Perspectives on the Aging Process

Is Social Work Prepared for Diversity in Hospice and Palliative Care?

Christine M. Rine

The purpose of this article is to assess current and future trends in hospice and palliative care with the objective of informing culturally appropriate best practice for social work. Concern for the intersectionality of racial, ethnic, social, and other differences in end-of-life (EOL) care is imperative given the ever growing range of diversity characteristics among the increasing aging populations in the United States. A review of literature from the current decade that is pertinent to the profession contributes to the ability of social work to consider evidence and build agreement germane to EOL practice settings. Administrative reports, government data, academic literature, professional standards, and assessment tools contrib- ute to the profession’s ability to work toward cultural competence and develop practice strategies for EOL care. The varied roles held by social workers across health care arenas provide a unique opportunity to promote cultural competence and advance best practice on all levels of work.

KEY WORDS: cultural competence; diversity; end-of-life care; hospice; palliative care

Before the start of the 21st century, 2020 wasdemarcated as a year for goal setting basedon predictions and anticipated trends in at- tempts to properly prepare for the future. Now that 2020 is only a few years away, shedding all of its futuristic connotations, it is time to examine if and how aims for preparedness have been met. At pres- ent, efforts that have been made to plan for the future can be appraised on their ability to accom- modate both realized changes and those on the horizon. Of particular interest are shifts in culture; since the 2000 U.S. Census there has been a great deal of attention to demographic trends and their role in predicting dramatic changes to the world in which we live (Perez & Hirschman, 2009). Many anticipated developments have already manifested completely or to some degree often evidenced by sweeping consequence. For example, significant impact is directly observable in the language we use to understand commonplace terms long engrained in our society. To illustrate, the term “minority” to denote the proportion of individuals of nondomi- nant culture is currently statistically incorrect. This is evidenced in several states and has been inaccurate for many years in almost 50 metropolitan areas across the nation. It is estimated that by 2044 this misnomer will connote the nation as a whole (National Association of Social Workers [NASW],

2015a; U.S. Census Bureau, n.d.-a). Whether real or illusory, “minority” populations continue to bear plainly real racial and socioeconomic encumbrances of nondominant group membership. As a result, the oxymoron “majority minority” has become more widely used in our lexicon to represent statistical correctness while relegating nondominant groups of greater numbers to continued minority status.

Actualized and mounting changes demand that professionals across disciplines and settings consider how demographic developments currently and immi- nently bear on readiness and efforts for the future. Any field of professional social work practice is appropriate for consideration. However, of particu- lar interest is hospice and palliative care as aging po- pulations are more likely to require such services and the aging demographic will continue to drasti- cally increase in number (Bullock, 2011; Carson & Sabol, 2016; Cruz-Oliver et al., 2016; Doukas, 2014; Flores, Herman, Gates, & Brown, 2016; Ollove, 2016; U.S. Census Bureau, n.d.-a). Due to varied roles held by social workers within these set- tings, the profession is well positioned to promote culturally competent best practice across all levels of work (Agnew, Manktelow, Haynes, & Jones, 2011; Bosma, Johnston, et al., 2010; Bullock, 2011; Henry et al., 2015; Murty, Sanders, & Stensland, 2015; Watts, 2013; Yang & Mahon, 2012). Yet, the ever

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changing demographics of clients, caregivers, and families who may benefit from hospice and pallia- tive care present unique challenges for culturally competent social work practice. Although medical conditions are often the most conspicuous concern, a range of cultural dimensions require additional attention. This is imperative as populations who have been traditionally underserved by hospice and palliative care are now seeking this care. Other cul- tures may require increased engagement and recruit- ment efforts. Understanding current and future trends in this field of practice will bring social work profes- sionals closer to developing and applying culturally competent best practice strategies. A current review of literature pertinent to the profession contributes evidence that may be used to improve end-of-life (EOL) practice.

