Tag Archives: culture

I think therefore I am? – Loss of Signal

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Photo by Sincerely Media on Unsplash

He was worried that people couldn’t understand what he needed. His English was limited. Most of our staff’s Chinese was much more limited. Not an uncommon situation. We had previously prepared picture cards for other patients. Simple pictures with words in various languages for symptoms such as pain, breathlessness and nausea. A simple low-tech form of communication. Apps such as Google Translate can help when you are desperate but they are limited. What is required is Google Interpret. Not just the words but interpretation within a cultural context as well. The AIs are not quite there yet, soon come.

In the meantime, we try our best with second languages. A lot of people from China can speak Mandarin which is the government proscribed National Language. Mandarin is often their second language, with the language that their parents used with them at home being their first language.

Mandarin was my first language as a child but once I went to school it was shunted off to the side and English dominated. Many years later I find myself often having to use my now second language, Mandarin, in clinical interactions. Mandarin often is the second language of the person I’m dealing with. We both end up speaking our common second language. It’s not perfect, it’s not 100% fluent for either of us. It does make a difference and is much better than not being able to communicate at all.

The basic human connection. I hear and understand you. You hear and understand me. I can acknowledge your fears and needs. I want to do something about them. We will help you out. We are all here to help you, and to support your family. We’ll get you through this.

I think therefore I am? – Homonyms and Other Words

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Photo by Jackson Simmer on Unsplash

In the Chinese languages the word for the number 4 sounds like the word for death. Thus it is avoided as much as possible. In Chinese-dominated countries, buildings will have missing 4th, 14th, 24th floors, etc. On hotel room floors there will be missing rooms 4, 14, 24, etc. Such is the danger of the word that it must not be mentioned if at all possible. This can also occur in non-Chinese countries where members of the Chinese Diaspora have settled. Through a laborious application through the local city council, the former number 224 is now known as 222a.

To mention death is to welcome it. Don’t talk about it and you can avoid it. Keep away from hospitals if you don’t want to get sick. Don’t go to graveyards or the deadly malaise will be caught. Advance care planning can be a difficult subject to raise for members of such cultural/ethnic groups. Funeral insurance may be a hard sell. Death is not discussed and people become unfamiliar with it. What you don’t know about becomes a scary monster. Something to be feared.

Not many visitors want to take the tour of the local hospice. “What do you do for a job?” “Oh…you must be so…special,” whilst clutching a bulb of garlic in one hand and in the other prayer beads. Holy water, buy now before stocks run out.

The Palliative Care trainee greeted the Renal trainee, “How you doing?”

The Renal trainee replied, “I’m saving lives.”

The Palliative Care trainee thought to himself, “Sure you are, while I am saving quality of life.”

If people have trouble even talking about dying, how will they be when it comes to looking after dying people? How will the dying patient be treated? Will they be treated as a failure in life? Are they worthy of our care and attention? They can wait, they’re dying anyway. As if they had any say in the matter.

As medical technology has improved throughout the world, societies are less accepting that death is a fact of life. Death-denying cultures are on the rise at the detriment of some of the most vulnerable people on Earth, those who are dying. That doesn’t sound right to me. Maybe I’d better be careful in my choice of words.

Palace of Care – True Flies

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Photo by Dieter Pelz on Unsplash

Every summer the hospice is visited by thousands of flies.

We are situated next to a big park and flies are a constant presence in the warmer months.

They can be really annoying for our patients who may be too weak and tired to fend them off. Their family members may also have troubled keeping the flies away.

Every summer I have said that I would bring in an electric bug-zapping racquet to deal with the flies.

This summer I finally brought one in.

In recent weeks as well as doing a medical round I also do a fly-catching ward round at least once a day.

I made myself available 24/7 on-call for the purpose of catching pesky flies. I can be called in any time of the day or night.

This has led to great amusement for patients, family and staff members.

Yes, I am probably the most highly qualified pest control worker in the country.

As well as catching flies I practise some medicine as well.

I clear each room of flies and then I head outside to the balcony area and get rid of the ones that are out there as well.

It’s one man against thousands of flies but if it makes my patients’ time slightly more bearable it is worth it.

It is also a good way to add to my daily step counts.

I will continue to catch flies and expand my repertoire of work roles.

This is especially important each and every Flyday.

Palace of Care – Second Languages

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Photo by Tim Mossholder on Unsplash

They had lived in New Zealand for many years and could speak English as their third language. Their English was pretty good but they did not feel confident when discussing medical issues with healthcare staff. Their children had grown up here but were busy with work. One child worked in NZ, the other child was overseas. Thanks to time zone differences, their overseas child would sometimes be available to help with translation during our patient’s clinic appointments. The patient and their spouse didn’t want to risk any misunderstandings when it came to discussing medications and treatment plans.

