not consciously available to the thera- pist, may be perceptible to the client and impede or preclude their work together.

Although countertransference in the clinical relationship was originally seen as a lapse in the therapist ’ s stance as a neutral, objective observer, this view changed in recognition of the inevitability of the clinician ’ s own attitudes, values , and beliefs showing up in the therapeutic process and the understanding that this was important to attend to as it affects the course of that process ( Kernberg, 1965 ; Perez Foster, 1999 ). Perez Foster has argued it is precisely “ the cross-cultural clinical arena charged with its terrors, suspicions, and disavowed prejudices, [which] provides some of the most fertile spaces for minds to collide and collude in their attempts to know each other ” ( Perez Foster, 1998 , p. 269). Her aim was to address the dissociated ( counter ) transference phenomena occurring with the therapist – client dyad. This paper suggests that a similar phenomenon occurs within the caregiving dyad. The provider ’ s cultural countertransference — including ideas about health, agency and capacity, and unconscious or unexamined values, prejudices, and biases — may be activated and clash with the patient ’ s worldview to create unintended impasses in their work together, including interfering with the patient ’ s ability to have his decisions honored. The Health Care DM Domain The framework for health care DM builds on cultural assumptions that increase the potential for ethical dilemmas, and intercultural anxiety, for providers. The traditional Western biomedical DM model rests on the individual agent whose autonomy and right to self-determination are para- mount, as enshrined in the concept of IC. That agent either has DM capacity, which is honored by requiring his IC to treatment , or does not, which requires supplementing his impaired capacity with the judgment of others based on his “ best interests ” ( Karlawish & Pearlman, 2003 ). The model assumes a single decision maker in a dyadic relationship with a caregiver and may result in an overattribu- tion to individual choice, ignoring or minimizing important external factors ( Hsaio-Rei Hicks & Sau-Ching Lam, 1999 ; Perez Foster, 1999 ). Cer- tainly , geriatric social workers must appreciate the differences in cultural norms regarding the aging process, caregiving, the processes of death and mourning ( Allen-Meares, 2007 ), how successful aging is deﬁ ned ( Lewis, 2011 ) , and how cultural at Towson University on September 18, 2015 http://gerontologist.oxfordjournals.org/ Downloaded from 741 V ol. 52, No. 6, 2012 The Gerontologist 2 adults. The purpose of this paper is to bring that challenge front and center. First , the concepts of DM capacity, cultural competence , and cultural countertransference are described , and the literature on existing models for cultural competence in health care DM is brieﬂ y reviewed. The importance for providers of identifying their cultural ﬁ lters and evaluating the impact on care is then discussed. Key Concepts DM Capacity DM capacity in health care settings pertains to the patient ’ s ability to provide IC to, or to refuse, treatment. The Western bioethical framework for health care treatment rests on the fundamental principle that individuals have the right to autonomy to determine what happens to their own bodies ( Berg, Appelbaum, Lidz, & Parker, 2001 ). The com- mon law has long recognized that nonconsensual touching of the body violates this right and there- fore has honored the patient ’ s right to refuse treat- ment ( Grisso & Appelbaum, 1998 ). Over the years, this basic right has been augmented by the provider ’ s afﬁ rmative duty to disclose relevant information (including risks, beneﬁ ts, and alternatives to treat- ment) , a recognition that any decision must be informed to be meaningful. The legal requirements of valid IC are that it be voluntarily obtained , based on disclosure of ade- quate material information , by a patient with DM capacity ( Berg et al., 2001 ; Kapp, 2010 ). Thus , obtaining IC requires an evaluation of the patient ’ s capacity to consent, even if only done informally in conversation with the provider. Although some question whether assessing DM capacity and eval- uating the patient ’ s competence are equivalent, the American Bar Association and American Psycho- logical Association (2008) Handbook, Assessment of older adults with diminished capacity , does not make any distinction between these terms , nor will this paper. DM capacity in any patient involves four core abilities: to communicate a choice, to understand the disclosure, to appreciate the nature of the decision , and to reason (to manipulate the information in order to make the decision ; Farrelly, 2010 ; Grisso & Appelbaum, 1998 ; Smyer, 2007 ). Karlawish & Pearlman (2003) add a ﬁ fth functional area of evaluation: the ability to make a reasonable choice.

