Case Studies Cultural Competency
Cultural competency is illustrated in the following two cases:
o Cambodian Patient
o Hispanic Patient
Cambodian Patient
(Case developed by University of Pennsylvania, GITT Project)
Rom Seaung is a 75 year-old widower from Cambodia who arrived in the United
States in 1981. He lives with his 50 year-old widowed daughter, Ms. Veth, and
his three grandsons aged 19, 20, and 22. His 20 year-old grandson’s wife, who attends the University of Houston studying business
administration, works and also lives in the home. The total number of persons in the
three-bedroom Heights’ pier and beam home is six. Mr. Seaung’s 72 year-old sister lives with his niece in Southwest Houston.
Mr. Seaung, who is unable to speak English, has his daughter interpret in
broken English. She is the one who made the clinic appointment for her father.
Ordinarily he frequents the traditional pharmacy and visits a shaman for health
problems. Mr. Seaung prefers to visit the traditional healer rather than utilize
the Western medical system.
Ms. Veth reports that her father refuses to bathe, is not eating, and has
bladder incontinence. She also reports that he has insomnia and at one time was
diagnosed at an emergency room as having a stomach ulcer. The traditional healer
removed the evil spirits, according to Mr. Seaung, and his ulcer problems
seemed to dissipate. Mr. Seaung’s appearance is disheveled; he appears to be quite skinny and is reluctant to
participate in the examination. Ms. Veth reports that she wants her son’s wife to assist with respite and supervision of her father. You feel
uncomfortable because the daughter seems to be answering for Mr. Seaung and also seems
in your opinion to intimidate her father, although you cannot be sure. Ms. Veth
continues to complain that her daughter-in-law will not assist in bathing Mr.
Seaung or providing assistance with her grandfather-in-law’s care.
Mr. Seaung is living on Supplemental Security Income (SSI) and also has a
Medicaid card. He also benefits from his family’s paying most of the household expenses. His daughter is presently
unemployed. In Cambodia, she was a seamstress and utilized those skills from 1985 to 1990
in the United States. She left work to take care of her sick husband who died
a year later (1991) and then never returned to work. She appears to be the
only person providing informal support for her father.
Mr. Seaung’s 18 year-old grandson is completing his last year of high school and is
working to save money to attend a college out of state. His 22 year-old grandson
graduated from Houston Community College and is working as a draftsman, while his
20 year-old grandson is also working and pursuing his pre-med studies at the
University of Houston. He hopes to attend medical school next year.
Upon examination, the nurse practitioner discovers that this patient has
bruises up and down his arms and back. The bruises resemble large hematomas. Mr.
Seaung’s blood pressure is 100/60 mmHg and he has a slow irregular heart beat and a
temperature of 101
.
The providers caring for Mr. Seaung will need to go beyond simple knowledge of
Western medicine.
What are the cultural issues in this case?
Hispanic Patient – Mr. Vega
(Case developed by Patti Savage, L.M.S.W., and Steven Lozano Applewhite, Ph.D.)
Mr. Vega is an 83 year old Hispanic male with a history of dementia with
alcoholic psychosis. Mr. Vega comes from a traditional Mexican background with an
extended family that reflects a blending of traditional and acculturated views
about family values, roles and responsibilities. Mr. Vega also has a history of
using folk remedies for ailments as companion alternatives to conventional
health care. Mr. and Mrs. V were both born in Mexico and became naturalized;
however, all their children were born in the United States. Mr. Vega worked as a
mechanic and Mrs. V was a homemaker and on different occasions worked as a
domestic worker. His diagnoses are: Alcohol Related Dementia, Alzheimer’s disease, Seizure Disorder, and Hypertension. Monthly income is comprised of
his Social Security ($687) and his wife’s Social security benefits ($258). They have no other liquid assets. He
scored 18/30 on the Mini Mental State Exam (MMSE) administered at his outpatient
clinic. His wife, also a clinic patient, reports Mr. Vega has aha a continuous
cognitive decline which was first noted several years prior. He has an unsteady
gait and has fallen several times. He also exhibits condescending and
aggressive behavior, particularly toward his wife and two daughters. The youngest
daughter, age 45 and single, is employed and resides with the couple, but usually
is only home at bedtime and provides no patient care assistance. The other
daughter, the eldest, resides across town and provides transportation to the
couple for medical appointments. She is divorced and is the sole provider for three
children. Mr. Vega frequently berates this daughter for her inability to keep
her husband in the home.
The couples also have three sons (two reside in Houston and one resides in
Austin). They provide little daily assistance due to family commitments. A
relationship between Mr. Vega and his sons appears nonexistent due in part to his
history of drinking and abusiveness. Other reasons may relate to their
perceptions of family caregiving, and their commitment to provide for their own families
first. Mr. Vega’s psychotic symptoms include being verbally explicit with his sons, reading
the imagined sexual behavior of his wife with a man who Mr. Vega "sees"
frequently in their home. In fact, Mr. Vega’s inappropriate sexual comments and behaviors almost resulted in a physical
altercation with his son; therefore, Mrs. V has requested that the children no
longer visit. Mr. Vega has a 20 year history of becoming intoxicated daily
before returning home from work. He allegedly had numerous extramarital affairs and
was frequently verbally and physically abusive to his wife. Mr. Vega requires
assistance with most ADLs. Mrs. V is medically stable, but is experiencing
severe caregiver burnout. She scored 10/15 on the Geriatric Depression Scale
(GDS) at the time of initial assessment. She refuses nursing home placement for
Mr. Vega. She keeps the outside gate locked to prevent Mr. Vega from walking to
the local bar. Mr. Vega has a Medicare HMO.
One month ago, Mr. Vega was admitted to a contract skilled nursing facility
for physical therapy after being diagnosed with a compression fracture, secondary
to falling. The family has experienced difficulty in dealing with any
long-term placement decision due to cultural, social and economic reasons. The case
was referred to the interdisciplinary team for staffing.
Throughout the following year, the social worker became the primary mediator
of conflicts between Mr. Vega and his wife, Mr. Vega and the adult children, and
Mrs. V and the adult children. The interdisciplinary team made multiple
referrals for psychosocial intervention to various agencies. Mr. Vega’s cognitive status continued to decline affecting his physical status. His
MMSE score is 10/30. As the result of a fall, Mr. Vega has been readmitted to
the skilled nursing facility for physical rehabilitation. Mr. Vega has become
almost total care. His aggressive behavior has lessened.
Mrs. V scores 6/15 on the GDS. She states that she feels stronger
emotionally; however, she acknowledges the progression of the dementia and her own
physical exhaustion, which prevents her from providing optimal care for her husband.
She reports that most family members are working and are unable to provide any
daily assistance.