C lt l t i E d f Lif C

Cultural Competence

Cultural competence in End of Life Care for Asian Indian ImmigrantsCultural Competencefor Asian Indian Immigrants

Farhana KanthDalhousie University

School of Health Services Administration

September 8,2006

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Copyright for this presentation belongs to the author.py g p gPermission for its use is granted for non-profit purposes to

improve the education and provision of palliative and end oflife care.

In all instances where this source is used, it should be citedand the author contacted regarding copyright privileges.

Any questions or comments may be directed to :NELS@dal.ca

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OutlineOutlinMethodology

M lti lt li i C dMulticulturalism in Canada

Culture and Palliative Care

Asian Indian immigrantsAsian Indian immigrants

Concepts in Cultural competence

Culturally Competent Palliative Care Culturally Competent Palliative Care

Conclusions

Civilization will judge us by the way we treat our minoritiesMahatma Gandhi

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MethodologyM gy

Literature ReviewElectronic and print journals, books, publications and web sources from 1985 to 2006.

Key words used in search: East Indian, Palliative care, Death, y , , ,Dying, Indian religions, Hindu, Muslim, Sikh, Hospice, Cultural Competence, End of life, Religious beliefs etc

Search engines and Sources: Pubmed, Proquest, Google Scholar, Google, Novanet libraries

Lived ExperiencesProfessional and personal experiences in multicultural environments like India, Saudi Arabia and Canada

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Multicularism in CanadaM CCanadian Charter of Rights and Freedoms recognizes

l i l li i i l (1982)multiculturalism as constitutional (1982)

Multiculturalism Act commits the Government of Canada to

helping communities in bringing about equal access and p g g g q

participation for all Canadians (irrespective of their origins) in the

economic, social, cultural, and political life of the nation (1988)

Cultural Mosaic and not a Melting pot-The Act gives the right to

individuals to practice the religion, belief and customs of their

ethno cultural heritage and denies the notion that everyone must

fit into some set mold

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Palliative Care and CultureP C C

“Palliative Care is the physical, psychological, social and Palliative Care is the physical, psychological, social and

spiritual care to individuals suffering from life threatening

conditions”-WHO

Understanding of culture and its role in caring is important for

professionals providing end of life care since cultural

perspectives influence attitudes towards sickness, dying , death

and griefand grief

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Asian Indian immigrants A I g

Demographics(2001 census, Statistics g p ( ,Canada)

Second largest group of Asian Canadians in most cities

2180 C f2180 Asian Indian Canadians in Halifax

Diversity of the Indian CultureDiversity of the Indian CultureLanguages : 1652 languages and dialects - 18 official and 2 national

Subcultures : Gujrati, Bengali, Marathi, Punjabi, Tamil, Malayalam

Religions : Hinduism, Islam, Christianity, Sikhism, Buddhism,

Jainism, Judaism and Zoroastrianism,

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Religions of IndiaR ligions o IndiaHinduism

God can be worshipped in many forms

Brahma,Vishnu,Shiva are the 3 main gods

Beliefs around end of life: Karma and Rebirth

Sacred Text : Bhagavad Gita

Symbol : Om

Holidays : Holi and Diwali

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Religions of IndiaR ligions o IndiaIslam

B li f i O G d All h d P h M h dBelief in One God - Allah and Prophet Muhammad

5 Pillars of Islam

Major sects Shia S nni S fism in IndiaMajor sects - Shia , Sunni , Sufism in India

Belief in after life and Day of Judgment

Sacred Text : Holy QuranSacred Text : Holy Quran

Symbol : Crescent and star

Holidays : Eid-ul-Fitr and Eid-ul-AdhaHolidays : Eid ul Fitr and Eid ul Adha

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Religions of IndiaR ligions o IndiaSikhism

Belief in one God - Wahe Guru

5 Signs - Hair & beard unshorn, Comb, Dagger, Knee-length pants and Bracelet length pants, and Bracelet

Follow teachings of 10 Gurus

Sacred Text : Guru Granth SahibSacred Text : Guru Granth Sahib

Symbol : Glyph (Khanda)

Special Holiday : BaisakhiSpecial Holiday : Baisakhi

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Religions of IndiaR ligions o IndiaChristianity

B li f i T i i G d J Hi d h H l Belief in Trinity - one God, Jesus His son and the Holy Spirit