Although countertransference in the clinical relationship was originally seen as a lapse in the therapist ’ s stance as a neutral, objective observer, this view changed in recognition of the inevitability of the clinician ’ s own attitudes, values , and beliefs showing up in the therapeutic process and the understanding that this was important to attend to as it affects the course of that process ( Kernberg, 1965 ; Perez Foster, 1999 ). Perez Foster has argued it is precisely “ the cross-cultural clinical arena charged with its terrors, suspicions, and disavowed prejudices, [which] provides some of the most fertile spaces for minds to collide and collude in their attempts to know each other ” ( Perez Foster, 1998 , p. 269). Her aim was to address the dissociated ( counter ) transference phenomena occurring with the therapist – client dyad. This paper suggests that a similar phenomenon occurs within the caregiving dyad. The provider ’ s cultural countertransference — including ideas about health, agency and capacity, and unconscious or unexamined values, prejudices, and biases — may be activated and clash with the patient ’ s worldview to create unintended impasses in their work together, including interfering with the patient ’ s ability to have his decisions honored. The Health Care DM Domain The framework for health care DM builds on cultural assumptions that increase the potential for ethical dilemmas, and intercultural anxiety, for providers. The traditional Western biomedical DM model rests on the individual agent whose autonomy and right to self-determination are para- mount, as enshrined in the concept of IC. That agent either has DM capacity, which is honored by requiring his IC to treatment , or does not, which requires supplementing his impaired capacity with the judgment of others based on his “ best interests ” ( Karlawish & Pearlman, 2003 ). The model assumes a single decision maker in a dyadic relationship with a caregiver and may result in an overattribu- tion to individual choice, ignoring or minimizing important external factors ( Hsaio-Rei Hicks & Sau-Ching Lam, 1999 ; Perez Foster, 1999 ). Cer- tainly , geriatric social workers must appreciate the differences in cultural norms regarding the aging process, caregiving, the processes of death and mourning ( Allen-Meares, 2007 ), how successful aging is deﬁ ned ( Lewis, 2011 ) , and how cultural at Towson University on September 18, 2015 http://gerontologist.oxfordjournals.org/ Downloaded from 742 The Gerontologist The Gerontologist 4 dissonances can affect health care outcomes ( Stein, Sherman, & Bullock, 2009 ). When operating from within her own cultural norms, the caregiver tends to see herself as without culture and the others — her clients or patients — as “ like ” or “ unlike ” her ( Dewees, 2001 ; Kohli et al., 2010 ). When she fails to see them within the con- text of their own norms and values, this limits not only her understanding but also their power to develop and actualize their own values ( Geiger, 2007 ; Kohli et al., 2010 ; Shah, 2007 ). It will also affect her ability to assess their health care DM capacity, potentially interfering with their right to make the rational or correct choice on their terms — not hers. To develop cultural competence, workers have been advised to begin by becoming self-aware, examining their own cultural biases, prejudices , and attitudes ( Kohli et al., 2010 ); by being attuned to the cultural and religious values that patients and families will bring to any signiﬁ cant decision ( Rose & Shelton, 2006 ) and the importance of supporting their engagement with those values ( Park, Roh, & Yeo, 2011 ); and by considering the impact of the dominant culture in which they oper- ate, to the extent it differs from their own ( Panos & Panos, 2000 ). The literature has focused on several key DM areas in which the cultural conﬂ icts can arise. The most apparent is the question of the proper locus of DM: who must consent to treatment? In the Western model, it is the patient, the one to be treated.

