Cases That Test Your Skills

When culture complicates treatment

Mr. V, a Laotian refugee, will not consent to post-amputation wound closure, which would prevent further infection and limb loss. The challenge: to break through cultural barriers and gauge this diabetic patient’s mental state.



History: Noncompliance and ‘resignation’

Mr. V, 43, has a history of diabetes. He was admitted to the hospital with altered mental status as manifested by confusion, fluctuating sensorium, and disorientation. His altered mental status was most likely caused by septicemia secondary to osteomyelitis from a right plantar foot ulcer that had become necrotic, tracking through the foot bones into the tibia and fibula.

An emergent amputation was performed of the right tibia and fibula approximately 15 cm distal to the patella, with intent to close the wound within 24 to 48 hours; Mr. V also was started on IV antibiotics. The patient, however, refused the closure procedure, stating that he had not been properly informed before the amputation and would not consent to another procedure until he could speak with his elder brothers.

The surgical team noted that Mr. V had signed the consent form before the amputation. The surgeons also feared that not closing the wound promptly could lead to reinfection, further limb loss, or even death.

The hospital’s psychiatric consultation service was asked to determine the patient’s mental capacity. It should be noted that Mr. V emigrated to the United States from a Laotian refugee camp 12 years prior to admission. He speaks only Hmong, the language of the Hmong people indigenous to Southeast Asia.

Mr. V was diagnosed 12 years ago with insulin-dependent diabetes mellitus and has been hospitalized numerous times for foot ulcers. His chart indicates that he has repeatedly disregarded doctors’ orders and has not performed proper foot hygiene.

Previous physicians and caregivers, however, were even more frustrated with the apparent attitude of resignation with which Mr. V has approached his diabetes. He seems to believe that his medical condition is causing his problems and that he cannot prevent diabetic sequelae. He has no history of mental disorders and to our knowledge had never received a psychiatric evaluation.

Why has Mr. V. not complied with diabetes treatment? Is he unable to understand the gravity of his condition?

Dr. Krassner’s observations

Noncompliance is a recurring theme in the treatment of Hmong patients,1-4 as is clinician frustration with their lack of compliance.5,6 This suggests that cultural differences that could have contributed to Mr. V’s noncompliance need to be examined before determining his mental state.

Approaching a culturally sensitive case with an open mind and a respectful attitude will increase the chances of a positive outcome and provide a valuable learning experience for the clinician. You might proceed as follows:

Question your assumptions. Some clinicians assume that psychiatry applies universally to any patient, regardless of cultural background. However, the categories psychiatry imposes on illnesses may not adequately describe an illness as a patient of a different culture experiences it.7-9

Find an interpreter—one who speaks the language and has a “lexicon for emotional experience” similar to the patient’s.10 In this case, we wanted an interpreter who not only spoke Hmong, but who understood the complexities of the animistic Hmong spirituality and could reconcile it with our empirically derived Western belief system.

Depending on a family member to translate can be problematic if that person cannot accurately explain the patient’s disorder, the need for treatment, or the implications of noncompliance. We found the ideal interpreter: a Hmong registered nurse. If you cannot find an interpreter of the same ethnicity as the patient, at least find one who speaks the same language.

Beware of misinterpretation. A patient from another culture who understands some English may not assign the same meaning to words or phrases that we do. For example, when a Hmong says yes, he or she means, “I am listening, and I respect what you’re saying.” In this way, “yes” can be mistaken for consent; noncompliance by Hmong patients can often be traced to this misinterpretation.11

Define “capacity” and its implications. Capacity is always assessed in the context of the question, “capacity to do what?” The context must be explicitly identified, because life decisions require varying levels of capacity. For example, elderly patients with dementia often lack capacity to manage their finances, but have capacity to resolve end-of-life issues (e.g., hospice placement, do-not-resuscitate requests).

For Mr. V, the question was whether he had capacity to refuse the second surgery. To have capacity to consent to or refuse a procedure, a patient must understand the procedure, its risks and benefits, and the risks and benefits of refusing the procedure. The patient also must not be vulnerable to coercion (e.g., by a family member).

Clearly, Mr. V understood the procedure based on his notions of health, illness, life, death, family, social structure, and other concepts.6,12,13 One might question whether a patient such as Mr. V is ever fully informed before giving consent. Even though he had signed a consent form for the amputation, the signature in his eyes did not qualify as consent. Further, having read through our hospital’s consent form, I defy anyone to translate its legal subtleties into Hmong.

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