Registered nurses experienced more moral distress and lower collaboration than physicians, they perceived their ethical environment as more negative, and they were less satisfied with the quality of care provided on their units than were physicians. Provider assessments of quality of care were strongly related to perception of collaboration. Improving the ethical climate in ICUs through explicit discussions of moral distress, recognition of differences in nurse/physician values, and improving collaboration may mitigate frustration arising from differences in perspective.

Objective.\p=m-\Tostudy differences in the attitudes of elderly subjects from different ethnic groups toward disclosure of the diagnosis and prognosis of a terminal illness and toward end-of-life decision making.Design.\p=m-\Survey.Setting.\p=m-\Thirty-one senior citizen centers within Los Angeles County, Califor-nia.

The ethical and legal implications of decisions to withhold and withdraw life support have been widely debated. Making end-of-life decisions is never easy, and when the cultural background of doctor and patient differ, communication about these issues may become even more difficult. In this study, we examined the attitudes of people aged 65 and older from different ethnic groups toward foregoing life support. To this end, we conducted a survey of 200 respondents from each of four ethnic groups: European-American, African-American, Korean-American and Mexican-American (800 total), followed by in-depth ethnographic interviews with 80 respondents. European-Americans were the least likely to both accept and want life-support (p < 0.001). Mexican-Americans were generally more positive about the use of life-support and were more likely to personally want such treatments (p < 0.001). Ethnographic interviews revealed that this was due to their belief that life-support would not be suggested if a case was truly hopeless. Compared to European-Americans, Korean-Americans were very positive regarding life-support (RR = 6.7, p < 0.0001); however, they did not want such technology personally (RR = 1.2, p = 0.45). Ethnographic interviews revealed that the decision of life support would be made by their family. Compared to European-Americans, African-Americans felt that it was generally acceptable to withhold or withdraw life-support (RR = 1.6, p = 0.06), but were the most likely to want to be kept alive on life-support (RR = 2.1, p = 0.002). Ethnographic interviews documented a deep distrust towards the health care system and a fear that health care was based on one's ability to pay. We concluded that (a) ethnicity is strongly related to attitudes toward and personal wishes for the use of life support in the event of coma or terminal illness, and (b) this relationship was complex and in some cases, contradictory.

Culture fundamentally shapes how individuals make meaning out of illness, suffering, and dying. With increasing diversity in the United States, encounters between patients and physicians of different backgrounds are becoming more common. Thus the risk for cross-cultural misunderstandings surrounding care at the end of life is also increasing. Studies have shown cultural differences in attitudes toward truth telling, life-prolonging technology, and decision-making styles at the end of life. Using 2 case studies of patients, one of an African American couple in the southern United States and the other of a Chinese-American family in Hawaii, we outline some of the major issues involved in cross-cultural care and indicate how the patient, family, and clinician can navigate among differing cultural beliefs, values, and practices. Skilled use of cross-cultural understanding and communication techniques increases the likelihood that both the process and outcomes of care are satisfactory for all involved.

dvance care directives for health care have been promoted as a way to improve end-of-life decision A making. These documents allow a patient to state, in advance of incapacity, the types of medical treatments they would like to receive (a living will), to name a surrogate to make those decisions (a durable power of attorney for health care), or to do both. Although studies have shown that both physicians and patients generally have positive attitudes about the use of these documents,' relatively few individuals have actually completed one?What underlies this discrepancy between amtudes and behavior with regard to advance care directives? One obvious explanation is tack of acccss. Emanuel et al. estimated that approximately 90 percent of the population desire an advance care directive;' and they pointed to access as the major barrier. Yet interventions that increase accessibility have typically failed to yield more than a 20 percent completion rate.' Thus, it appears that access is not the sole determinant of advance care directive completion. r\ second and related factor oftcn cited to account for the relatively low completion rate is knowledge. It has been argued that if individuals simply had sufficient information &out advance directives, they would complete one. The bulk of existing research, however, does not support this proposition. Far instance, in a random study of 302 patients, Jacobson et al. found that although 90 percent of them knew about living wills, only 20 percent had actually completed one? Moreover, in a study by Sachs, Stocking, and Mils: fifty-two patients were specifically given both information on advance care directives and copies of forms for living wills and durable powers of attorney for health Journolof trUy Mcdicbte &l3bh, 24 (1996): 108-17. 0 1996 by the American Sodety of h , Medicine & Ethics.care. Six months after this intervention, the study group found no difference in the rate of completion between patients who had information about and access to advance directives and a connol group. As these authors conclude, factors other than information and access appear to be involved.One often overlooked factor may be that attitudes toward advance care directives are closely tied to one's values and beliefs, which, in turn, may be d a t e d with one's cuIturd or ethnic background. T y p i c a l l y , studies of advance carc completion involve predominantly white middle-class respondents. Indeed, in the study by Emanuel et al., individuals with a "language barrier" w = -r q s m~ atically excluded, resulting in a sample in which 25 percent of the respondents had a postgraduate level of educanon.'That almost all (93 percent) of these respondents desired an advance care directive has been widely cited to support legislation of advance directives.Studies that have included patients from diverse ethnic backgrounds reveal that this is a far from universal consensus.' For instance, one survey of HN-infected patients found that in comparison with their white counterparts, "nonwhite" patients wer...