DIVERSITY AND CULTURAL COMPETENCE NASW’s (2015b) Standards and Indicators for Cultural Competence in Social Work Practice upholds that “cul- turally competent social workers need to know the limitations and strengths of current theories, pro- cesses, and practice models, and which have specific applicability and relevance to the service needs of culturally, religiously, and spiritually multicultural clientele” (p. 26). However, achieving cultural com- petence is somewhat limited by the amount of liter- ature that examines the role of various diversity factors across social work fields of practice. Although hospice and palliative care settings benefit from research on some areas of difference, many diversity subjects are not well represented in the literature (Bullock, 2011; Doorenbos et al., 2010; LoPresti, Dement, & Gold, 2016; NASW, 2015b; Schim & Doorenbos, 2010; Witten, 2014). Furthermore, government and private organizations who collect and report characteristics of those receiving hospice and palliative care often use narrow response catego- ries that fail to capture the breadth and depth of diversity among this population (Schim & Doorenbos, 2010; Witten, 2014). The concept of cultural com- petence must appropriately parallel current and future demographic trends by expanding its mean- ing to include a broad definition of culture. It is not enough to consider culture relegated to outdated binary concepts such as African American or His- panic in an era when a growing majority are a unique combination of characteristics that cannot be adequately captured in a checkbox. To be truly cul- turally competent, a host of diversity characteristics

far beyond race and socioeconomic status (SES) must be considered. Therefore, considering diversity on a continuum is more realistic and reflective of the actual people with whom social workers engage. A starting point would be to include continuums of race; SES; age; religion; spirituality; sexual orienta- tion; gender identity and expression; national origin; offender and incarceration status; refugee and immi- grant status; veteran status; urban versus rural loca- tion; health behaviors; health conditions including diagnosis and prognosis; various developmental, learning, physical, and psychological abilities by diagnosis and functional level; family composition and dynamics; and trauma history. Broadening the concepts of culture and diversity and viewing these abstractions as a range of possible characteris- tics specific to each person is daunting to consider. Cultural competence can easily be perceived as overwhelming and impossible if presented with a large range of client descriptors. However, if cul- tural competence is considered as an ongoing area of professional development, rather than a skill that is learned once, then this goal becomes achievable. NASW offers an operational definition of cultural competence that reflects fluidity, intersectionality, syn- thesis, reflection, and an other-oriented perspective (NASW, 2015a, 2015b). This definition demon- strates that cultural competence is a moving target, a lifelong process, and a professional standard to undertake. Furthermore, expectations of cultural competence have long been rooted in the profession within NASW’s (2017) Code of Ethics and the person-in-environment framework (NASW, 2015a, 2015b); in essence, this endeavor is quite familiar yet constantly evolving to meet challenges of the time.

HOSPICE AND PALLIATIVE CARE How diversity is defined and how social workers respond with cultural competence does not change from one setting to another; however, some factors may emerge as more significant than others due to setting. As expected, health behaviors, medical con- ditions, and diagnosis and prognoses may be the most obvious presenting concerns often taking precedence in hospice and palliative care settings. However, the importance of diversity should not be underestimated as these characteristics can significantly affect health- related concerns, convey how some populations respond to EOL care, and indicate underrepresented groups in this setting (Bosma, Apland, & Kazanjian, 2010; Bosma, Johnston, et al., 2010; Bullock, 2011;

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Cagle, Pek, Clifford, Guralnik, & Zimmerman, 2015; Cruz-Oliver et al., 2016; Demiris, Wittenberg-Lyles, Parker Oliver, & Washington, 2011; Doorenbos et al., 2010; Drisdom, 2013; LoPresti et al., 2016; Lynch, 2013; Moore, 2015; Murty et al., 2015; Schim & Doorenbos, 2010; Witten, 2014).

