Workshop Guide



Open Workshop


Open Instructor

Challenging Patient Curriculum Instructor Guide^

Refugees and Immigrants

Ethical Issues in Caring for Refugees and Immigrants



The overall goal of this session is:

  1. A PGY-3 resident will be able to identify and address common ethical challenges in caring for refugees and immigrants.

Specific Objectives:

    1. Review principles of Western ethical principles in healthcare, including patient autonomy.
    2. Discuss the role of family members in medical decision among culturally diverse groups.
    3. Identify ways to communicate bad news to patients from different cultures.
    4. Identify patient preferences regarding disclosure of information.

ACGME core competencies:

Patient Care

  • Demonstrate the ability to communicate effectively with patients regarding diagnosis and treatment decisions, especially regarding terminal illness

Medical Knowledge

  • Learn how different cultures wish to approach advance directives and living wills

Practice-Based Learning and Improvement

  • Gain competence in consulting with other members of the healthcare team, such as the Ethics Committee, when working with patients and families on complex ethical issues in relation to communication about terminal illness and treatment

Interpersonal and Communication Skills

  • Demonstrate the ability to communicate effectively with patients and their families from different cultures with regard to delivering bad news, advance directives and other critical decision making processes


  • Be aware of his or her own personal attitudes, beliefs, biases and behaviors and how these may impact clinical care
  • Recognize the tensions that can result from different viewpoints about patient autonomy and a western-centric model vs. diverse viewpoints from other cultures

Systems-Based Practice

  • Identify community resources to assist refugees in end of life decision making


Session Guide^


Time Needed:   1.5 hours: ppt, movie (condensed version), “Hold Your Breath” and discussion.

Equipment Needed:

  • Computer
  • LCD projector
  • VCR and TV monitor (the movie is a videotape; it would be good to get this on DVD)

Personnel Needed: Instructor

Suggested Readings (attached):

Marshall PA, Koenig BA, Barnes DM, Davis AJ. Multiculturism, bioethics, and end-of-life care: case narratives of Latino cancer patients. From Monagle JF, Thomasma DC (Eds). Health Care Ethics: Critical Issues of the 21st Century. Sudbury, MA: Jones and Bartlett Pub, 2005 (Originally published by Aspen, 1998).

Instructor Script and Notes:

Part 1 – PowerPoint Presentation

  1. Review the objectives of the session as outlined on the ppt slide
  2. Discuss each slide, self-explanatory.
  3. Slide 15-introduce the film, Hold Your Breath, and review the questions for later discussion after the film. Discussion points:
    1. Role of patient’s Muslim faith
    2. How did Mr. Kochi and his family respond to his diagnosis
    3. Why were there misunderstandings about treatment options?

Part 2 – Video: Hold Your Breath
(running time: 14 minutes)

This is a condensation from the full film which runs an hour. Show the video. It is a documentary about an Afghan man who is diagnosed with stomach cancer. The story is told from multiple perspectives: the patient’s, his family’s, his friend’s, and his doctors’. There are many communication misunderstandings and valuable reflections are made by the various people interviewed. The importance of the patient’s deeply religious faith in his decisions is also highlighted. The group should return to the questions above after the video is shown. Initially, can ask the group for their overall reactions to start the conversation.

Part 3 – Discussion of personal examples and experiences

The residents are asked to share their own examples of ethical challenges in caring for refugees or immigrants around end-of-life planning and communication.


Open Questions
for PGY-3

Questions for PGY-3^

Subject: Ethics in the Care of Patients from Diverse Cultures

  1. Which of the following groups is least likely to want to be told a terminal diagnosis:
  1. African Americans
  2. Mexican Americans
  3. European Americans
  4. Korean Americans  X
  1. Surveys of oncologists have shown that they are generally:
  1. Comfortable with disclosing the diagnosis to the patient’s family member rather than directly to the patient.
  2. Comfortable asking the patient what he or she prefers with regard to disclosure of diagnosis to him or her.
  3. Comfortable with telling the patient directly his or her diagnosis without going through family or other intermediaries.  X
  1. All of the following are reasons for patients from minority groups to not have advance directives, except:
  1. Mistrust of the medical establishment.
  2. Belief that every disease, with the proper technology, is curable. X
  3. Lack of knowledge about advance directives.
  4. Lack of fit with their cultural beliefs about death and dying.
  1. You have been caring for a patient with severe CHF for one year and his long-term prognosis is poor.  The patient is Turkish, and communication must be through the use of an interpreter. The patient is brought to his visits by different family members each time and it appears that they don’t talk with each other or fully understand the seriousness of the patient’s illness. It has been very frustrating since you often have to repeat the same thing, while often finding it difficult to find the time to therefore bring up important issues with the patient and his family, such as DNR and other end of life decisions.  Which is the best strategy at this time for you to try:
  1. Tell the patient and family that it is in his best interests to sign a DNR document.
  2. Make a home visit to see the patient in his home to get an idea of how he is coping with activities of daily living.
  3. Arrange a one-hour office visit for all the key family members and patient to attend to discuss these issues. X
  4. Ask permission to speak to the family lawyer to prepare the necessary documents.
  1. What is the most effective strategy in delivering “bad news” to patients?
  1. Assume all patients want to hear everything about their diagnosis, unless they tell you otherwise.
  2. Provide the prognostic information in detailed statistical terms.
  3. Wait until something bad actually happens before asking what they would like to hear about it.
  4. Discuss patients’ preferences about what they want to be told before they become ill. X