Culturally competent hospice care: a guide for nurses and families

What does cultural competence mean in hospice and nursing?

Cultural competence is the ability of a clinician, and the organization behind the clinician, to give care that works for people whose language, beliefs and family life differ from their own. The CLAS Standards call it care that is effective, understandable, respectful and responsive to a person's beliefs, language and health literacy.

Nurse educators pair it with cultural humility: treat each patient as the expert on their own culture, and ask rather than assume. In hospice, pain medicine, feeding, who hears the prognosis and what happens after death are all shaped by culture, and there is little time to get them right.

What does culturally competent care look like at the bedside?

What are the National CLAS Standards?

The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care are 15 standards from the HHS Office of Minority Health. The principal standard asks organizations to provide effective, equitable, understandable and respectful care that responds to diverse cultural health beliefs, preferred languages, health literacy and other communication needs.

The other 14 cover leadership and workforce; communication and language assistance (language help at no charge, qualified interpreters rather than untrained staff or minors, easy-to-understand materials); and engagement and accountability. They are not a law. They describe what the laws below expect in practice.

What is the patient's right to information in a language they understand?

Hospice patient rights (42 CFR 418.52). Before care starts, the hospice must give the patient spoken and written notice of their rights in a language and manner the patient understands. See patient rights.

Title VI of the Civil Rights Act. Every provider paid by Medicare or Medi-Cal must take reasonable steps to give people with limited English proficiency meaningful access.

Section 1557 of the Affordable Care Act (45 CFR 92.201). A qualified interpreter must be provided when needed, at no charge to the patient. A provider may not require a patient to bring an interpreter, or rely on a minor child or an accompanying adult, except in an emergency or at the adult patient's own request after an interpreter is offered. See language assistance.

How do interpreter services work in hospice?

1. Step 1

   The preferred language is recorded

   At the first call or visit, the hospice asks which language the patient and main caregiver prefer for health conversations, and records it.

2. Step 2

   An interpreter is offered before each important conversation

   Consent, the notice of rights, medicine teaching, prognosis and advance care planning all count. A phone or video interpreter can join a home visit.

3. Step 3

   Family members translate only if the patient asks

   Relatives may sit in, but may soften or skip what the nurse says. The patient decides, after being offered a qualified interpreter. The nurse then checks understanding with teach-back.

How does an assessment ask about culture and spirituality without assuming?

Medicare requires the hospice comprehensive assessment (42 CFR 418.54) to cover physical, emotional, psychosocial and spiritual needs. Good assessments use open questions:

For families: how do you tell the team what matters?

You do not have to wait to be asked. Tell the nurse or social worker at the first visit, or call the office. A hospice nurse answers the phone 24 hours a day, 7 days a week, and can visit when needed.

Common questions