cultural & religious considerations in end-of-life care & the donation decision
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Cultural & Religious Considerations in End-of-Life Care & the Donation Decision
FirstName LastNameTitle
Organization
Hospital-MCT_HAguiar 2
Question to Run on:
How comfortable are you with your knowledge of
cultures and religions and
how does that impact your care?
Spring2011
Hospital-MCT_HAguiar 5
Objectives
By the end of this presentation the learner will:
1. Understand the definitions of culture, race, and ethnicity
2. Recognize nursing theory supporting cultural competence
3. Recognize the risk of cultural assumption and imposition
4. Be empowered to draw upon their professional strengths
5. Be equipped with practical tips to become culturally
skilled
Spring2011
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Overview
Spring2011
• Laying Foundations
• Need for Multicultural Skills
• Culturally Sensitive End-of-Life Care
• Basic Principles
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Laying Foundations
Operational Definitions of
Culture, Ethnicity, and Race and
the Differences Between These Terms
Spring2011
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Laying Foundations
Spring2011
• Culture is requires a broad definition and should
include:
─ Ethnographic variables
─ Demographic variables
─ Status variables
─ Affiliation variables
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Laying Foundations – Defining Culture
Spring2011
“Culture is defined as a specific
set of social, shared,
educational, religious, and
professional behaviors,
practices and values that
individuals learn and ascribe to
while participating in or
outside of groups with whom
they typically interact.” (Bomar, 2004)
Hospital-MCT_HAguiar 10
Laying Foundations – Defining Ethnicity
Spring2011
“Ethnicity is a key facet of culture and refers to a common
ancestry, a sense of ‘peoplehood’ and group identity. From
a common ancestry and a shared social and cultural
history and national origin have evolved shared values and
customs.”
(Friedman et al., 2003)
Laying Foundations – Defining Race
Spring2011
“…an ancient, nonscientific, political
classification of human beings and is
based on physiological
characteristics, such as skin color, eye
shape, and texture of hair.” (Bomar, 2004)
• It is a narrower term then ethnicity and denotes a
human biological definition
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Laying Foundations
Spring2011
Important Clarifications:
• Race and ethnicity should NOT be confused
• People of one race can vary in terms of their
ethnicity and culture
• Race is NOT considered a correct or useful means of
classifying people
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Laying Foundations
Spring2011
Important Clarifications:
─ There are no distinct,
pure races today
─ Religion is very much
entwined with ethnicity,
shaper of health values,
beliefs, and practices
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Thought Question
Spring2011
Knowing that people of one race can vary in terms
of their ethnicity and culture, can we truly make
assumptions about someone based on their
biological looks or even based on the little we may
know of their “culture” or “ethnicity”?
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Need for Multicultural Skills
Nursing Theory
&
Regulatory Standards
Requiring Multicultural Skills
Spring2011
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Need for Multicultural Skills
• Nurse Theorist• PhD in Anthropology• Transcultural Nursing• Transcultural Nursing
Society• Journal of Transcultural
Nursing• Talks about culturally
congruent care
Spring2011
Madeleine Leininger
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Need for Multicultural Skills
Leininger says that nurses
are realizing the critical
need to become more
culturally competent and
knowledgeable in working
with individuals
of diverse cultures. (Leininger, 1994)
Spring2011
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Need for Multicultural Skills
Spring2011
• Health Care Professionals’ Multicultural Needs
– The Joint Commission requirement
• Data reported to The Joint Commission demonstrates
most root cause of sentinel events is due to
communication:
• Many standards relate to importance of
understanding, acknowledging and respecting the
patient’s culture
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Need for Multicultural Skills
Spring2011
• U.S. Department of Health & Human Services – The
Office of Minority Health standards
– 14 CLAS standards set for health care organizations
with the following themes:
• Culturally Competent Care (Standards 1-3),
• Language Access Services (Standards 4-7), and
• Organizational Supports for Cultural Competence
(Standards 8-14)
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Need for Multicultural Skills
Spring2011
The Joint Commission definition of
cultural competence:
• the ability of health care providers and
organizations to understand and respond
effectively to the cultural and language
needs brought by the patient to the
health care encounter
Hospital-MCT_HAguiar 21
Need for Multicultural Skills
Spring2011
The Joint Commission definition of cultural competence (cont.):• Cultural competence requires organizations and their
personnel to: 1. value diversity;2. assess themselves; 3. manage the dynamics of difference;4. acquire and institutionalize cultural knowledge; and5. adapt to diversity and the cultural contexts of individuals
and communities served• culturally and linguistically appropriate
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Need for Multicultural Skills
Spring2011
“Cultural competence is
a journey,
not a destination.”(Galanti, 2008)
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Culturally Sensitive End-of-Life Care
Cultural Assumptions & Imposition,
Cultural Beliefs about EOL & Donation &
Cross-Cultural Communication
Spring2011
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Play Video
YouTube - Seinfeld. Is he black?