Definitions Although herein the terms “hospice” and “palliative care” are used collectively to represent an array of EOL care options and distinctly when required for accuracy, it is important to clarify each individually. Although these terms often intersect, they have dis- crete differences. Palliative care most often refers to an array of services offered to individuals who have a serious and possibly life-threatening illness with the aim of relieving symptoms and side effects; these ser- vices are not restricted to those who are dying. Rather, palliative care addresses all areas of well-being with the overarching goal of improving an indivi- dual’s quality of life. These services are most often covered, to varying degrees, by health insurance including Medicare and Medicaid. While receiving such services, individuals may also be seeking curative and life-prolonging care (National Consensus Project, n.d.). Hospice care comprises services provided in vari- ous settings to those who are anticipated to live six months or less and are not receiving life-prolonging or curative treatments. Those accepting hospice care also receive palliative care including support for indi- vidual patients as well as their caregivers, which is sus- tained after the death of a loved one (National Hospice and Palliative Care Organization [NHPCO], n.d.). In essence, all who receive hospice care also benefit from palliative care while not all who receive palliative care are eligible for hospice designation as their prognosis and use of curative services may pre- clude it. The majority of hospice care services are paid for through the Medicare Hospice Benefit; this ac- counts for slightly over 80 percent of all hospice reim- bursements. A Medicaid Hospice Benefit is available in many states for those who are eligible; approxi- mately 5 percent of hospice costs are paid in this man- ner. Last, private insurance accounts for about 8 percent of hospice recompense (Centers for Medicare & Medicaid Services [CMS], n.d.). Herein, both hos- pice and palliative care are explored to inform cul- turally competent best practice in the overarching area of EOL services provided by social workers in various settings with the understanding that palliative care occurs as a part of hospice care.

Demographics Every state across the nation provides hospice care with varying availability. Since the earliest hospice program in 1974, numbers have increased to over 6,000 programs serving as many as 1.7 million pa- tients and their families annually constituting the inclusion of hospice care in approximately 44.6 per- cent of all deaths (NHPCO, 2015). Primary medical diagnosis of those receiving hospice care changes with incidence of terminal disease; 36.6 percent are cancer diagnoses, whereas 63.4 percent of diagnoses are non–cancer related, with dementia, heart dis- ease, lung disease, and stroke or coma constituting the highest four respectively (NHPCO, 2015). Hos- pice patients receive care in a variety of settings that are intended to reflect a home environment; 2014 data reveal that 58.9 percent of those receiving hos- pice services do so in their place of residence, which may be a private home or long-term care setting; the remainder receive care in a hospice-specific facility or hospital. Demographic characteristics of hospice patients in 2014 as per NHPCO reveal the following composition: 53.7 percent female; 46.3 percent male; 84 percent age 65 or older; 41.1 per- cent age 85 or older; 7.1 percent Hispanic or Latino origin (reported separately from race as per U.S. Census standards); 76 percent Caucasian; 13.1 per- cent multiracial or other race; 7.6 percent African American; 3.1 percent Asian, Hawaiian, or other Pacific Islander; and 0.3 percent American Indian or Alaskan Native (NHPCO, 2015). When compared with U.S. Census Bureau (n.d.-a, n.d.-b) reports, it is easy to see racial disparities among those served. For example, 16.3 percent of the nation’s popu- lation is Hispanic or Latino (U.S. Census Bureau, n.d.-a), yet that group has a hospice usage rate of 7.1 percent among the 44.6 percent of all hospice users. In part, differences can be explained by cul- tural preferences that are at odds with how hospice services are provided. Specifically, Hispanic popula- tions tend to favor family-centered decision making and indirect communication about the dying pro- cess so as not to cause harm, whereas hospice ser- vices often use a patient-centered approach and include frank discussions of death (Cruz-Oliver et al., 2016).

The focus is to inform culturally competent best practice by understanding current and future trends among hospice and palliative care constituents; however, as available demographic data demon- strate, the complexity and scope of diversity fails to

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be adequately captured. Although this information provides a general sense of those served, it is lacking in detail. For instance, gender response categories are binary in nature, limited to indicating one choice of either male or female. The simple addition of “other” or “check all that apply” options would significantly improve applicability and inclusion. In a world where Facebook has offered users 71 gender options since 2014 (Wong, 2016), it seems that principal data sources regarding hospice and pallia- tive care could be more inclusive, current, and rigor- ous. The mismatch between diversity characteristics captured by data and the actual cultural differences of those receiving services has been noted as a con- cern (Schim & Doorenbos, 2010; Witten, 2014). The consequences threaten to further solidify incor- rect assumptions, neglect multicultural identities and acculturation, and discount varied levels of impor- tance that individuals may place on their culture (Bosma, Apland, & Kazanjian, 2010).