We had offered them a virtual appointment but they wanted to come in person. Face to face it was easier to communicate even with masks on. I greeted them in our shared second language, Mandarin Chinese. This made them feel at ease right away. They felt they would be able to communicate better with me. They had come for a pain review and I was able to quickly assess our patient. Our patient would be seeing their Oncologist the next day. I provided them with written instructions and also wrote a note to the Oncologist asking them for advice about another problem they had mentioned to me.

The communication was by no means perfect as my Mandarin is not 100% fluent, especially when talking about medical issues. I had to use occasional English words interspersed between paragraphs of Mandarin but we were able to understand each other well in terms of language and also cultural expectations. They were pleased to meet our pharmacist who could also speak Mandarin.

It felt good that our diversity and inclusion recruitment programme was making a difference. Our effort to reflect our demographic continues to be beneficial and is another patient-centric point of difference in the services we provide. We are doing better than before and will continue to keep trying to make our ability to connect better.

Palace of Care – Songs of Gratitude and Connection

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This morning’s Waiata Singing Practice was special. Our team were joined by three generations of our late patient’s whānau/family who returned to the hospice a week after his death. We all crammed into the big patient lounge which has a view of the local park through the windows.

The whānau sang original songs that had been composed by our late patient, their husband/brother/father/father-in-law/grandfather. A man of musical and poetical talent who had shared his knowledge with his children and the many other schoolchildren he had taught.

His songs were written in a combination of Te Reo Māori and English. Integration of the different cultures had always been on this songwriter’s mind. He had led by example and his family did him proud this morning. They sang from their hearts and channelled his voice.

They shared with us precious gifts this morning with their spine-tingling renditions of beloved family songs. The beautiful whānau harmony uplifted us all. Even the most battle-hardened palliative care physicians were overcome by a sudden attack of hay fever.

They thanked us for the care we had provided to their loved one and their whānau members. “His wairua/spirit felt cared for here, that’s why he wanted to come back at the end.”

We thanked them for allowing us the privilege of looking after their loved one.

Our connection was further affirmed when both the whānau and our gathered staff sang a final waiata together, Purea Nei.

We promised to meet again.

I think therefore I am? – Culture Clash

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Photo by Nick Fewings on Unsplash

Each place has its way of doing things and when people from different cultures intersect there may be clashes and discord. Some cultures will under-treat, and others will over-treat. Where will Goldilocks feel most comfortable? Too much of a good thing isn’t always a good thing. The most expensive treatments aren’t always the most effective.

Inequity pervades the world. NZ-trained doctors who have traveled back to Asia may be shocked that people with non-survivable strokes are kept on life support for weeks or even months as standard practice. Their relatives with end-stage dementia are fed via tubes and the quantity of life may be prolonged for lengthy periods, of up to years. This does not always come with any discernible quality of life benefits.

People may be from healthcare cultures in which the patient and family can have whatever they desire if they can pay for it. This can include experimental therapies with or without scientific bases. Desperation can lead to high sales figures but is there any care in those types of healthcare? People search all points of the compass but do they find any compassion? Expectations are set but people do not become settled. When time is of the essence is it correct to waste it without people’s informed assent?

Sneak Preview from Bedside Lessons – Chapter 65 – Please Take A Seat

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Photo by Stephen Audu on Unsplash

Family meetings are common in healthcare settings and are organised to convey a point of view or to try to bring together disparate points of view. These events may be the first chance that some of the key stakeholders, i.e. the family and the healthcare team, have to meet each other. First impressions, as within any first meeting, are important. As you can only meet for the first time once, you’d better do your best to make sure it goes well. To establish a trusting therapeutic relationship between the patient, their family and the healthcare team, rapport must be established quickly. Every encounter can count, but not everything can be planned for.
“Come in, please take a seat.” Oops not enough seats, I didn’t think there would be so many people joining us. “I’ll get some more chairs.”

“No doctor, it’s okay, we’re Islanders, we’re used to sitting on the floor.” He sat down on the floor in a cross-legged position and the rest of his family followed.
While dropping to the floor and re-arranging my legs into a well-versed pose, “I’m an Islander too, and I’m used to sitting on the floor too.” I was joined by my cross-legged team member. Eyes were in contact and were levelled, as were some of the power differentials. Serious issues were discussed in a different but more trusting fashion.

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I think therefore I am? – The journey begins

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The largest health and disability system reforms for a generation will start in Aotearoa New Zealand (ANZ) starting in July of this year. One of the major changes is the creation of an independent Māori Health Authority. Its important task is to address the health inequities and disparities which lead to Māori people dying seven years earlier than other residents of ANZ. It has taken us 182 years to reach this sorrowful state and a real change of mindset is required if anything is to change at all. It can feel almost too big. What can I do to make things better? What difference can I make as an individual when the system has been designed to continue producing the same results? Nothing changes if nothing changes.

