Check My Work Considering multicultural issues related to end-of-life concerns is important while working with clients/patients and their families. An expanded multicultural population in the United States increases the opportunity for case managers to work with individuals with different cultural origins. The beliefs and values that these individuals have are greatly influenced by their culture; this means that many clients/patients may have different meanings and traditions for the end of life and its care. The following case gives you an opportunity to think about cross-cultural issues that case managers may face when working with end-of-life care. Part One: Read the first part of Wilmas case and then answer questions 1-3. Wilma Martinez, a 67-year-old Spanish-speaking woman, has congestive heart failure due to inoperable coronary artery disease. She has been hospitalized three times during the past six months, even though she has reliably taken five medications daily. She seems distressed when her physician discusses advance directives and encourages her to designate a health care proxy. She says she wants everything done to help her survive. The patients daughter usually accompanies her to clinic appointments and serves as translator. A few months after the discussion about advance directives, the physician asks more specifically about Mrs. Martinezs preferences of end-of-life care. This time, Mrs. Martinezs daughter expresses a strong desire that her mother not receive mechanical ventilation or cardiopulmonary resuscitation. It is unclear whether this represents a change in the patients preferences or reflects the daughters wishes (Crawley, Marshall, & Lo, 2002). The physician comes to you as the case manager for Mrs. Martinez to ask several questions. Respond as best as you can. Part Two: Read the second part of Wilmas case and then answer question 4. Wilma Martinez, a client introduced in Part One, moved from El Salvador to the United States to live with her daughter. Mrs. Martinez speaks only Spanish. Through her daughters translations, the patient appears to comprehend details of her illness and treatment. When asked if she understands what the doctor is saying, she invariably nods affirmatively. During a clinic visit when the patients daughter is not present, the physician arranges for a trained medical interpreter to be present. When the physician discusses end-of-life preferences, the interpreter reports that Mrs. Martinez thought that ventilator support and cardiopulmonary resuscitation would hasten her death. Later, the interpreter explains that Mrs. Martinez could not understand why staff were insistent that she, rather than her daughter, make decisions. Mrs. Martinez stated, In my country, the family decides. Assuming that her daughter would make decisions for her, she saw no reason to sign forms. She worried that signing forms would cause legal problems because of her immigration status. The interpreter also suggests that Mrs. Martinezs nodding indicates politeness and respect for the physician, not assent. The physician arranges for a trained interpreter to be present at subsequent clinic visits. By probingfor example, asking, Tell me what you believe is going on in your illnessthe physician ascertains that Mrs. Martinez does not expect to survive her illness. By asking, How would you like decisions to be made about your medical care? the physician confirms that Mrs. Martinez wants her daughter to make decisions for her. Rather than assuming that Mrs. Martinezs nods signifying assent, the physician asks her specifically whether she has any questions or disagreements with the care plan (Crawley, Marshall, & Lo, 2002). After reading the second part of Wilmas case, identify the issues: family disagreements, autonomy, and confidentiality. Discuss in detail the complications of the issues and how cultural considerations relate to each Question: 1. Explain in as much detail as possible what Mrs. Martinez's wishes are. 2. Is the daughter providing alternative directions for medical care? 3.Can you give any reasons why the daughter responds the way she does? 4. Identify the issues: family disagreements, autonomy, and confidentiality. Discuss in detail the complications of the issues and how cultural considerations relate to each