Many sects : Roman catholic Protestant Syrian Many sects : Roman catholic, Protestant, Syrian Catholic

Belief in resurrection

Sacred Text : Holy Bible

Symbol : Cross

Special Holiday : Christmas

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Religions of IndiaR ligions o IndiaZoroastrianism

O COne Creator (Ahura Mazda) and Prophet Zarusthra Belief in judgment of soul after deathSacred Text : Holy Zend AvestaySymbol : FaravaharSpecial Holiday : Navroz

JudaismOne Yahweh (God) and Prophet MosesBelief in judgment after deathBelief in judgment after deathSacred Text : Holy TorahSymbol : Magen (Star) DavidSpecial Holiday : Hanukkah

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Religions of IndiaR ligions o IndiaJainism

Follow teachings of MahaviraFollow teachings of MahaviraBelief in cycle of birth and deathSacred Text : Akaranga, Kalpa SutraSacred Symbol : Ahimsa (Peace)Special holiday : Birthday of Mahavira

BuddhismFollow teachings of Lord BuddhaB li f i “ ight f ld th” f M k hBelief in “eight fold path” for MokshaSacred Text : Tripitaka,Sacred Symbol : Dharmachakra (Wheel)Special holiday : Birthday of Buddha

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Concepts in Cultural competenceC p C p

Cultural competence

Culture, Subcultures and Ethnicity

Hierarchical versus Egalitarian culturesHierarchical versus Egalitarian cultures

Acculturation and Assimilation

Stereotypes and Generalizations

Ethnocentrism and Cultural RelativismEthnocentrism and Cultural Relativism

Emic and Etic perspectives of Culture

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Cultural considerations for Palliative care

Home, hospice or hospital?

C P

, p pHome preferred but hospice use can be encouraged

Patient Autonomy and decision makingy gPhysician and family based decision making preferred over autonomy

Language and Communication in the hospiceLanguage and Communication in the hospiceLanguage - Most understand English

Disclosing Diagnosis – Often conveyed to family first, sc os g ag os s O te co eyed to a y st,sensitivity and subtleness important.

Taboo words - Death, Dying, Cancer-non verbal cues, indirect nuances preferred over truth telling.

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Cultural considerations for Palliative careC PRole of family in caring

Caring for the sick and dying is the duty of the familyCaring for the sick and dying is the duty of the family

Attitude towards pain reliefLess demanding more tolerant with possible myths Less demanding , more tolerant with possible myths about addiction and dependency

Diet and food in the hospiceDiet and food in the hospiceCultural and religious differences in eating habits of people. Restrictions on beef for Hindus, restrictions on pork for Muslims etcpork for Muslims etc.

Toilet and washroom habitsCultural differences related to sanitizing after washroom Cultural differences related to sanitizing after washroom use, running water preferred over baths.

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Cultural considerations for Palliative careC P

Self CareThe family takes care of the sick particularly if it is an elderly member

Cultural BeliefsEvil Eye is neutralized in different ways R i i i h if i i A i lReciprocity with gifts quite common in Asian cultures

Religious Practices and BeliefsMost revert to traditional ways in stress or a serious illnessInfluence of religious practices and symbols Exchange of greeting on their specific holidaysExchange of greeting on their specific holidays

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Cultural considerations for Palliative careC P

Alternative Medicines - AyurvedayHealth is a dynamic integration between environment, body, mind and spirit and not just an absence of disease

Healing by

• Lifestyle changes

• Herbal supplements

• Meditation

• Nutritional and dietary regimens

• Breathing exercises

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Cultural considerations for Palliative careC P

Advance Directives, Prolongation of life and , gEuthanasia

Advance directive uncommon

Prolongation of life generally unacceptable

Attitude towards euthanasia varies across faiths

Post mortem and Organ DonationReligious sentiments make these generally unacceptable unless necessary

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Cultural considerations for Palliative careC P

Death and Dying Rituals, Funeral and burial Death and Dying Rituals, Funeral and burial Practices

Hindus - Cremation

Muslims - Burial

Sikhs - Cremation

Zoroastrians Towers of SilencesZoroastrians - Towers of Silences

Bereavement and Expression of GriefGrieving is generally associated with a lot of emotions often expressed as crying and wailing

Visiting the bereaved to offer condolences is a religious dutyVisiting the bereaved to offer condolences is a religious duty