Data Sources Data and demographic information on those receiv- ing palliative and hospice care in the United States have many sources, some of which are federally mandated and others that are not. Recently, new requirements for the former were initiated by the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), which requires participation in the Hospice Quality Reporting Program (HQRP) com- prising two compulsory measures developed by CMS. These methods include the Hospice Item Set (HIS) for patient-level data compiled by service pro- viders and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) administered to families or caregivers after patient death to assess their experiences with care (CMS, n.d.). Both of HQRP’s measures are limited in their ability to capture diver- sity factors. For example, both the HIS and CAHPS contain one item titled “Race/Ethnicity” that com- prises six discrete categories wherein “Hispanic or Latino” is an option; this shows less sensitivity than the U.S. Census metric in which Hispanic original is asked separately to distinguish between heritage or nationality versus race (CMS, n.d.). As referenced previously, a primary resource for voluntary hospice and palliative care data is the NHPCO, which is the principal professional nonprofit membership group in the country promoting quality of life through excellence in EOL care. NHPCO collects data through its National Data Set survey, which covers

a variety of items related to hospice care including a limited amount of demographic items reported ear- lier (NHPCO, 2015).

However, an overall lack of information persists about individuals receiving care who can be charac- terized by diversity factors outside of those cited. Unknown numbers of individuals possessing attri- butes that may vitally affect hospice and palliative care efforts remain completely invisible due to the lack of inclusiveness in large-scale data sources. This information does not appear to exist within report- ing requirements and academic literature alike (Hasnain-Wynia & Baker, 2006; Schim & Doorenbos, 2010; Weech-Maldonado et al., 2012; Witten, 2014). Best practice suggests that systematically collecting data using culturally sensitive instruments can reduce health disparities and ensure patient-centered care (Hasnain-Wynia & Baker, 2006; Weech-Maldonado et al., 2012). Many culturally sensitive assessment models exist and are used with differing prevalence; assessment tools exclusively pertinent to distinct po- pulations are also available to a varying degree (Hasnain-Wynia & Baker, 2006; Schim & Doorenbos, 2010; Weech-Maldonado et al., 2012; Witten, 2014). Among more globally applicable assessment models, two are prominent. First, the ABCDE Cul- tural Assessment Model (Kagawa-Singer & Blackwell, 2001) assesses levels of cultural adherence in at- tempts to improve communication and decrease stereotyping through five dimensions: attitudes, be- liefs, context, decision-making style, and environment. The second multifaceted assessment is the Transcultural Assessment Model (Giger & Davidhizar, 2002), which was developed almost 30 years ago but has been up- dated several times to ensure its continued applica- bility. This model focuses on uniqueness of the individual and assesses dimensions of communica- tion, space, social organization, time, environmental control, and biological variations.

Overall, the use of comprehensive assessments that capture a range of diversity factors and their perceived importance can improve service delivery and patient outcomes (Bosma, Apland, & Kazanjian, 2010; Cruz- Oliver et al., 2016; LoPresti et al., 2016). The use of more sensitive assessments and the resulting data can help social work professionals develop a basis for best practice that is cognizant of the complex cul- tural identities of those served in EOL settings. Like- wise, more research specific to hospice and palliative care is needed to undergird this area of professional social work practice. Research is needed to inform

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why and how culture is important in relation to family and patient engagement, assessment, service delivery, intervention outcomes, and overall satisfac- tion with services provided. Both inclusive assess- ment tools and increased research are paramount to developing best practice for EOL care.

