Medical Decision Making among Foreign Born Latino Elders with Multiple Chronic Conditions
Author(s) Bravo, Rosana Leos Advisor(s) Wallace, Steven P Abstract: Background and Significance: Patient centered care is based upon the fundamental focus of the clinician creating a dialogue with patients to assess their preferences and engage in medical decision making. Medical decisions are multidimensional, dynamic and complex and the process may vary given the sociocultural differences presented by the growing Latino elderly population. To be patient centered, we must understand how patterns of engagement, cultural concepts of illness and faith play in meeting elder Latino immigrants needs and preferences and how clinicians may more effectively interact with this patient population. This study identifies typologies of decision making with foreign born Latino elders with multiple chronic conditions who are enrolled in an integrative geriatric health care program. Three separate yet interconnected research aims include how patients engage medical encounters (aim 1) using their cultural concepts of illness (aim 2) and their faith (aim 3) Methods: This study used qualitative methods influenced by grounded theory to conduct three in depth interviews in Spanish per respondent over 9 months with a convenience sample of 13 Latino immigrants (39 total interviews) from Central America, South America or Mexico. All had multiple chronic conditions and participated in PACE (Program of All Inclusive Care for the Elderly) an integrated medical care program for nursing home eligible Medicaid Medicare recipients. Interviews were audio recorded and transcribed verbatim in their original language. All audio recorded field notes and memos were also transcribed verbatim. The interviews explored participants' medical experiences, paying attention to the patients' patterns of engagement during medical encounters, their illness experiences and their faith in God. Data was analyzed using an interpretative lens based on a grounded theory constructivist approach. Findings: Foreign born Latino elders' decision making processes were made within a cultural context and were unique to each person. Decisions followed a pattern described by a proposed model that involved balancing a fear of perceived results with or without medical intervention and hope both in medicine and God. Personal and vicarious experiences, knowledge, available resources and, most importantly, cultural beliefs, values and norms informed the pseudo cost benefit analysis of perceived risk and benefits. Regardless of type of medical decision, therefore, some criteria held more influence than others at any one time, yet all were included in the decision deliberation process. Aim 1: Latinos engaged the medical encounter using three types of engagement and communication: technical, social and emotional. Participants were most likely to engage in medical encounters in social and emotional ways. Trust increased with level of patient doctor relationship (good doctor, person of trust, advocate) Aim 2: Immigrant elders held on the traditional belief on the importance of maintaining the human body in a state of balance and harmony to avoid disease yet still believed in biomedical treatments. Biomedicine and traditional remedies often functioned to complement one another. Aim 3: Faith was not found to serve in direct opposition to medical care treatments, except for mental health disorders when mental illness was perceived to be caused by the accumulation of social and life stressors. Given the belief that God is in control, faith indirectly influenced decision making. Faith was particularly magnified in times of crisis where critical decisions were contemplated. Faith served as a coping mechanism most often manifested through prayers and helped to create meaning to life's circumstances (e.g. death, miracles) including legitimizing the doctor's actions as part of God's overall plan serving as the "hands of God." Like medicine, faith provided hope. Conclusions: Multiple chronic conditions pose many challenges, including the questions of how to provide patient centered care in the context of competitive health care priorities for diverse populations. Study findings contribute to practice based conversations, particularly around the implementation of patient centered care in specialized populations. The outcomes of this descriptive research project serve as building blocks to larger hypothesis testing investigations of older adults and decision making.