Carel Jacobs died November 26, 2022

Carel was a friend and colleague for 37 years.

Before his death we frequently discussed life and what it meant for Carel.

He had only two regrets:

• He wanted to write a book about Vincent van Gogh after the success of his paper on the same artist. For the paper see: https://www.academia.edu/49555191
• He wanted to write a book on his main subject of the last few years. End of life Healthcare for Migrant families.

The following is a reconstruction of his ideas about the latter, based on our intensive talks. I cannot pretend to be complete. Carel had a lot of experience in dealing with the subject. The book would have encompassed a lot more details.

A reconstruction of his thoughts:

1.Look into the history of the specific migrant group:

• Guest labor
• Enslavement
• Colonialism: Ambon, Indonesia, Surinam

2.Be aware of the Cultural attributes of the majority culture and the differences with the countries of origin of the migrant groups.

This implies self-awareness and an understanding of what is superficial and what is more fundamental.

A research based way of looking at cultural differences is formulated by Geert Hofstede.

In a special article Jacobs and Wursten described earlier the relationship between a doctor and a patient an Intercultural comparison

https://www.academia.edu/38934793/

3.Carel Jacobs used the Force Field Analyses of K. Lewin to describe the dynamics of how to deal with potential friction between healthcare workers of the majority culture and Migrant families. See https://www.academia.edu/22417583/Culture_and_Change_Management

In summary: to be effective don’t start pushing against resistance. The harder you push, the harder the resistance force is pushing back.

It is much more effective to minimize the resistance because then the change you are aiming for will do its work.

According to Jacobs, this solves for a big part the problem of the reoccurring principled question: who must adapt to whom? The approach should avoid this principled question and should refer to the saying: different strokes to different folks. 

4.In describing the attributes of the Dutch Majority culture Jacobs used the following analysis: https://www.academia.edu/24233495 (In Dutch)

Important cultural issues: 

The implications of the egalitarian Dutch culture on healthcare.

-Difference in expectations around the behavior of experts.

Healthcare professionals in a country like the Netherlands should be aware that expert behavior is highly important in high Uncertainty countries and that the trust in expert knowledge of Dutch healthcare professionals is questionable for many non-Dutch, including for people from migrant groups. This is objectively unjust, but this lack of trust is caused by the Dutch version of equality and autonomy.

Dutch healthcare professionals are trained to take the patient seriously as a source of information. In principle, they know best what happened and where the complaints come from. This means that a stereotypical question from a Dutch Doctor to a patient is: what do you think what is causing your complaints? The Doctor uses this information then to come to a good diagnosis. For most Dutch patients this confirms that the Doctor is taking them seriously as an autonomous person. For many other cultures, the message is: the Doctor is not an expert, because he is not making a diagnosis. There is evidence that some expats in the Netherlands are preferring to go to Germany or Belgium if they have complaints. They radiate expertise through their confidence in making a diagnosis without asking the patient about his/her opinion.

This trust in expertise is reinforced by doctors in high UAI cultures to write multiple recipes for the patient. The patient can take these recipes to the pharmacy. The pharmacy is reinforcing the trust in professionals by providing the patient with a bag of medication.

This is seen by many healthcare workers in the Netherlands as unwanted because the Doctors (and Pharmacists) are wary of the negative side consequences of the use of medication.

Dutch Doctors should be aware of the influence of these attitudes on their credibility. In the same line, they should be aware that their attitude to first try simple treatments reinforces the mistrust about their credibility.  In high Uncertainty Avoidant Cultures like Belgium, France and Germany, Turkey, and Morocco doctors have a tendency (sometimes for non-medical reasons) to let patients undergo expensive tests in hospitals. While Dutch Doctors see this as unnecessary and unnecessarily costly, the patients from high Uncertainty avoidant cultures are strengthened in the feeling that they (and their complaints) were taken seriously by de Doctors.

Collectivism as a common trait of migrant cultures.

The Netherlands is an individualistic culture. This means that individual rights and autonomy are the focus of how people relate to each other. The core family is the center.

In Collectivist cultures the in-group people belong to is the source of identification. The in-group can take different shapes. It can be the tribe, Ethnic group, the religious group or even the region where people come from. But in all cases, the extended family is the foundation. Not the individual is making autonomous decisions but the whole family is involved.

In Collectivist cultures there is a rule for behavior: in return for loyalty to the in-group, the in-group is taking care of you. In collectivist cultures, it is dangerous to have opinions or behavior that is seen as deviant. If you are seen as a troublemaker, the in-group will remove you from the in-group and will create a lot of difficulties for sometimes literally survival. Keeping harmony with the in-group (in the first place the family) is essential.

This has consequences for communication. In collectivist cultures, people are educated to use indirect communication, so that nobody is hurt or is losing face. This trait of collectivist cultures is called high context communication. Because of their upbringing people are very sensitive for the indirect, sometimes hidden content of a message. Direct language is considered as uncivilized and blunt.

The Dutch pride themselves in their direct language. It is frequently connected to being honest and open. Again, this is experienced by even some other individualistic cultures as bluntness.

Knowing this, Carel Jacobs formulated a few recommendations for Dutch healthcare workers:

To be effective try to avoid unnecessary resistance in dealing with patients and their families from Migrant backgrounds by:

-avoiding too direct language.

  Avoid saying We cannot do something anymore, the treatment is not making further sense and will be stopped, you are dying

  because of the disease. 

Instead, say to the patient and the family:

  We are very worried about your condition; your life is in God’s (Allah’s) hand, we will make it as comfortable as possible for

you. Because of the sensitivity for high context communication, the message will come across

-Realize the need for trust in expert behavior. This means also avoiding the impression that medical next steps are part of shared

 decision making between doctor, patient and  family. It is the role of the expert to make these decisions. The family is put in an

  impossible position if they think they can be held accountable by their community for agreeing in decisions that involve life and death.

-Have a plan to deal with the family. Ask the patient who the speaker is for the family,

  Make a plan for regular meetings with the designated speaker to avoid speaking with the whole group and make a planning for

  family visits to avoid conflicts if too many people are around the bed.

 -Consider the role of religion. Sometimes the family interpretation of the Book is differentfrom what God or Allah expects.

  Shame and moral obligation are not necessary, a peaceful and painless treatment is what God and Allah really want for the

  patient.

 Note: 

Lewin, K., “Group dynamics and social change” (1958) in:  A. Etzioni, “Social change”, Basic Books Inc. Publishers, New York/London (1964)