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Cultural safety


Respect for patients and families

When culture and duty clash


  • Despite potential cultural differences, all physicians practising in Canada have an obligation to be truthful about all aspects of care, to provide the opportunity for informed consent, to disclose adverse events (accidents in Québec), and to discuss end-of-life issues.
Scales of Justice

There may be times when a physician's legal and professional duty to proceed in a certain manner will be at odds with a patient's desired approach to care. Consider that in some cultures:

  • Physicians are ultimate authorities who are to be obeyed and not to be questioned.
  • It is considered inappropriate for physicians to tell someone that they have a terminal disease. The family is felt to be the best judge of whether and when a patient should be informed.
  • Patients' spouses or their extended family are expected to make decisions for a patient, even if the patient is mentally capable (competent) to do so themselves.
  • Women do not make their own healthcare decisions; instead, male family members do so on their behalf.

Being asked to hide a cancer diagnosis
Elderly woman with two young adults

Background

An elderly Chinese widow is operated on for a bowel obstruction. During surgery it is found that she has a tumour of the descending colon, which is completely resected with no evidence of peritoneal or nodal spread. The surgeon speaks to the patient's family while she is still recovering from the anaesthetic. Her eldest son thanks the surgeon for the information and indicates that his mother should not be told about the tumour given that no further treatment will be required.

Think about it

How would you ensure that you meet your legal and professional duties as a physician practising in Canada, while respecting the patient's and her family's cultural wishes.

Suggestions

Meeting your obligations does not mean sacrificing respect for others' cultural traditions, beliefs, or wishes. You can find balance by:
  1. Offering to tell the truth and full disclosure to mentally capable (competent) patients. Respectfully acknowledge the wishes of the family, but explain you have a legal and ethical duty to inform patients of the medical condition and options for treatment.
  2. Determining whether patients appear to understand the risks and benefits of not being fully informed about their condition, including their entitlement to make their own decisions under Canadian law.
  3. If possible, speaking to patients in private to ensure they are not being coerced into a decision.
  4. Considering the involvement of a cultural broker to facilitate your mutual understanding.

Lessons learned

Respect the patient's wishes and confirm the identity of the person to whom the patient wishes to delegate the right to be informed or to consent to treatment. Document your conversation and don't hesitate to revisit the topic as required. When necessary consider getting a second opinion from a colleague.
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Being told not to speak to the patient
Doctor and male in heated discussion

Background

A patient requires a cesarean section for failure to progress. Her husband refuses to let the male physician speak to her about the situation, insisting that he must speak only to him.

Think about it

How would you approach this situation in a culturally safe mindset?

What are the issues you need to address?

Practice writing a progress note which summarizes your discussions.

Lessons learned

Whatever your clinical decision may be, documenting your rationale for it will allow others to understand the circumstances you faced and thus how and why you came to make that decision.
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