Farhad Tabrizi, a 69-year-old immigrant from Iran, is brought to the emergency room at St. Vincent's Medical Center (a private urban hospital) after coughing up blood. He presents with severe coughing, fatigue, chest pain, shortness of breath, and headaches. After stabilizing Mr. Tabrizi, the emergency room team admits him to the hospital, where he is given (over the course of a few days) a thorough workup, including chest x-rays, CT scans, mediastinascopy, and a PET scan.
At the start of the visit, the nurses attempt to gather a detailed health history; but this proves difficult, since Mr. Tabrizi speaks almost no English. He does speak fluent Farsi, but there are no Farsi-speaking medical personnel readily available. However, Mr. Tabrizi is accompanied on-and-off by his adult son, who is reasonably fluent in both English and Farsi. He is also accompanied intermittently by his wife, who speaks only Farsi. (The wife makes it a point of regularly offering prayers for her husband's health.) The nurses attempt to gather a health history whenever the son is present, which is not always easy, since his visits are unpredictable. Even when his son is present to help translate, Mr. Tabrizi seems extremely uncomfortable offering up any detailed information about his own or his family's health history, causing high levels of frustration among the medical staff.
Additionally, Mr. Tabrizi appears extremely reluctant to eat whatever food is offered him in the hospital. This is most pronounced when he is alone-if neither his son nor his wife is present at a mealtime. On the second day of his stay, his son explains to the flustered nurses that Mr. Tabrizi is fearful that the hospital food may contain hidden pork by-products. Since he is a devout Muslim, he feels it is safest to refuse the food altogether unless he is absolutely certain. Although the son has attempted to persuade Mr. Tabrizi that he (as a sick person) must eat, Mr. Tabrizi apparently is determined to eat as little as possible. The chief nurse curtly replies that, while religious belief is important, Mr. Tabrizi needs to keep his strength up if he hopes ever to go home; thus he will need to nourish himself by eating more. She says that she will "see what we can do" about ensuring that there is no pork used in the hospital's food preparation. The son thanks her for her help. From then on he and his mother attempt to bring outside food to Mr. Tabrizi whenever they visit.
After almost three days in the hospital, the results of the various scans are in; and the attending physician, Dr. Looke, sits down with Mr. Tabrizi to discuss his situation. His son and wife are also present. Dr. Looke first offers a handshake to Mr. Tabrizi's son. He inquires explicitly about the extent of his English skills and asks if the son would be willing to translate what he is about to say to Mr. Tabrizi. He agrees, while Mr. Tabrizi and his wife sit by. The doctor then gazes directly into Mr. Tabrizi's eyes and tells him that he has extensive small cell lung cancer.
After a moment of stunned silence, the son turns to his father and tells him in Farsi that the doctor believes that he is very sick, with some "growths" in his body. Dr. Looke goes on to say that Mr. Tabrizi most likely does not have long to live. The doctor holds up two fingers (at which point the patient grows increasingly alarmed and agitated), describing that there are basically "two possible treatments" available for this cancer: chemotherapy and radiation; Dr. Looke strongly prefers beginning with the first (chemotherapy). In spite of Mr. Tabrizi's alarm and confused expression, the doctor presses on that, given the apparently advanced stage of the disease, even chemotherapy would be very unlikely to provide a complete cure, but it could provide some relief and lengthen the remainder of his life. The son, again silent for several moments, then turns to his father and also holds up two fingers. He tells him that the doctor says he must do two things to care for himself: eat well and get more rest. He also relays that his father could take some "strong medicines" which would most likely help him to get better. Mr. Tabrizi looks extremely uncomfortable but says nothing.
After a few more moments, Mr. Tabrizi, somewhat confused, asks (via his son) what the "strong medicines" would consist of. The doctor replies by describing (in some detail) what the course of chemotherapy would look like-how often it would be administered and that the treatments would last for several weeks. He also describes that it may produce severe side effects such as nausea, vomiting, increased fatigue, and elevated risk of infection. In spite of his hesitations, the son attempts to translate the bare outlines of this information (leaving out the term "chemotherapy"), at which point Mr. Tabrizi declares flat-out that he doesn't want any such cumbersome treatments; they would compromise his relationships with his family and friends and place too heavy a burden on his wife. Further, he doesn't really know what might be in such a strong medication that could help him get better. Instead, he will simply do the two things the doctor had recommended-improve his diet and get more rest.
What could/should the doctor/hospital have done differently in order to handle this case in a more helpful and culturally competent manner?
Reflection by Doha Raik Hamza
Reflection by Sheik Hassan and Hossam E. Fadel
Reflection by Abdelmalek Yamani
Reflection by Karen Peterson-Iyer
Introduction to Culturally Competent Care
Introduction to Culturally Competent Care for Muslim Patients
Karen Peterson-Iyer is a program specialist in health care ethics at the Markkula Center for Applied Ethics.
The cases here are fictional composites made up from the details of many different real situations.
