Bringing Cultural and Spiritual Sensitivity to End-of-Life Care

The ethnic, cultural, and religious diversity that gives America its own unique background is also adding a new dimension to the special needs that healthcare practitioners must address when providing end-of-life care to members of these different communities.

"Because patients make medical decisions based on cultural and religious needs, those aspects must always be taken into account and those borders must not be violated when we are discussing terminal illness and end-of-life care," said M. Terrance Simon, DO, a family physician in Massillon, Ohio. He stressed the osteopathic medicine approach involves caring for the "whole" patient, from the beginning of life until the end of life. "Within that framework, DOs typically discuss quality of life with their patients, as well as their personal philosophy of how they want to mature, and ultimately how they want to approach the end-of-life process," he said.

Along with the more than 200 living languages spoken in the US comes a multitude of cultural attitudes and rituals regarding death, dying, and end-of-life healthcare that physicians must consider. For example:

• Some West African cultures believe that telling a person they are very sick or dying is predicting the future. if you say something bad will happen, it will.
• In many cultures, it's believed that if the body is opened up for surgery there is a chance for evil spirits to enter the person.
• Latinos typically do not believe in nursing homes and tend to make their own care arrangements for terminally ill family members.
• European- and African-Americans generally believe a patient should be told the diagnosis of a terminal illness, while Korean- and Hispanic-Americans do not.

In addition to its cultural diversity, America has more religions and faith groups than can be calculated. And each of these groups has specific rituals and approaches to dealing with death and dying, such as:

• The Buddhist faith teaches that a person's state of mind while dying is of great importance. To help achieve a peaceful state of mind, the dying person is surrounded by family, friends, and monks who recite Buddhist scripture and mantras.
• Practicing Catholics who are dying let their relatives and friends know they wish to receive the "last rites," which is usually accompanied by the sacrament of reconciliation and receiving Holy Communion as "viaticum," or food for the journey.
• Islamic practices surrounding death vary, but generally the dying are positioned on their backs with their heads facing Mecca. The room is perfumed and Islamic scriptures are read by the dying person or a relative.
• In the Hindu religion, at the time of death, holy ash must be applied to the forehead while holy mantras are chanted.
• Judaism mandates the body be treated with awe and reverence and embalming or viewing of the body is usually not permitted because this tends to turn the person into an object.

Religious or spiritual beliefs can have a powerful impact on end-of-life care and the outcome for a dying patient. In fact, the importance of addressing patients' spirituality is considered so important that a number of colleges of osteopathic medicine offer coursework on the topic of spirituality as it relates to end of life.

According to Dr. Simon, physicians need to be prepared for. and be open to. the spiritual and cultural differences of patients. Developing an approach to end-of-life care that respects patients' and their families' requirements requires open dialog between everyone involved. He said the following key areas should be addressed and considered regarding cultural and spiritual sensitivity:

• If appropriate, physicians should ask patients if they wish to receive information and make decisions for their own care, or if they prefer that their families handle such matters.
• If religion is an important part of the person's life, clergy members should be included in the discussions.
• The physician must be straightforward with patients. Let them know that you will tell them what they want to know, and ask if you should talk to their family members or not.
• If there is a language barrier, the family and doctor should request that an independent, outside translator be brought in, particularly if the burden of translating would otherwise fall on the shoulders of a young or adolescent family member.
• In terms of determining spirituality, a physician may ask open-ended questions, such as "What gives you your strength?" or "What is the most meaningful thing in your life?"

Regardless of the patient's ethnic background, religious affiliation, or cultural beliefs, each individual's situation truly is its own culture. "That means the end-of-life caregiving team must always be sensitive to the issues at hand and then treat each individual case as its own," Dr. Simon said. "All people have their own unique beliefs and philosophy of how they will spend the last moments of their journey."