In California, an ethnic majority does not exist. At least 59 languages are spoken in the state's public schools, 27% of Californians are foreign born, and people of color make up 60% of California's population. California has
more foreign-born, limited-English proficient residents that any other state in the union.

Thus throughout the Coalition's existence, finding a way to address the impact of cultural diversity upon ACP has been a priority. We've had several projects related to diversity, including translation of materials, supporting an outreach worker to the Latino community, and helping create the Chinese American Coalition for Compassionate Care.

Our work we believe to have the most potential to broadly impact ACP is our educational curriculum on EOL from a multi-cultural perspective. To develop the curriculum, we convened an advisory group made up of experts on cultural diversity, EOL care, and POLST education.

Soon after the group met, it was clear that the idea of anyone being “competent” in the cultural richness that comprises California seems questionable. Thus, we took the approach of addressing diversity from a multicultural perspective. We adopted the belief that culture involves more than ethnicity. To the contrary, culture is shaped by numerous factors, including socioeconomic status, birth order, geography, religion, family history, education level, professional training, personal experiences, and much more. As a result, a person is expert only in his/her individual, personal culture.

We identified several models to reflect our view of culture. One is the use of an iceberg to illustrate that certain aspects of culture are easily seen by others, whereas other just-as-important aspects are “below the surface” and out of sight. As a result, health care providers need to “become a student of the patient” to understand the patient's perspective.

Another model is to view culture as a “pair of glasses” or a lens through which we interpret our lives, including how we understand treatment options, medical decision making, pain and suffering, interactions with health care providers, dynamics with loved ones, death and the afterlife, and more. Our views of illness and medical care are seen through the “lens” of our personal culture.

Health care providers also need to be aware that they have their own unique culture—the culture of health care. Health care has its own language and communication style, its own way of viewing relationships, and its own concept of time. Within health care, each health care profession has its own sub-culture. The culture of physicians is different from the culture of nurses, which is different from the culture of social workers, chaplains, aids, and others. Furthermore, palliative and EOL care has its own subculture.

As a result of this effort, the Coalition created Building Bridges, a 4-hour curriculum that is highly interactive and involves self-reflection. To personalize this training, participants in the workshop are asked to draw their own cultural maps—a visualization of their lives and culture. Participants
are also asked to describe the prominent “cultural” features of their work environment and how EOL care is viewed within that environment. The workshop also includes discussions of acculturation versus assimilation, challenging cross-cultural experiences and eliciting a patient's explanatory model. The training closes with a case study and role play during which participants take on different roles and discuss the conversation about goals of care in the context of culture.

The goal of this training is to transform the way attendees think about themselves, and the patients and families they serve. We've received feedback from attendees that confirm the Building Bridges curriculum has achieved this objective, such as:

■ I realized that one of my “negative” patients was not actually noncompliant. Rather, I was simply imposing my values on him.

■ For the first time, I see that culture, race, and nationality are not the same thing. The workshop made me change the way I've been thinking about culture my whole life.

■ I had never thought of becoming a student of my patients.

The Coalition's success in this area is a direct result of our collaboration with a range of people from a variety of backgrounds. Through that process we listened and learned. We became students of our collaborators.

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