Spring2011
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Culturally Sensitive End-of-Life Care
Spring2011
• What assumptions were being made in this clip?• What were the characters basing their
assumptions on?• Have you ever made an assumptions about
someone’s culture / religion / race purely based on their looks?
• Did you ever discover that your assumption was completely wrong?
Hospital-MCT_HAguiar 26
Culturally Sensitive End-of-Life Care
Spring2011
Culture Assessed by Observation:
• Dress
• Appearance
• Speech
• Education
Hospital-MCT_HAguiar 27
Culturally Sensitive End-of-Life Care
Spring2011
Practices in EOL & attitudes about donation• Preconceived ideas about cultures– African American– Filipino– Hispanic– Asian
• Religious background– Jewish– Jehovah Witness– Hindu
• Bias vs.. reality
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Culturally Sensitive End-of-Life Care• Belief in Sickness
– Imbalances causes sickness– Focus on symptoms vs. illness– Comfortable with Western medicine,
but more likely to try traditional first
• Values in Death and Dying– Monks need to recite prayers, family
members should be present, family faces death quietly, incense may be burned
• Belief in Donation– Unlikely to allow donation, body
cremated, due to belief in reincarnation, desire for body to be intact
Spring2011
Cambodia
Hospital-MCT_HAguiar 29
Culturally Sensitive End-of-Life Care
Spring2011
Native Americans • Values in Death & Dying– May avoid contact with the
dying– Family present 24 hrs/day– Atmosphere may be jovial with
eating, joking, playing games, and singing
– Once death occurs – wailing, shrieking may occur
– Children included– May prefer open window
• Belief in Donation– Depends on tribe – generally not supported but this is changing
• Belief in Sickness– Interconnectedness leads to
relationship between man, God, fellow man, and nature
– Sickness is an imbalance– Healing is not separated from rest– Healing cannot happen without
spiritual intervention
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Culturally Sensitive End-of-Life Care• Belief in Sickness
– Illness can have natural or supernatural etiologies, possible belief of illness might be soul loss or ancestral spirit seeking attention
• Values in Death and Dying– Amulets need to remain in place,
Shaman rituals may be performed, after death specific rituals performed to help send person’s spirit to heaven
Spring2011
Hmong
• Belief in Donation– Traditionally will not donate because they believe one of three spirits
will remains with body, therefore the body needs to remain whole. Christian Hmong believe body and soul are separate and may consent
Hospital-MCT_HAguiar 31
Culturally Sensitive End-of-Life Care• Belief in Sickness
– Illness and death part of life, many believe, illness is bad luck or misfortune or karma
• Values in Death and Dying– Mourning and crying may appear over-
dramatized to outsider, chanting, incense burning, praying, etc. may be involved. Family will want to spend time with patient after death and may request to cleanse body
– Cremation not common• Belief in Donation
– Donation usually considered negatively. Associated with tampering of body/soul/spirit
Spring2011
Korean
Hospital-MCT_HAguiar 32
Culturally Sensitive End-of-Life Care• Belief in Sickness
– Result of imbalance, associated with bad behavior punishment, may not respond to illness until it is advanced
• Values in Death and Dying– Death is a spiritual event, family
may want to wash the body, will want all the family to say good-bye prior to the body being taken
• Belief in Donation– The body is given high respect,
cremation is not common practice, may not allow donation
Spring2011
Filipino
Hospital-MCT_HAguiar 33
Culturally Sensitive End-of-Life Care
Spring2011
Hispanics• Belief in Sickness
– Columbians – severe illness attributed to God’s design or punishment for bad behavior
– Central Americans – imbalance, concern with hot/cold & strong/weak, caused by strong emotions and/or evil eye or curse
• Values in Death and Dying– Columbians – may be surrounded by all family members except small children,
catholic prayer common, may ask for priest, may cry uncontrollably and loudly, women may be hysterical
– Central Americans – Assure privacy and quiet for sacrament of sick, candles may be used, family members prepare body for burial, death considered a spiritual event
• Belief in Donation– Columbians – may consent to donation– Central Americans – donation acceptable if body treated with respect
Hospital-MCT_HAguiar 34Spring2011
Culturally Sensitive End-of-Life Care
• Belief in Sickness– Illness discussed and challenged,
remedies and advice solicited, body viewed in relation to environment, e.g. God, society, nutrition, etc.
• Values in Death and Dying– Notify head of family first, DNR not
difficult, death seen as beginning of spiritual existence
• Belief in Donation– Organ donation acceptable, speak
to head of family
Iranians
Hospital-MCT_HAguiar 35Spring2011
African American• Belief in Sickness
– Illness due to natural causes, poor life-style, exposure to cold air/winds, unnatural or supernatural causes, God’s punishment, work of the devil or spell
• Values in Death and Dying– Family wants professionals to cleanse and prepare body, deceased
highly respected, cremation avoided
• Belief in Donation– Taboo to donate organs and blood, exception if there is a need in
the family
Culturally Sensitive End-of-Life Care
Hospital-MCT_HAguiar 36
Culturally Sensitive End-of-Life Care
Spring2011
“Unspoken assumptions regarding
meaning of health, illness, and
death may affect communication
regarding donation.”