(Even in America, however, cultural assumptions and values may override self-determination. In cases such as assisted suicide and abortion, the state restricts the DM process despite infringing on the individual’s right to control over his or her own body.) Many patients are not comfortable with their role in the model of autonomous DM by an informed individual agent ( Berg et al., 2001 ; Kwak & Haley, 2005 ; Turner, 2002 ). This model of DM, embodying a mechanistic approach to health care, viewing the body as distinct from the soul, may also violate the spiritual beliefs of patients from other cultural traditions ( Karel, 2007 ; Mobeireek et al., 2006 ). Some propose that care- givers obtain “ informed refusal ” in such instances ( Berkman & Ko, 2010 ). This arguably still enshrines the individual as the ﬁ nal decision maker rather than accommodating other values. DM models privileging the ideal of “ free choice ” may be inadequate for other reasons. Illness does not happen to a single individual, in a vacuum; individuals often do not have an array of known and available choices — for ﬁ nancial and other reasons — nor does a chronic condition, such as dementia, constitute a single “ event ” as to which that individual agent must apply his DM capacity.

Thus , values embodied in autonomous DM may be a poor ﬁ t with the cultural values of the patient and his life circumstances. Another apparent dilemma relates to disclo- sure or truth telling: what information must the decision maker have to make a valid informed decision? IC to treatment requires the disclosure of sufﬁ cient information to appreciate the nature and purpose of the treatment, risks and beneﬁ ts , and available alternatives ( Berg et al., 2001 ; Grisso & Appelbaum, 1998 ). This model is based on the values of self-determination, autonomy , and self- control ( Berkman & Ko, 2010 ). But bioethics concerns itself with a number of additional values, including beneﬁ cence and nonmaleﬁ cence ; not every society privileges autonomy ( Searight & Gafford, 2005 ). Values differ sharply on the beneﬁ ts of truth telling — that is, what a Western doctor might consider material information for consent to be “ informed ” ( Berg et al., 2001 ; Blackhall, Frank, Murphy, & Michel, 2001 ; Searight & Gafford, 2005 ). Thus , the cultural context of disclosure becomes important.

What if the cultural values of the patient and/or his family rest on the premise that such disclosure is either unnecessary or even harmful? This ques- tion reﬂ ects differences in societal attitudes about the value of life and whether the individual ’ s or the family ’ s interests should determine when to with- draw or withhold treatment as well as the appropri- ateness of written advance directives ( Chan, 2004 ).

Individual consent, even if informed, may expose patients and their families to “ payback ” if appropri- ate consent within the community is not sought ( McGrath & Phillips, 2008 ) . Some cultural beliefs discourage verbally conveying information (bad news) to obtain consent, valuing instead a process of nonverbal communication which allows the patient to intuit what is wrong without others being obliged to speak the medical “ truth ” ( Blackhall et al., 2001 ).

Individuals who ascribe to a set of cultural values that place beneﬁ cence and nonmaleﬁ cence above autonomy and disclosure have a preference for less individualistic modes of DM and tend to favor a family-centered DM process ( Back & Huak, 2005 ; Searight & Gafford, 2005 ). Similarly, the need for IC may collide with perspectives that do not view the body as distinct from the soul ( Kagawa-Singer & Kassim-Lakha, 2003 ) or illness as something 5 physical as opposed to spiritual ( Pavlish, Noor, & Brandt, 2010 ); that view the verbal imparting of “ bad news ” to be harmful ( Berkman & Ko, 2010 ; Blackhall et al., 2001 ); that regard questions about whether the patient has advance directives in place as intrusive or hostile ( Candib, 2002 ); or that require community, rather than individual, consent ( McGrath & Phillips, 2008 ). Models of health care DM that place it within a cultural context, and the social context of chronic illness, may be more appropriate in such instances ( Candib, 2002 ; Hsaio-Rei Hicks & Sau-Ching Lam, 1999 ; Kagawa-Singer & Blackhall, 2001 ; Kapp, 2010 ; Schim & Doorenbos, 2010 ; Searight & Gafford, 2005 ; Smyth, Riedl, Kimura, Olick, & Siegler, 1997 ).