TRENDS Although current national data provide limited insight, support for the importance of developing culturally competent best practice in hospice and palliative care settings is evident in academic literature. Material that explores cultural competence within this area of prac- tice is dwarfed by articles focusing on the experiences of specific populations by diversity factor or diagnosis. Yet, literature from a broader perspective is useful in establishing a sense of the knowledge base within the subject matter and provides a foundation for more narrowly focused contributions. Of particular use- fulness is a value-based model that provides a wide- ranging approach to diversity considerations in EOL care. This model suggests that understanding cultural value distinctions on a continuum of individ- ualism to collectivism, independence to interdepen- dence, and self-reliance to interconnectedness may be at the crux of differences seen across populations and indicators. To illustrate, white Americans and African Americans tend to emerge on opposite ends of the spectrum on each of these values. These dif- ferences affect the likelihood of completing advance directives, family inclusiveness in decision making, and overall view of hospice care (Bullock, 2011). Therefore, value orientations can play an important role in informing best practice in hospice and pallia- tive care settings. This is supported by findings that indicate care choices during EOL are often more dependent on ethnicity and culture rather than other demographic characteristics such as age and SES (Bosma, Apland, & Kazanjian, 2010).

The impact of culture is shown to go beyond med- ical decision making to also influence verbal interac- tions, reactions to medical conditions, and affective characteristics (Bosma, Apland, & Kazanjian, 2010). Likewise, service delivery is a major area of consider- ation; inattentiveness to patient’s cultural factors is shown to result in substandard levels of hospice and palliative care treatment, unequal access to services, disproportionate usage rates, and a wide range of other disparate outcomes (Bosma, Apland, & Kazan- jian, 2010; Cruz-Oliver et al., 2016; LoPresti et al., 2016). However, data are not available in this regard

on all ethnic and cultural groups; in particular, indig- enous populations are greatly underrepresented in the literature (Moore, 2015). Not surprisingly, access and utilization differences have the ability to affect health conditions, pain management, and location of death (Bosma, Apland, & Kazanjian, 2010); collectively, these consequences may negate the primary goals of palliative care. These findings are especially impactful as care providers, patients, and their families are likely to encounter height- ened diversity distinctions at the end of the life cycle due to the cultural significance of mortality (Agnew et al., 2011; Bosma, Apland, & Kazanjian, 2010; Bullock, 2011).

Whereas some diverse populations are repre- sented in current literature, others are not. Regard- less, findings specific to particular populations in this decade have increased awareness of diversity differ- ences among those receiving hospice and palliative care and those who underuse these services. To illustrate, a brief review of current literature that focuses on the experiences of specific populations by diversity factor follows.

Although a good deal of research and program effort has emerged to increase cultural competence with African Americans, this population remains the least likely to use hospice services even though a greater need for such is noted. Among the reasons for these findings are a general lack of adequate knowledge about services, values that oppose the nature of services, and subsequent preference for aggressive curative treatments (LoPresti et al., 2016). Consequently, these outcomes perpetuate one another given that a lack of accurate information about varied EOL options can leave African American populations with less support and the inability to make informed choices for care (Drisdom, 2013). Due to value or- ientations, the terms “hospice” and “palliative” have become problematic as they have grown to connote ideas that may be contrary to individual beliefs. For instance, “hospice” can be internalized as “giving up” (Drisdom, 2013). Therefore, best practice suggests that the use of different terminology may help to negate some racial disparities.

Hispanic Americans and African Americans share some similarities among hospice indicators in rela- tion to value distinctions and religious and spiritual beliefs. For example, both groups are less likely than others to complete advance directive documents for religious reasons (LoPresti et al., 2016). A good deal of current literature examines the experiences of

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Hispanic populations; however, diversity within these Hispanic populations is not addressed. Regard- less, findings indicate that Hispanic populations expe- rience low rates of service usage and are less likely to experience “good death,” which includes features such as having one’s wishes followed, service pro- vider ability to manage pain and reduce stress and anxiety, attention to nonmedical needs, active pro- vider involvement, possessing accurate knowledge, and perceiving compassion (Cagle et al., 2015). In response to these shortcomings, support for best prac- tice can be found in various intervention models. For example, to better support a good death, implemen- tation of culturally sensitive case-based intervention shows improvement in the level of knowledge and overall attitudes about hospice and palliative care ser- vices (Cruz-Oliver et al., 2016). Similarly, the well- being of Hispanic caregivers shows improvement through a psychoeducational problem-solving skills intervention that supports collectivistic cultural val- ues (Demiris et al., 2011).

