Academic journal article Generations

Cultural Awareness in Health and Social Services: The Experience of on Lok

Academic journal article Generations

Cultural Awareness in Health and Social Services: The Experience of on Lok

Article excerpt

An organization's commitment to serve a diverse and changing client population.

On Lok Senior Health Services in San Francisco provides community-based, comprehensive medical, social, and rehabilitative services to frail elders, integrating acute care and long-term care under one healthcare delivery system. Capitation payments from Medicare, Medicaid, and private sources are combined into an unrestricted pool to pay for all health and related services provided to On Lok enrollees. On Lok's commitment to serve a culturally diverse population is rooted in the organization's origins.

Begun in 1972 as a social model and adult day healthcare program in the Chinatown and North Beach areas of San Francisco, On Lok served frail elders who were Chinese American, Filipino American, or Italian American. As demographics have changed in the San Francisco Bay Area, and as On Lok has expanded from one small site to eight sites, so has the diversity of On Lok's enrollees changed. In 2001, On Lok's 1,070 enrollees comprised the following ethnicities: Caucasian, 12 percent; African American, 10 percent; Hispanic, 12 percent; Asian or Pacific Islander, 63 percent; American Indian or Alaskan Native, 1 percent; other, 1 percent.

This article examines two aspects of On Lok's efforts to incorporate cultural awareness into its delivery system: (1) the organization's experience in obtaining advance directives from participants of many ethnicities, and (2) the organizational commitment to train staff throughout On Lok to be more culturally aware.


The Patient Self-Determination Act (PSDA), implemented in December iggi, requires that all healthcare facilities receiving Medicare or Medicaid reimbursement ask admitted or enrolled patients whether they have an advance directive document indicating how or by whom they would want end-of-life decisions to be made in the event they were unable to communicate this information. Otherwise, the institution must provide the patient with information about advance directives. The PSDA seems to have increased the number of patients who have some form of advance directive, formal or informal (Emanuel et al., 1993). Still, only a small percentage of patients actually discuss advance healthcare directives with their physicians. Many factors influence this choice, including the presence of frail health (Emanuel et al., 1993), the quality of information provided by the primary care physician about cardiopulmonary resuscitation (CPR) (Murphy, 1984; Wagner, 1984), religion (Grodin, 1993), and the ethnicity of the patient (Garalis et al., 1993). Expanding upon research by Klessig (1992) on cross-cultural values and life-support decisions among seriously ill young patients, Eleazer and colleagues (1996) looked at the impact of ethnicity on end-of-life decisions in frail elders from four ethnic groups: Caucasians, African Americans, Hispanics, and Asians. In the study, Caucasian elders were the most likely to have a formal legal document designating a durable power of attorney for healthcare; Asian elders were the most likely to designate healthcare proxies for decision making; Hispanic elders were the least likely to have indicated advance healthcare directives, either formal or informal; and African American elders were particularly unlikely to execute written advance directives due to a fear of exploitation by the medical establishment.

Eliciting advance directives for healthcare from any patient, and especially frail older people, requires discussion of two important concerns: decision making and death. Both raise issues tied to fundamental cultural beliefs. For example, Chinese elders, especially first-generation U.S. immigrants, are reluctant to talk about death. Many believe that just talking about death can bring bad omens. At the same time, many Chinese elders hold the traditional cultural beliefs, rooted in Buddhism, Taoism, and Confucianism, that there is a natural time for death. …

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