Kuczewski and McCruden (2001) argue that cultural sensitivity should not impinge on each patient ’ s right to explicitly grant or waive IC. They challenge assumptions that culture is somehow only knowable from the inside; that medical actors do not have cultures; or that culture is a homogeneous entity in which patients only act in congruence with certain identiﬁ able norms. These are points worth considering, but their argument obscures the founda- tional problem with the approach, viz., its grounding in the provider ’ s value system — not the patient ’ s. Others have acknowledged the dangers of cultural relativism in health care DM without rejecting the importance of incorporating cultural values exam- ination into the process ( Berkman & Ko, 2010 ; Kobylarz et al., 2005 ; Schim & Doorenbos, 2010 ).

For example, the health care DM model of Kagawa- Singer and Kassim-Lakha (2003) incorporates the matrix of values of providers and patients and demonstrates how to negotiate objectives to maxi- mize outcomes for health. They observe that beliefs and practices initially seen by providers as obstacles or weaknesses can be viewed as resources and pro- moters of optimal health in a cultural competence framework. Some go further, arguing that the fail ure to incorporate diverse cultural values into the DM process will always be at the expense of what is best for the patient ( Dewees, 2001 ; Shah, 2007 ). Yet , a third question: what is culturally competent practice in assessing DM capacity? Cultural issues may affect the assessment process where values are n o t congruent ( Karel, 2007 ). For example, the client may have a culturally appropriate religious or spir- itual understanding of his illness that appears delu- sional to his Western caregiver, such as a belief in miracles. This may inﬂ uence the caregiver ’ s percep- tion of the client ’ s capacity to appreciate his condi- tion and his choices. Older clients in particular may have treatment preferences based on religious or cultural beliefs but may be unable to provide a list of rational reasons for their decisions. This may affect their performance on the reasoning por- tion of a standard assessment tool ( Karel, 2007 ).

Consistency of the patient ’ s decision with his known values and beliefs may be a better indicator of sound DM capacity than consistency with the caregiver ’ s.

Practitioners must also distinguish between an inabil- ity to verbally communicate and an incapability to make a decision ( Beaulieu & Leclerc, 2006 ). Karel (2007) speaks of the subjective nature of the assessment and the need for providers to monitor the effects of their values and biases on their judg- ments. For example, if one views the individual as the sole locus of DM, one would be more likely to refer that patient for a capacity assessment than if one views that locus as residing in a larger group.

Karel points out the importance of ﬁ nding cultur- ally appropriate ways to communicate verbally and nonverbally with patients, such as addressing elders by their last names and of asking questions regard ing the patient ’ s views and values in clinical interviews and in using formal assessment tools with them. Fail- ure to create an atmosphere of safety and respect may result in a breakdown in communication and of trust and conﬁ dence in the provider and the system. Geiger (2007) advocates the use of a Cultural Assessment Interview Protocol (CAIP) developed for mental health professionals working with cli- ents belonging to either the dominant culture or an identiﬁ able racial or ethnic group. The categories of data elicited by the CAIP include the following :

problem conceptualization and attitudes toward helping , cultural identity , level of acculturation , family structure and expectations , level of racial/ cultural identity , experiences with bias , immigra- tion issues , existential/spiritual issues , and the client ’ s perception of the provider ’ s cultural identity and behaviors. The information obtained via CAIP, together with the provider ’ s self-appraisal of these same factors and the intra- and intercultural trans fer- ences and countertransferences she identiﬁ es, are incorporated into a summary which informs diag- nosis, case conceptualization , and treatment — or indicates the need for referral to another provider.