Encouraging a broadening of diversity character- istics outside of ethnic and racial factors, there is some limited literature concerning populations that are now likely to enter hospice and palliative care settings in higher numbers or perhaps for the first time. Among these are methadone patients. At this time, patients entering methadone programs are more likely to be between 50 and 70 years of age than ever before; this trend is expected to increase and requires increased attention and culturally com- petent responses. Significant concerns that affect EOL care for this population include a host of pro- gressively life-threatening comorbid medical condi- tions. Culturally competent best practice among this group calls attention to treatment planning that pro- motes not only health management and quality of life, but also a biopsychosocial approach that ad- dresses a multitude of problems related to opioid dependence through a palliative care philosophy (Doukas, 2014).

Prison inmates in the United States who receive hospice and palliative care services present new challenges for social workers and the correctional facilities where they are delivered. Currently, incar- cerated individuals over the age of 55, which is con- sidered elderly as this population is clinically10 years ahead of those not incarcerated, constitute the fastest growing demographic group within the nation’s prison systems (Supiano, Cloyes, & Berry, 2014). By 2030 it is estimated that individuals over 55 years

of age will comprise one-third of all incarcerated peo- ple (Osborne Association, 2014). Data updated on June 25, 2016, by the Federal Bureau of Prisons esti- mate that 19,683 inmates (10.2 percent) in federal prisons are over age 55. State data differ greatly and are not as current; as of 2013, 131,500 or 10 percent of all inmates of state prison systems were age 55 or over (Carson & Sabol, 2016). However, some states such as Virginia report that 20 percent of their state inmates are 55 or over (Ollove, 2016). Although most states are burdened by the cost of providing services related to aging, they vary considerably as to the manner in which they choose to meet their in- mates’ needs. Some have instituted “compassionate release” or “geriatric conditional release” programs where state laws allow; others provide aging and EOL care within their correctional facilities. This setting presents best practice challenges related to strict boundary structures that do not match well with the fundamental tenets of hospice and palliative care (Carson & Sabol, 2016). Social workers deliver- ing services in prison settings are confronted with the need to support patient and worker relationships appropriate for the work at hand, while carefully negotiating professionalism within a multidisciplin- ary team (Supiano et al., 2014).

Individuals who identify as transgender express worry over their EOL prospects yet are poorly equipped for these considerations due to poor re- lationships with health care systems marred by discriminatory and often traumatizing practices (Witten, 2014). Overall, this population continues to receive little positive public attention, remain underrepresented among research studies, experi- ence disparate medical care, and endure discrimina- tion. A simple Web search of “transgender and hospice” surprisingly delivers no applicable results. Nonetheless, knowledge about these individuals would be invaluable for hospice and palliative care settings based on population estimates alone. For example, approximately 1.4 million people in the United States identify as transgender (Flores et al., 2016), yet there is little research about this popula- tion as they age or around EOL issues (Witten, 2014). Furthermore, long-standing and far- reaching marginalization experienced by transgender individuals results in trauma reactions to various health care and service providers, which further chal- lenge the provision of appropriate hospice and pallia- tive care services (Witten, 2014). Although research about transgender EOL concerns is lacking, a large

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study of lesbian, gay, bisexual, and transgender older adults may shed some light on the topic. Study find- ings among this population indicate that 44 percent live alone compared with 18 percent of the general population; over 50 percent report the loss of close personal relationships due to gender identity; and, perhaps most striking, 48 percent depression rates are reported compared with 5 percent among older adult heterosexuals (Fredriksen-Goldsen, Kim, & Goldsen, 2011). It is suggested that increased cultural com- petence is greatly needed for successful work with transgender populations later in life; areas for increased attention to best practice is suggested at all levels including practitioners, agencies, facilities, religious and spiritual groups, and legal consult (Witten, 2014).