Dr. Hawryluck & Knickle (n.d.)
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Culturally Sensitive End-of-Life Care
Spring2011
Risk of Cultural Imposition
“The nurse must examine his/her biases and prejudices
toward other cultures as well as explore his/her own
cultural background….Without becoming aware of the
influence of one’s own cultural values, a risk exist for the
nurse to engage in cultural imposition”. (Campinha-Bacote et al 1996)
Hospital-MCT_HAguiar 38
Culturally Sensitive End-of-Life Care
Spring2011
• Generalization vs. Stereotyping
• Arthur Kleinman’s Explanatory model
• Unbiased approach to an individual
• Gain the emic perspective versus our etic perspective
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Culturally Sensitive End-of-Life Care
Spring2011
Anthropological terminology:
• Emic perspective –
insider’s perspective
• Etic perspective –
outsider’s perspective
• Both perspectives –
most effective vantage point
Hospital-MCT_HAguiar 40
Culturally Sensitive End-of-Life Care
Spring2011
Explanatory Model – 8 Questions by Arthur Kleinman:
• What do you call your illness? What name does it have?
• What do you think has caused the illness?
• Why and when did it start?
• What do you think the illness does? How does it work?
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Culturally Sensitive End-of-Life Care
Spring2011
Explanatory Model – 8 Questions (cont.)
• How severe is it? How long do you think you will have it?
• What kind of treatment do you think the patient should
receive? What are the most important results you hope
he/she receives from this treatment?
• What are the chief problems the illness has caused?
• What do you fear most about the illness?
Culturally Sensitive End-of-Life Care
Simple triggers - the 4 Cs:
1. Call
2. Cause
3. Cope
4. Concerns
Spring2011 Hospital-MCT_HAguiar 42
Cross-Cultural Communication Skills
• Culture & communication
connected
• Communication –
driven by culture
• Connection forgotten =
risk for misunderstanding
Spring2011 Hospital-MCT_HAguiar 43
• Effective communication is your responsibility
• Anxiety
• Stereotypes and prejudice
• Language problems
• 6 barriers to communication:
• Nonverbals
• Ethnocentrism
• Assuming similarities vs.
differences
Spring2011 Hospital-MCT_HAguiar 44
Cross-Cultural Communication Skills
Cross-Cultural Communication Skills
Spring2011 Hospital-MCT_HAguiar 45
• Good intercultural communicators:
– Personality strength
– Communication skills
– Psychological adjustment
– Cultural awareness
• Eight different skills:
– Self-awareness, self-respect, interaction, empathy,
adaptability, certainty, initiative, and acceptance
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Cross-Cultural Communication Skills
Spring2011
Cultural considerations
• Identify the Decision Maker
• Give the family what they need and want
• Do not project your own personal feelings
• Assess their readiness – let the family guide the
conversation
Cross-Cultural Communication Skills
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• Understand your motives
– Concerns for the family
– Concerns for the recipient
– Turning a negative situation
around to be positive
Cross-Cultural Communication Skills
Spring2011 Hospital-MCT_HAguiar 48
• Communication varies:
– overt & direct vs. covert & indirect
• Overt & direct challenged by covert & indirect
• Covert & indirect find overt & direct aggressive
• Use indirect communication to identify and
uncover perceptions of disease causation and
best treatment
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Cross-Cultural Communication Skills
Spring2011
Professional Empowerment• Developed their your interpersonal skills• Utilize your strengths• Focus on the family– Time – Taking care of their needs– Pick-up on cues from the family– Sensibility, sensitivity and adaptation
Basic Principles
Practical Tips for Working with
Various Cultures
Spring2011 Hospital-MCT_HAguiar 50
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Basic Principles
Spring2011
Reflections – know & understand yourself:
• What is your culture? Your beliefs?
• Have your culture and beliefs been influenced by
your family? Has it evolved?
• If you have changed your perspectives, what led you
to change your perspectives?
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Basic Principles
Spring2011
Cultural-Communication Tips
• Learn and use a few phrases of greeting and
introduction in the patient’s native language
– conveys:
– Respect
– Demonstrates your willingness to learn about their culture
• Avoid saying “you must….”, use, e.g., “some people in this
situation would….”
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Basic Principles
Spring2011
• Do not assume you know the culture
• Seek to understand –
Don’t be afraid to ASK!
• Become a student of the person / the family
• Identify what provides value in death to that
individual
Remember - your culture is not superior.
55
Question to Run on:
How comfortable are you with your knowledge of
cultures and religions and how does that impact
your care?
Spring2011 Hospital-MCT_HAguiar
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