Case Study

Mr. Chu

Source: Les Gallo-Silver, MSW
Program Director
Associate Professor
Human Services Program
LaGuardia Community College, CUNY

Mr. Chu, a 67-year-old man born in China, emigrated to the United States 40 years ago. While fluent in English (although with a heavy accent) he is most comfortable speaking Cantonese. He has been married to his wife for 35 years, having met her in the U.S. Mrs. Chu, who is 12 years younger than her husband, is not fluent in English. They have three children, all now adults living out of the home: two married daughters ages 36 and 37, and an unmarried son age 28. Until recently Mr. Chu worked as a jeweler repairing jewelry and watches in a shop owned by his cousin. He presented with a profound loss of weight, coughing and having difficulty swallowing. Through an out-patient medical work-up, he was diagnosed with esophageal cancer. The social worker met the family on the medical visits at which the diagnosis and treatment were discussed. Their older daughter, a lawyer (recently a stay-at-home mother with her third child), acted as a translator and interpreter for her family. Mr. Chu refused the service s of a hospital translator. The daughter and Mrs. Chu did not want the doctor to use the word cancer but agreed to the use of the word tumor. They family feared Mr. Chu would give up and die quickly if told he had cancer. The social worker explored this with the wife and daughter to gain an understanding of how the Chinese community copes with a diagnosis of cancer. The social worker also explored the family's previous experiences with cancer. Mrs. Chu indicated that her father died of lung cancer and that Mr. Chu's mother died of stomach cancer. Both died soon after their diagnosis but were treated with chemotherapy that made them very ill. Both were admitted to hospitals and neither was ever discharged. Both died in a hospital. Mr. Chu's mother was treated in China; Mrs. Chu's father was treated in the U.S.

The health care team agreed to refer to Mr. Chu's illness as a tumor in his esophagus, but they indicated to the family that they were obligated to answer all of Mr. Chu's questions honestly and clearly. The social worker discussed with the health care team the cultural issues involved, the family history, and the family's concern about Mr. Chu giving up hope.

When Mr. Chu received his diagnosis, he seemed to understand he had cancer even though the word was not specifically used. Mr. Chu indicated he would refuse treatment and go home to die. He ordered his daughter to inform the immediate and extended family so they could visit him to say good-bye. His wife began to cry, and his daughter engaged Mr. Chu in what seemed to be a heated discussion. The health care team left the family with the social worker to sort through the information given and to assist Mr. Chu in planning and decision-making.

The social worker empathized with the daughter and in English she discussed her fears and anger about her father's refusal of treatment. It seemed that her mother agreed with Mr. Chu that there was no hope for him. In the family meeting, the social worker validated Mr. Chu's right not to seek treatment but indicated that it was important for Mr. Chu and his family to understand exactly what he was refusing. What ensued was a review of the patient education materials provided to Mr. Chu by the nurse on the health care team. During this intervention the social worker was able to help the family explore their fears as a unit but also evaluate the treatment outlined. In addition the social worker was able to point out the contrast between Mr. Chu's current situation and those of close family members regarding different types of cancer, different types of cancer treatment, and different ways of managing side effects. Mr. Chu agreed not to make a final decision until he spoke with his son and asked the soci al worker to meet with the son as well. The social worker reminded Mr. Chu that the doctor's were concerned about him and needed him to make a decision. The social worker was able to open up the dialogue about treatment without negating Mr. Chu's initial feelings. The social worker had Mr. Chu sign a HIPPA release form indicating who in the family the health care team could discuss his medical condition with.

Mr. Chu's son was a financial manager who indicated that he was not fluent in Cantonese like his sisters. He indicated his parents were upset that he moved out of the house before getting married. He was not surprised about his father's decision against treatment indicating that his father is very old fashioned and traditional. This was also an issue of contention between father and son, and they frequently argued about the son not following the father's ways and traditions. The social worker commented that it was interesting that Mr. Chu chose his son to help him. The social worker indicated that his father was making his decision based on his understanding of cancer and cancer treatment yet asks his son who is labeled as "too modern" to help him in this situation. The social worker wondered if Mr. Chu was still open to being treated if the information gathered by the son allayed his concerns.

