Instructor Guide

Open Instructor

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.