Although Geiger ’ s work is, like Perez Foster ’ s, ori- ented toward clinical practice, the CAIP suggests lines of inquiry that can be incorporated into cultur- ally competent capacity assessments. Panos and Panos (2002) provide a model incorporating similar kinds of questions. Further research into this aspect of assessment will be needed. at Towson University on September 18, 2015 http://gerontologist.oxfordjournals.org/ Downloaded from 743 Vol. 52, No. 6, 2012 The Gerontologist 4 dissonances can affect health care outcomes ( Stein, Sherman, & Bullock, 2009 ). When operating from within her own cultural norms, the caregiver tends to see herself as without culture and the others — her clients or patients — as “ like ” or “ unlike ” her ( Dewees, 2001 ; Kohli et al., 2010 ). When she fails to see them within the con- text of their own norms and values, this limits not only her understanding but also their power to develop and actualize their own values ( Geiger, 2007 ; Kohli et al., 2010 ; Shah, 2007 ). It will also affect her ability to assess their health care DM capacity, potentially interfering with their right to make the rational or correct choice on their terms — not hers. To develop cultural competence, workers have been advised to begin by becoming self-aware, examining their own cultural biases, prejudices , and attitudes ( Kohli et al., 2010 ); by being attuned to the cultural and religious values that patients and families will bring to any signiﬁ cant decision ( Rose & Shelton, 2006 ) and the importance of supporting their engagement with those values ( Park, Roh, & Yeo, 2011 ); and by considering the impact of the dominant culture in which they oper- ate, to the extent it differs from their own ( Panos & Panos, 2000 ). The literature has focused on several key DM areas in which the cultural conﬂ icts can arise. The most apparent is the question of the proper locus of DM: who must consent to treatment? In the Western model, it is the patient, the one to be treated.

Consistency of the patient ’ s decision with his known values and beliefs may be a better indicator of sound DM capacity than consistency with the caregiver ’ s.

Although Geiger ’ s work is, like Perez Foster ’ s, ori- ented toward clinical practice, the CAIP suggests lines of inquiry that can be incorporated into cultur- ally competent capacity assessments. Panos and Panos (2002) provide a model incorporating similar kinds of questions. Further research into this aspect of assessment will be needed. at Towson University on September 18, 2015 http://gerontologist.oxfordjournals.org/ Downloaded from 744 The Gerontologist The Gerontologist 6 Achieving Cultural Proﬁ ciency In our rapidly aging society, in which costs restrict access to health care for many, cultural factors affecting care become more signiﬁ cant in deter- mining outcomes ( Allen-Meares, 2007 ). Perez Foster warns that “ the hidden discomforts and anxieties of cross-cultural therapeutic interactions, and most particularly the disavowed prejudices and fears of the clinician, are in fact the propelling factors behind the stunning statistics that ethnic minori- ties show the highest premature termination rates of all mental health service consumers [citations omitted] ” ( Perez Foster, 1999 , pp. 270 – 271). As in clinical work, a culturally competent approach to the health care DM domain directs providers to bring their hidden or disavowed responses to light, lest they unknowingly deprive patients of the com- petent care they deserve, as manifested by prema- ture termination or noncompliance ( Geiger, 2007 ; Perez Foster, 1998 ). Dewees (2001) proposes combining a social con- structivist approach with the traditional strengths- based orientation of social work. This orientation shifts the practitioner ’ s perspective from that of an objective observer using empirical values to evalu- ate a patient, toward the view that the patient is the expert in her culture, and her life experience.

