Table 2 Themes, subthemes and supporting quotes

Theme 1: Interpretating and understanding of cultural humility in palliative and EOL care

Subtheme 1a: Recognizing my positionality, biases, and preconceived notions

“People are going to have had different experiences, different upbringings… the things that you value and think are important and proper are not necessarily going to be the same as them…the humility piece is just acknowledging that there’s more than one way to do things… it can’t be about what you would want or what you would do in a particular situation” (RT-008, physiotherapist).

“I am someone who identifies as like moderately religious, I’m kind of like ‘Whoa, whoa’ especially if it’s someone within my same kind of religion; someone who is a version of Christianity…I find it sometimes harder not to fight against it and be like ‘No, that’s not how this works’” (RT-003, occupational therapist).

Subtheme 1b: Check myself: Learning from patients

“When families don’t want their loved ones knowing about their cancer diagnosis and or prognosis and thinking ‘I would want to have that information’ you worry about them, like, are they hiding stuff? Are they wanting mom to keep fighting and not giving them the full info? But then I learned a little while ago that in some cultures, they’re shielding this information because they don’t want to burden the person and they want them to just be not carrying the weight of knowing prognoses- Like, oh, that’s interesting. I never would have thought of that, so I need to like check myself if a patient family that’s maybe being a bit more secretive in their approach with what info they want the family to learn, it’s not necessarily for sinister reasons. They’re not trying to hide, they’re trying to not burden, so always opportunities to learn different perspectives” (RT-006, physiotherapist).

Theme 2: Values, conflicts, and ethical uncertainties when practicing cultural humility at EOL

Subtheme 2a: Values and conflicts between provider and patients and family, and within the team

“Where it can be tricky is specifically when a family will not want you to talk about the fact that a person is palliative; a patient. Because it’s important, in their culture, not to talk about death or dying. It makes it hard to navigate, I guess, open discussion. ‘Cause I often, if I can, to ask a person how much they know about their prognosis and what kinds of choices they’re going to want to be making given how much- Like, how they see their health progressing. And there’s a few families where it’s been very clear, like, don’t mention that you’re from palliative home care. Like, please don’t talk to the client about their diagnosis or their prognosis. And so, it’s uncomfortable” (RT-012, occupational therapist).

“Eating is just so important and so central to the culture of the family. There’s, in advanced cancer, I mean, everybody loses their appetite and there’s a phenomenon called anorexia and cachexia…the family, you know, is thinking like ‘Oh my gosh, you’re starving. You’re losing so much weight. You’re not eating. You have no appetite. If you’re ever going to get better, like, you need to eat.’ And so, my role in something like that, like the way that I will approach it is to just affirm…this is not actually a function of their choices, but this is like a part of their disease and something…this is going to be another stage in accepting the fact that their family member is dying” (RT-011, occupational therapist).

Subtheme 2b: Constraints/biases within the system which prevent culturally humble practices

“I also do have an agenda where I need to also synthesize information quickly because as a clinician – especially in acute care – I don’t really have the time. I don’t have time to make, you know, dedicated appointments. I have a huge- Like, I have to triage appropriately on an ongoing basis because I also have referrals, I also have to balance like my own clinical duties” (RT-001, speech-language pathologist).

Theme 3: The ‘how to’ of cultural humility in palliative and EOL care

Subtheme 3a Reflective strategies

“You can’t rid yourself of your biases. I think if you, you know, if you tell yourself that you can, there’s something that you’re going to miss. Like, there’s something that you’re hiding…but it’s about being as aware of them as I can be so I can make sure that those aren’t the things that are in the driver’s seat when I’m making decisions” (RT-011, occupational therapist).

Subtheme 3b: Relational strategies

“When you work with different cultures when you enter the room – because you know the basis before entering the room – not assuming things which is associated to a specific culture and not approaching them with your biases or any biases you have heard or you have seen; being more neutral. That’s what I understand about cultural humility” (RT-010, physiotherapist).

“Let’s say it’s a Chinese family, and so I know that, like, many times there is that preference not to have someone die in a home, I go in but I adjust my language vague enough. So, for example, talking about- I still reference like, you know, ‘At home this is what it would look like: You would need a hospital bed.‘ At home, this is-‘ I’m not saying for when you go home, I’m using a language that’s general enough to, you know, let the family know that I’m not making any assumptions about whether they are going home or not, but that if they want to, that option is still there” (RT-002, occupational therapist).

“Be culturally sensitive to different kinds of religions and how it related to speech. One example I will just kind of discuss is kind of like when we’re doing assessment for like Ramadan, we should be more culturally sensitive on like ‘Okay, can I actually assess you? Can I give you something to eat and drink?’ And also, food that’s halal, like, that’s something at least, again, a lot of my- like I said my interventions with food; making sure, okay, I can’t give them- I have to make sure this is, like, kosher or halal before I actually feed them as part of my assessment. So not only that, like I have to even look at my food just to make sure that I’m providing something that’s respectful. Also asking first, also not assuming that, you know, but asking ‘Are you okay? Can I try this? Is there anything that you can’t eat?’ Kind of like treating it like an allergy I guess, not that it is an allergy, but asking for that information openly” (RT-001, speech language pathologist).

Subtheme 3c: Contextual/health system enablers

“Make sure that I’m doing everything that I can, and also just grounding my decisions in, like, our, you know, policies” (RT-011, occupational therapist).