Communication and disclosure norms

Context

How bad news should be delivered, who makes the decision, and what role a written directive plays all vary. The temptation is to turn that variation into a lookup table by group, which is precisely what the evidence does not support: the differences are real at population scale and useless at the bedside, because the person in front of you may hold any position within them. The usable finding is not a set of group defaults but a practice, which is to ask.

What this changes in practice

• Treat how bad news is communicated, where decisions sit, and attitudes to advance directives as things to elicit, not predict.

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• Ask what the person believes caused their illness, what worries them most, and what they hope treatment achieves; their explanation shapes the decision more than the diagnosis alone.

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• Aim for cultural humility, a standing practice of self-critique and redressing power imbalance, rather than 'competence' in a set of groups.

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• Hold that goal honestly: a Cochrane review of cultural-competence education found positive but low-quality evidence for patient involvement, and no evidence of effect on treatment outcomes.

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What to ask

• “How much would you like to know about what is happening?”
• “Who should be part of decisions about your care?”
• “What worries you most right now?”

Sources

• Searight, H. R., Gafford, J. (2005). Cultural diversity at the end of life: issues and guidelines for family physicians.
• Kleinman, A., Eisenberg, L., Good, B. (1978). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research.
• Tervalon, M., Murray-García, J. (1998). Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education.
• Horvat, L., Horey, D., Romios, P., Kis-Rigo, J. (2014). Cultural competence education for health professionals.