Last, rural geographic residence of those seeking EOL care bring distinct challenges to service provi- sion and outcomes for patients and families. In these settings, proximal access to adequate hospice and palliative care services are of concern as location can affect the amount of services available, shortages of professionals to provide various services, the ability of health care providers to facilitate quick referrals and admissions, capacity to attract and retain profes- sionals with appropriate educational backgrounds and training, and presenting cultural differences par- ticular to rural settings. Overall, rural areas have fewer hospice providers resulting in potentially greater proximal distances for patients, caregivers, families, and provider staff to negotiate. Greater distances, coupled with less available public transportation, can often be a significant barrier to services. Best practice recommendations look to novel hospice and pallia- tive care delivery models such as telehealth, provider training, and changes to Medicare Hospice Benefits, which can improve EOL care in rural areas (Lynch, 2013).

DIRECTIONS FOR SOCIAL WORK The importance of culturally competent best practice in hospice and palliative care settings is far-reaching given the ever-growing range of diversity characteris- tics and a marked increase of aging populations in the United States. The administrative reports, govern- ment data, academic literature, professional standards, and assessment tools discussed are a starting point to advance culturally competent practice guidelines for EOL care. However, this goal remains challenging because the numbers and needs of individuals posses- sing particular diversity characteristics remain largely

unknown. Although pertinent literature identified numerous shortcomings, strategies to develop empir- ically supported culturally competent practices are suggested. NASW Standards and Indicators for Cultural Competence in Social Work Practice (2015b) and NASW Standards for Palliative and End of Life Care (2004) pro- vide a foundation for appreciating the intersectional- ity of diversity factors in the context of EOL settings. This is a good place to start to formulate directions for the future as these standards bear on the develop- ment of best practice. Specifically, NASW (2004) cautions that “culture influences individuals’ and families’ experience as well as the experience of the practitioner and institution. Social workers should consider culture in practice settings involving pallia- tive and end of life care” (p. 26). This points to the importance of understanding the interdependent and overlapping nature of multifaceted cultural dimen- sions and their impact on various EOL concerns as experienced by each individual and family member. It is further suggested that practice competence can help to properly prepare professionals for individual- ized client-centered care that can more effectively and positively affect psychological distress, pain, and the dying process for both individuals and families. Recommendations for practitioners include con- tinuing education and training, specialization and certification programs, engagement in research, and appropriate use of supervision and community ex- perts; support from all available resources is needed to keep up with the demands of this field of work (NASW, 2004).

In sum, recommendations for more accurate and inclusive data, the use of professional standards, and practitioner knowledge and skill acquisition place the onus on social workers to achieve cultural com- petence. However, awareness and familiarity with various areas of difference may not adequately pre- pare social workers for diversity in hospice and palli- ative care. The cultural competence approach lacks attention to reciprocal personal and professional reflection and cognizance of the complex structural forces that form client experiences. To advance prac- tice, a cultural humility approach offers social workers a deeper way to understand and respond to cul- tural differences of others as well as themselves. Sim- ply defined, cultural humility is a “process of committing to an ongoing relationship with patients, communities, and colleagues that requires humility as individuals continually engage in self-reflection and self-critique” (Fisher-Borne, Montana Cain, & Martin, 2015,

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p. 171). Applied to diversity in the context of EOL care, cultural humility can ease the burden on social workers to attain competence as a discrete goal by instead actively participating in a continual process with clients, constituencies and institutions, and within themselves. HSW

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Christine M. Rine, PhD, is assistant professor, Department of Social Work, Edinboro University of Pennsylvania, 235 Scot- land Road, Hendricks Hall G-37, Edinboro, PA 16444; e-mail: [email protected].

Original manuscript received August 1, 2016 Final revision received December 21, 2016 Editorial decision February 9, 2017 Accepted February 9, 2017 Advance Access Publication December 13, 2017

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