The son then met with the nurse clinician, who reviewed the treatment protocol, which included chemotherapy, radiation, and ultimately surgery if the tumor size is reduced by the treatments. The social worker suggested that the son discuss all of this with his father and emphasize that this was a step-by-step process in which Mr. Chu could decided not to have further treatment at any point. It was agreed that the son would accompany his father to the next appointment with the doctor to review all of this and to determine what Mr. Chu would or would not accept as a next step. At this meeting, Mr. Chu agreed to begin the chemotherapy. He asked very specific questions about his prognosis, which the doctor answered. The son was far less uncomfortable about this information being discussed openly than his mother or sister had been. The social worker pointed out that perhaps Mr. Chu had him involved in this process because he was more comfortable with what his father would describe as a "modern" discussion about cancer.

Mr. Chu struggled through his chemotherapy treatment and was challenged by side effects. The social worker remained involved and helped Mr. Chu find a comfortable way to ask for help from the health care team for his treatment side effects. Mr. Chu believed that making "a request" of the health care team was at best rude and at worse a challenge to their authority. The social worker helped Mr. Chu find the words he was comfortable using to ask questions which entailed reassuring Mr. Chu that the health care team was aware of his respect for them and his feelings of gratitude. The social worker met with the team to address these communication issues and how to reassure Mr. Chu that he was not being inappropriate.

The discussion of having a feeding tube placed in anticipation of the side effects of the radiation portion of Mr. Chu's treatment protocol was very distressing for the family and for him. Cooking and preparing food for Mr. Chu was a primary function for his wife that she felt was her contribution to helping Mr. Chu. Again, through the use of Mr. Chu's son, discussions were able to focus on this as a temporary measure. Other important roles for Mrs. Chu were identified, validated, and encouraged.

Recovery from the surgical removal of the tumor and a part of Mr. Chu's esophagus was complicated by issues of pain and pain management. Mr. Chu associated pain medication as an indication that the treatment did not work and that he was dying. His mother was given morphine to ease her pain before she died. The pain nurse explained the different medications and how they help the body recover by alleviating pain. The social worker suggested that Mr. Chu keep a diary to indicate how he felt when he was on pain medication, how he felt before taking it, and what he was doing during these times. Mr. Chu determined from his own diary that he felt better and more lively on the pain medication. The social worker pointed out how this did not match his fears that pain medication meant he was dying. He also determined that he could distract himself from his feelings of pain because he felt better when he saw or spoke to his grandchildren and could concentrate on brief games of Mahjong. Mr. Chu continued to have p ain issues weeks after the surgery but was willing to use pain medication to obtain relief.

Mr. Chu continued to recover slowly and to adjust to the changes caused by his surgery. This had particular impact on eating and meals. Mrs. Chu "experimented" with what foods were comfortable for Mr. Chu to eat and digest. She now had to prepare frequent small meals, which she liked because she "could do more" for her husband. Mr. Chu is aware that his tumor could come back but has been able to enjoy his survivorship through being with family and friends.

Discussion questions:

1. Using Table 3, the biopsychosocial health needs and services required to address them, answer the following questions regarding this case:

   Of the seven assessment areas outlined in Table 3, what information do you have for each?

   Which of the seven areas were most prominent in the assessment and development of a treatment plan for the short term and for the long term with this family?

2. How was the family history of illness relevant to assessment of the family’s understanding of the current illness?
3. How did the family’s culture influence their decision-making process? How important was the son’s, as contrasted to the wife’s and the daughters’, involvement in the father’s decision-making process? What interventions did the social worker use to integrate the family’s culture in the decision-making process?
4. What strengths does this family’s culture evidence for adaptation to a cancer illness?
5. What are the vulnerabilities of their cultural approach to adaptation to chronic or advanced cancer illness? What interventions might help them prepare for future adversities?
6. Describe the various methods of education and information provided throughout the illness process.
7. What was the social worker’s role in providing emotional support to this family?
8. Discuss other cases that present these types of issues of communication in your own practice setting and the intervention approaches that were used.

Care/patient navigation programs are care coordination approaches currently recommended for vulnerable populations of cancer patients.

1. How might such a program, implemented by a social worker, be developed to provide education and advocacy, link services, and reduce barriers to treatment and recovery for this older Asian patient and his family?
2. How might a patient/care navigation program be used with this family or others from this or a different cultural background?
3. Include longer term follow-up plans as well as psychosocial screening to identify vulnerable clients and to link services, education, and advocacy functions.

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