By acknowledging that every patient has strengths, and every environment resources, the practitioner helps patients identify them, and marshal them in the service of building the capacity to cope with the challenges at hand, and affords the patient greater power in the relationship. In contrast, a focus on a patient ’ s pathologies, as quantiﬁ ed within the framework of an “ objective ” scientiﬁ c approach, inevitably devalues the patient ’ s lived experiences and resources ( Dewees, 2001 ). Within the social constructivist framework becoming culturally competent requires not only that workers examine their own cultural perspective but also that they move toward an active understanding of how power and dominance affect every provider – patient relationship. As Dewees explains, workers tradi- tionally are expected to learn how to recognize their internal responses, including those not ini- tially accessible to consciousness. Cultural compe- tence requires that they extend that understanding to become aware of the unexamined role of cul- ture in their work — “ the way it generates a world- view (i.e., a ‘ reality ’ ), and how that might clash with another reality generated by another culture ” (p. 39). This perspective meshes with Perez Foster ’ s directive to attend to the mix of cognitive and affective elements of cultural countertransference operating at various levels of consciousness. This attention could illuminate how Western concepts of personhood manifest themselves in providers ’ attitudes about truth telling, autonomy, capacity , and the value of life ( Candib, 2002 ) and how these values become enshrined in the ways they assess DM capacity in patients. Need providers do more? Some have suggested that cultural competence should not be the end goal but rather a step in achiev- ing cultural proﬁ ciency ( Kohli et al., 2010 ; Wells, 2000 ). How would providers move from compe- tence to proﬁ ciency in practice? A social construc- tionist stance invites the provider to think critically about the arrangements of power and politics in the dominant culture in which the provider/patient dyad operates and appreciate how these affect caregiving ( Dewees, 2001 ). This approach goes beyond being respectful of and knowledgeable about differences with patients who are “ cultural others ” and invites providers to reexamine these arrange- ments with respect to their impact on patients ’ interests and values. Differences in how patients who belong to less powerful groups are treated by, and thus come to perceive, the health care system and individual providers affect their conﬁ dence in the process and its outcomes ( Kagawa-Singer & Kassim-Lakha, 2003 ; Stein, Sherman, & Bullock, 2009 ; Wells, 2000 ). If the dominant group in society can impose a hierarchy of norms with its own self-interest in mind, this allows the group to assign positive or negative values to different norms and to create groups whose nonnormative cultural values deﬁ ne them as other , allowing them to be controlled and exploited. This process of othering is often auto- matic, involving unexamined constructions that create a worldview that differs from the reality of the other ( Dewees, 2001 ; Kohli et al., 2010 ). The result robs the individual patient of his power in the relationship and, as Shah (2007) warns, leads to negative outcomes for all patients. Privileging a Western, empirically based, biomedical model and ignoring or devaluing the models and practices embedded in other cultures, he says, is a form of neo- colonialism, which drives out the devalued practices and leads away from, not toward, best practices in health care. Wells (2000) describes a continuum of behavior ranging from cultural incompetence (a state of ignorance) through cultural knowledge, awareness, 7 sensitivity, competence, and ending with cultural proﬁ ciency, a state in which culturally competent practices are integrated into an organization ’ s cul- ture, and both the cognitive and affective stages of development are fully realized. On this continuum, knowledge acquired in the beginning stages must be applied to create attitudinal and behavioral changes. Thus , the worker ’ s lived experience of working with cultural others — experiential and emotional working through of undiscussed, unex- amined , and unconscious attitudes and assumptions about those others and about her own identity — is essential ( Perez Foster, 1998 ; Wells, 2000 ).

