Tips for Clinicians: Decision Making and Disclosure

In general, Hmong recognize that any life event or decision that affects one family member will have a direct or indirect impact on all of its members. Consequently, health care decisions are considered within the realm of the family as a whole rather than the individual alone. Traditionally, decisions were made as a group by kwv tij (the husband’s side of the family) under the supervision and guidance of the eldest male, with minimal input from the ill person. For elders, this often involved the eldest son or a male sibling.

Expanding Participation

Contemporary practice is expanding participation to include the ill person, wife, daughter-in-law (who often serves as the caregiver) and children with advanced education who contribute economically to the household. It is now becoming more prevalent that the eldest son takes into consideration the wishes of the elder who is ill, along with other family members. Individuals that contribute financially to the elder in question and their extended families tend to have more power in making decisions regardless of gender. For example an employed female may have more say in the funeral arrangements of her parents than her unemployed older brother.

Role of Women

The power that women hold in Hmong families is usually unseen by the public eye, but felt by the family nonetheless. While traditional power holders (men) are most often the official spokespeople for the family, women, must also be consulted in important decisions.

Ultimate Goal of Discussing Medical Decisions

The ultimate goal of discussing medical decisions and treatment plans with the patient and his/ her family is to obtain a consensus of opinion. Conflicts about treatment options are ideally settled through continued family discussions until a resolution is reached. A dispute may be resolved by consensus, but the final decision may be made by the individual of greatest power (i.e., an elder brother, a woman’s husband, or a couple’s eldest son).

Variety of Practices

It is important to recognize that there are a variety of family-based decision-making practices. Some elders will appear passive in family discussion and will defer to family members, such as spouses, older sons, or the family’s male leader. Others will actively participate in discussions about medical pros and cons and may express an opinion that is contrary to the family’s desires. Health care providers must find out who the appropriate people are to include when making critical decisions.