During a visit to one of the local marae/meeting place years ago my hospice staff were asked, “What do you have at your hospice that would make Māori feel welcome?” We struggled to answer the question. “Well here is your wero/challenge. How can you make us feel more welcome? Show us some evidence, don’t just talk.”

Thus began our journey of discovery, we needed to be educated. Bi-cultural competency training was arranged for all staff members throughout all levels of our organisation. For both clinical and non-clinical staff. We learnt about the adverse effects of colonisation, and the poison of institutional racism. We are encouraging each other to use more Te Reo Māori words in day to day hospice life. Bilingual signage has been placed as we seek a more open cultural direction.

We are singing Māori waiata/songs together every Wednesday morning. Today we were graced by a special impromptu guest. One of our tangata whenua/Māori inpatients walked into the room where we were singing. She had a big smile on her face as she joined her voice with ours. It was a privilege to be able to sing alongside her for those few minutes.

We have only just begun our journey of discovery but it is making a difference already. Another tangata whenua patient we cared for recently told me, “I started laughing as soon as I walked in. The wairua/spirit of your place felt good. I feel comfortable here. I trust you guys.”

It’s a small step in the right direction. Are you going to join us on the hīkoi/walk?

PIANO lessons

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Realisation

Photo by Anastasia Kalinkina on Unsplash

I arrived around the same time as the Eat My Lunch delivery arrived. This was a local social enterprise which had been set up and the concept was that if you bought a lunch, the company would provide a lunch to a student in need. The company had delivered some school lunches to be distributed to the students. From one of the other network attendees I learnt that the school also provided breakfast for the kids as well as lunch. The lady said that she helped with the breakfast serving at least once a week. She admitted to initially being against the idea, that she had believed that children’s nutrition was supposed to be under the remit of their parents. Over time she came to the realisation that due to personal circumstances this was not always possible, and that providing children with one or two meals a day really enhanced their health, and their learning ability. Since then she happily reported to duty each week, and sometimes even filled in shifts for other people.

Disconnection

Photo by Erik Mclean on Unsplash

A family had come back recently from the Islands, the husband was unwell with metastatic cancer. The teacher asked if the patient was under hospice. I thought that service was only for Palagi – The foreigner – the white people. Despite us having been the hospice for the local area for the past 35+ years local people still did not know that we were available to help our local community members regardless of who they are. A gap that we still haven’t been able to bridge despite many years of trying to connect. What we had done over the past three decades just wasn’t working. We need to try something different. The same old, same old just doesn’t cut it any more. What else can we do to make the connection? That we are here for people just like you. We have been trying to recruit to reflect our local demographic. For our staff to look like our community, and we are hiring for inclusion to encourage diversity of thought at all levels of our organisation. People like us look after people like you, we are one and the same.

Traumatisation

Photo by Andre Benz on Unsplash

The family had lost their father and husband due to a brutal act of violence at the local train station. His life was cruelly stolen from them, and the grief was too much for them to handle. They were lost, set adrift in a cruel sea of grief, with no land in sight, no hope of rescue. Every week they would visit the site of his death, the mother and the children, would weep and could not move on with their lives. This important local community hub held onto their agony with an iron grip. A local amenity that could not be avoided, became not just a place to catch a bus or a train, but a deva-station. Transporting them to a painful past, a tormented present and an uncertain future.

I think therefore I am? – A definition of Grace

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http://www.flickr.com/photos/144232185@N03/30117339256″>PARMIGIANINO,1534-35 – Deux Canéphores se donnant la Main (Louvre INV6466)

In healthcare it is important to set clear boundaries in order to care for yourself and your patients in a sustainable fashion. In the practice of palliative care, boundary setting is even more important, as the therapeutic relationship can be very intense and intimate at times. We have to keep in mind that this relationship will likely end soon, with the death of our patient. It can be a difficult balancing act; using your humanity to make important connections with another human being; while at the same time keeping professional distance to protect the both of you.

That being said, it is inevitable that there will be some cases which will hit you harder than others. When a deeper connection has been made, you will feel the loss and grief much more strongly. Informal reflection with your team members and professional supervision have an important role to play in keeping us palliative care providers safe to continue doing the important job that we have to do. We need to remind ourselves that this is a job that not everyone in healthcare can handle. That those of us who chose to work in palliative care, owe it to ourselves and our patients to look after ourselves. We are a precious resource and if we do not take care of ourselves, we will deny our patients and their families the difference that we can make in their lives, and deaths.

After almost ten years of working exclusively in full-time palliative care practice I would like to share a case that reminded me of just how human I am, and how much value I obtain from professional supervision and from sharing with my team members.

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