Perez Foster ’ s descriptions of her own experiences and process of working through them are instruc tive on how this occurs. The cultural countertransference approach is valuable because it predicts that interac- tions with patients will inevitably trigger responses in the provider , which affect, if they do not impede, the process of DM and of assessment, and it provides assurance that attending to these responses will result in real beneﬁ t to the caregiving relationship. When turning the lens inward, providers might consider how seemingly neutral terms reﬂ ect values and attitudes. Personal agency, autonomy, truth telling, and disclosure are the normative values in the dominant culture of the United States These values sound so admirable and right that one strug- gles to ﬁ nd adequate words to describe their oppo- sites in positive language. One might consider how words create mental categories and foster a mental habit of “ othering ” a patient. For example, is it accurate to speak as if cultures were somehow homogenous items or ﬁ xed over time? What exactly is the culture of the American-born child of parents born and raised, respectively, in South Asia and Turkey? Or, for that matter, the child of two American-born parents belonging to different classes and ethnic groups? Not all individuals born and raised within one “ culture ” embrace its normative values and attitudes. Age alone can make a differ- ence in how closely an individual allies herself with a given cultural value ( Berkman & Ko, 2010 ). Even beyond the effect of age, the passage of time plays a role. For example, in a country with an undevel- oped health care system having limited resources, sharing the bad news diagnosis of a life-limiting disease or condition may convey hopelessness and be detrimental to the patient ’ s mental state. As the practice of medicine changes and — one hopes — provides more options for intervention, younger peoples ’ attitudes toward individual DM and truth telling may change as well. A critical, and often uncomfortable, aspect of self-examination involves uncovering the implicit racial biases that form a part of practitioners ’ coun- tertransference. Because cultural proﬁ ciency involves using self-examination in the service of change beyond the individual level, the next step would be to extend the process beyond the practitioner ’ s inter- nal responses. The Undoing Racism training pro- grams run by The People ’ s Institute for Survival and Beyond offer this opportunity. (The Antiracist Alliance [ http :// www . antiracistalliance . com , last accessed January 28, 2012 ] provides information about the People ’ s Institute trainings and links to multimedia resources on this topic and to a com- parative survey of this and other training programs to combat racism, prepared by the Aspen Institute ; Shapiro, 2002 .) These programs enable partici- pants to explore both their internalized racism and the systemic nature of racism in the U nited S tates — how it is perpetuated and how it can be undone. The need to look beyond the individual practi- tioner ’ s internal processes is echoed in Shah ’ s (2007) call to move beyond cultural competence — which seeks to make patients comfortable within a Western paradigm of treatment — to what he calls ethnomedical competence, which concerns the systematic use of symmetrical learning pro- cesses to preserve culturally embedded con cepts.

This approach encourages the use of plural and hybrid (Western and non-Western) treatment modal- ities. Only by doing so, Shah argues, can providers and their organizations truly arrive at best practices.

The imperative to transcend the level of the indi- vidual actors represents the next challenge for providers, organizations , and society in developing cultural proﬁ ciency. Conclusion Working with older patients frequently requires caregivers, patients , and their families to grapple with highly charged issues when health care deci- sions must be made. Issues such as truth telling, personal autonomy, DM capacity, death , and dying may be associated for all these actors with strong, but not necessarily conscious, beliefs, attitudes , and values. A provider ’ s commitment to understanding the beliefs, values , and atti- tudes embedded in her own worldview — and that of her organization and her society — and to honoring her patient ’ s worldview when the two diverge will promote culturally proﬁ cient care and assessment . at Towson University on September 18, 2015 http://gerontologist.oxfordjournals.org/ Downloaded from 745 Vol. 52, No. 6, 2012 The Gerontologist 6 Achieving Cultural Proﬁ ciency In our rapidly aging society, in which costs restrict access to health care for many, cultural factors affecting care become more signiﬁ cant in deter- mining outcomes ( Allen-Meares, 2007 ). Perez Foster warns that “ the hidden discomforts and anxieties of cross-cultural therapeutic interactions, and most particularly the disavowed prejudices and fears of the clinician, are in fact the propelling factors behind the stunning statistics that ethnic minori- ties show the highest premature termination rates of all mental health service consumers [citations omitted] ” ( Perez Foster, 1999 , pp. 270 – 271). As in clinical work, a culturally competent approach to the health care DM domain directs providers to bring their hidden or disavowed responses to light, lest they unknowingly deprive patients of the com- petent care they deserve, as manifested by prema- ture termination or noncompliance ( Geiger, 2007 ; Perez Foster, 1998 ). Dewees (2001) proposes combining a social con- structivist approach with the traditional strengths- based orientation of social work. This orientation shifts the practitioner ’ s perspective from that of an objective observer using empirical values to evalu- ate a patient, toward the view that the patient is the expert in her culture, and her life experience.

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