Explore culture-specific assessments and communication approaches for the patient and the family.

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FILIPINO CASE STUDY #2 Sixty-eight-year-old Ramona Mag-pantay from the Philippines is visiting her daughter in New Jersey. She has been alternating with her husband in coming to the United States for 6 weeks at a time to keep their immigrant status in good standing. Although neither she nor her husband plans to reside in the United States permanently, they applied for immigration through the sponsorship of their daughter so they can facilitate immigration of their youngest child.

Ramona and her husband are both retired and live comfortably in the Philippines. She was an elementary school teacher and her husband maintains an accounting office with one of his sons, who is also an accountant. They have six children, three of whom reside in North America (two in New Jersey and one in Toronto). In the United States, they stay with their married daughter, Virginia, who lives with her husband and three children. Ramona’s son Roberto lives with his wife and two children: a 3-year-old boy and a 1-year-old girl. Because her daughter, Virginia, is a full-time homemaker, Ramona stays with her son on the weekdays to help look after her grandchildren while the couple are working. She goes home to Virginia’s family on weekends.

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One Friday evening, Virginia phoned her friend Rowena, a Filipino nurse residing in the same neighborhood. She asked Rowena to come and check her mother, who was not feeling well. Rowena sensed the urgency in Virginia’s tone of voice and quickly drove to her home. She found Ramona in bed, fully covered with a comforter, with visible chest heaves and lifts. After examining Ramona and taking her vital signs, Rowena spoke with Virginia alone in the kitchen so Ramona would not hear their conversation. Rowena told Virginia that her mother should be taken to the hospital.

Virginia explained that her mother does not have medical insurance because she stays for only 6 weeks at a time and has a medical examination before her trips.

She also told Rowena that her mother has diabetes, hypertension, and an irregular heartbeat. When Ramona’s heart medications (Digoxin and Inderal) ran out, she did not inform Virginia. She did not want her to purchase her medications because she is not “working and earning.” She also thought that, because she would be going home in 2 weeks, she could wait until then. Before calling Rowena, Virginia already consulted her cousin Leticia, a physician who lives in Long Island, New York.

Rowena called her cousin’s husband, who is a cardiologist, to get his recommendation. Upon hearing Ramona’s symptoms, the cardiologist insisted that she be taken to the emergency room (ER) at once. When she heard his recommendation, Virginia agreed to call for an ambulance and accompanied her mother in the ambulance to the local hospital.

The ER physician determined that Ramona should be admitted to the cardiac- care unit (CCU). Virginia requested that her cousin Leticia speak to the doctor before any decision was made. Leticia explained to the doctor the financial ramifications of Ramona’s admission and explored the possibility of her discharge on medications. The ER physician vehemently disagreed with Leticia and explained the seriousness of Ramona’s condition as well as her need for close medical supervision. Leticia then spoke with Virginia and apologized for her inability to convince the ER physician. She warned her to anticipate the high cost of CCU care.

Virginia’s husband was called to sign the promissory note of payment for Ramona’s hospitalization. He was resigned to the idea that Ramona’s life was in danger and money should not be a barrier to her well-being. He was also confident that Virginia’s two brothers in North America would share the cost. Ramona was never made aware of all these discussions. In her presence, Virginia and her husband did their best to present a calm, reassuring presence. She was told that she would be given a thorough examination, which is advantageous because it is done in a U.S. facility, far superior than health care in the Philippines.

Ramona spent 3 days in CCU, followed by 4 days in a medical unit. When visited by her daughter’s friend Rowena, she verbalized her concern for her daughter’s family paying the cost of her hospitalization. What she tried hard to accomplish (not to burden her daughter) turned out to be a very expensive mistake. She had always wanted her daughter to go back to work as a medical technologist to help her husband.

She said that with two incomes, her three grandchildren would be ensured a better future. Virginia admitted to Rowena that her mother had tried many times to convince her to return to work, but her previous experience with babysitters was traumatic and she decided to stay home and live economically to compensate for the loss of income.

She said that she would consider returning to work when the children were much older. Two weeks after her discharge, Ramona returned to the Philippines. She decided not to return to the United States, but assured her family that her husband would travel every year to maintain their immigration status. Her children make every effort to visit her regularly in the Philippines and speak with her frequently by phone.

Study Questions 1. Describe how these Filipino cultural values are manifested in this family:

• Utang na loob: reciprocal obligation to kin.

• Pakkipagkawa: shared identity.

• Pakiramdam: shared perception with others.

• Bahala na: fatalism.

2. Discuss how these values may have contributed to the crisis in the family.

3. Identify potential problems that can arise from these values in a different cultural context, such as in the United States.

4. Explore culture-specific assessments and communication approaches for the patient and the family.

5. Identify culturally competent care strategies for health promotion.