OBJECTIVE: Culture may have an important impact on a patient's decision whether to perform advance care planning. But the cultural attitudes influencing such decisions are poorly defined. This hypothesis‐generating study begins to characterize those attitudes in 3 American ethnic cultures. DESIGN: Structured, open‐ended interviews with blinded content analysis. SETTING: Two general medicine wards in San Antonio, Texas. PATIENTS: Purposive sampling of 26 Mexican‐American, 18 Euro‐American, and 14 African‐American inpatients. MEASUREMENTS AND MAIN RESULTS: The 3 groups shared some views, potentially reflecting elements of an American core culture. For example, majorities of all groups believed “the patient deserves a say in treatment,” and “advance directives (ADs) improve the chances a patient's wishes will be followed.” But the groups differed on other themes, likely reflecting specific ethnic cultures. For example, most Mexican Americans believed “the health system controls treatment,” trusted the system “to serve patients well,” believed ADs “help staff know or implement a patient's wishes,” and wanted “to die when treatment is futile.” Few Euro Americans believed “the system controls treatment,” but most trusted the system “to serve patients well,” had particular wishes about life support, other care, and acceptable outcomes, and believed ADs “help staff know or implement a patient's wishes.” Most African Americans believed “the health system controls treatment,” few trusted the system “to serve patients well,” and most believed they should “wait until very sick to express treatment wishes.” CONCLUSION: While grounded in values that may compose part of American core culture, advance care planning may need tailoring to a patient's specific ethnic views.

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BACKGROUND:Beliefs about what happens at the time of death surely affect a patient's whole dying experience and could help guide end‐of‐life care. Yet virtually no research describes those beliefs. This exploratory study begins the descriptive process.METHODS:Assuming culture is key, we interviewed 26 Mexican‐American (MA), 18 Euro‐American (EA), and 14 African‐American (AA) inpatients about their beliefs concerning what happens at the time of death.RESULTS:One belief, that death separates the dead from the living, was widespread. Majorities of all 3 ethnic group samples and of 5 of the 6 gender subsamples expressed this belief, saying the dead “go” or “leave” from this life. Other beliefs differed by ethnic group or gender. For example, more EAs (50%) than others said death is a momentary event, and more MAs (35%) than others said death involves “being taken” by an external force (always God or Jesus). Furthermore, considerably more EA women (45%) than others said some senses persist after death. In contrast, the physiologic signs that participants cited as defining the exact time of death varied from individual to individual with no ethnic or gender pattern, and no one sign predominated.CONCLUSIONS:A few beliefs about what happens at the time of death may characterize Americans in general; many other beliefs may characterize only certain ethnic groups, genders, or individuals. To identify such beliefs and to use them to guide end‐of‐life care, hospitalists and other health professionals may have to elicit them directly from patients or survivors. Journal of Hospital Medicine 2012. © 2011 Society of Hospital Medicine

As death nears, patients or survivors may want to discuss beliefs about the soul after death with their healthcare provider. This preliminary study characterizes some of those beliefs. By suggesting questions to ask and responses to give, the study provides healthcare professionals a supportive, knowledgeable way to participate in such discussions.

Proxy decisions about postmortem medical procedures must consider the dead patient's likely preferences. Ethnic- and sex-based attitudes surely underlie such preferences but lack sufficient characterization to guide decisions. Therefore, this exploratory study interviewed Mexican-American, Euroamerican, and African-American seniors in San Antonio, Texas, for their attitudes about discussing death before it occurs and about organ donation, autopsy, and practice on cadavers. A rigorous content analysis identified themes. Majority attitudes of an ethnic group or sex subgroup here may characterize the group generally. Attitudes about discussing death differed only by ethnic group. Mexican Americans and Euroamericans favored such discussions, but African Americans did not. Attitudes about the postmortem procedures differed by ethnic group and sex. Overall, Mexican Americans viewed the procedures most favorably; Euroamericans, less so; and African Americans, least so. Men and women differed further within ethnic groups. Mexican-American men and women split evenly over organ donation, the men expressed no majority preference about autopsies and the women agreed to them, and the men refused and the women agreed to practice on their cadavers. Euroamerican men expressed no majority preferences, but Euroamerican women agreed to organ donation, had no majority preference about autopsies, and refused practice on their cadavers. African-American men expressed no majority preferences, and African-American women expressed none about organ donation or autopsies but refused practice on their cadavers. If confirmed, these ethnic- and sex-based attitudes can help health professionals tailor postmortem care to individual patients' preferences.

To the Editor: Drs. Torke, Alexander, and Lantos have clearly and succinctly summarized the vast literature on the substituted judgment approach to surrogate decision-making. 1 This approach targets the exact decision the incapacitated patient would make under the circumstances. The authors point out that, despite the strong philosophical and psychological appeal of substituted judgment, considerable empirical evidence questions its feasibility. They then suggest two alternative approaches for making health care decisions on behalf of incapacitated patients. One, the narrative approach, reflects respect for individual persons and takes direction from the values, interests, and choices that characterize a patient's life.Yet the narrative approach never speaks for itself. A life history is multifaceted, and health professionals and surrogates need guidance in identifying those facets critical for making health care decisions authentic to each patient. Some of our prior research may help. It has explored the considerations seriously ill inpatients wanted to help guide health care decisions on their behalf. We compared subjects' responses by ethnic group and gender. The most striking differences occurred by gender. 2 Across all three ethnic group samples (Mexican Americans (MAs), Euroamericans (EAs), and African Americans (AAs)), the men focused almost completely on minimally acceptable future functional capacities. Yet the women took a broader view. They wanted consideration of not only future functional capacities, but also other factors such as meaningful times or places to die and the psychological or economic burdens their deaths might cause their families.Still, one striking difference occurred by ethnic group: MAs and EAs said detailing such considerations beforehand is good, but AAs disagreed. 3 AAs preferred to wait for a critical illness to express their wishes. That result suggests health professionals may need to divorce any life review for AAs from explicit discussions of death and terminal care.Though our results are preliminary, we hope the article by Drs. Torke, Alexander, and Lantos will prompt additional research-both conceptual and empirical-about this promising narrative approach to surrogate decision-making.

The factors that contribute to student dropouts have been the focus of extensive deliberation during the last decade. Despite expanded attention, the number of dropouts remains unacceptably high. Drawing on the authors’ 17-year history of dropout research in Texas, Arizona, and across the country, this article describes the alarming dropout rates, especially among Hispanic students; assesses efforts that have been undertaken to address the dropout issue, including proven dropout prevention programs; and provides a new paradigm for preventing dropouts.