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ConclusionsC

‘Asian Indian’ is a heterogeneous groupg g p

Individualized care plans

Family involvement in decision making and careFamily involvement in decision making and care

Accommodation of religious practices & beliefs

Awareness of religious influences on food

Same sex caregivers preferred

Anticipation of pain relief in spite of patients inhibitions

Involvement of cultural health interpreters and volunteersInvolvement of cultural health interpreters and volunteers

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ReferencesRAlagiakrishnan, K., & Chopra, A. (2001). Health and Health care of Asian Indian American. R t i d 3 d J l 2006 f htt // t f d d / / th / i i di htRetrieved 3rd July 2006, from http://www.stanford.edu/group/ethnoger/asianindian.htm

Alexander, L. (2006). Pain Management, Palliative Care and Treatment of the Terminally ill. Continuing Education For California Physicians, 131(5).

Dom, H. (2006). Vaisnava Hindu and Ayurvedic Approaches to Caring for the Dying: [Electronic Version]. Innovations in End-of-Life Care. Retrieved 3rd July, 2006 from http://www2.edc.org/lastacts/archives/archivesNov99/intlpersp.asp.

Elliot, G. (1999). Cross-cultural Awareness in an Aging Society: Effective Strategies for Communication and Caring –A Resource Book for Practitioners, Educators and Students. Ontario: Office of Gerontological Studies McMaster UniversityOntario: Office of Gerontological Studies, McMaster University.

Galanti, G.-A. (2004). Caring for Patients from Different Cultures (3rd ed.). Philadelphia: University of Pennsylvania Press.

Gatrad, R., Choudhury, P. P., Brown, E., & Sheikh, A. (2003). Palliative Care for Hindus. I t ti l J l f P lli ti N i 442 448International Journal of Palliative Nursing, 442-448.

Hopkins, W. E. (1997). Ethical Dimensions of Diversity. California: Sage Publications,Inc.

Joshi, S. (1998). Ayurveda and Panchkarma (First ed.). New Delhi: Motilal BnarasidasPublishers Private Limited.

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ReferencesRRaj, S. (2004, 30th July 2006). Asian Food Practices. Retrieved 30th July, 2006, from htt //h lth f i iti /f dFit /A i F dP ti fhttp://healthpowerforminorities.org/foodFitness/AsianFoodPractices.cfm

Sarhill, N., LeGrand, S., Islambouli, R., Davis, M. P., & Walsh, a. D. (2001). The terminally ill Muslim: Death and dying from the Muslim perspective. American Journal of Hospice and Palliative Medicine, 18(4), 251-255.

Searight, H. R., & Gafford, J. (2005). Cultural Diversity at the End of Life: Issues and Guidelines for Family Physicians. American Family Physician, 71(3).

Statistics Canada. (2003). 2001 Census: analysis series. Religions in Canada. Retrieved 30th July 2006. from http://www12 statcan ca/english/census01/products/analytic/companion/rel/pdf/96F00http://www12.statcan.ca/english/census01/products/analytic/companion/rel/pdf/96F0030XIE2001015.pdf#search=%22Analysis%20Series%20%2CReligions%20in%20Canada%2CMinister%20of%20Industry%22.

Taylor, A., & Box, M. (1999). Multicultural Palliative Care Guidelines. Retrieved 3rd July 2006 from http://www pallcare asn au/mc/mccontents html2006, from http://www.pallcare.asn.au/mc/mccontents.html.

Wells, S., & Black, R. (2000). Cultural Competency for Health Professionals. Maryland: American Occupational Therapy Association

WHO. (2006). WHO Definition of Palliative Care. Retrieved 30th July 2006, from http://www who int/cancer/palliative/definition/en/http://www.who.int/cancer/palliative/definition/en/

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Thank youThank you Thanks to Grace Johnston for giving me this opportunity Thanks to Grace Johnston for giving me this opportunity

Very special thanks to Victor Maddalena for continuous support

and guidanceand guidance

A big thank you to Judy Simpson, Donna Smith, Sharon

M d h J T k P t i i ‘O’ H ll G i d Dill Murdoch, Joy Tarasuk, Patricia ‘O’ Hollaran, Gurinder Dillon,

Swarna Weerasinghe, Merrie Mills and Dr Bhatia for taking time

to meet with meto meet with me

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