cultural & religious considerations in end-of-life care & the donation decision

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


Cultural Assumption

Spring2011


New Perspective

Spring2011


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


Overview

Spring2011

• Laying Foundations

• Need for Multicultural Skills

• Culturally Sensitive End-of-Life Care

• Basic Principles


Laying Foundations

Operational Definitions of

Culture, Ethnicity, and Race and

the Differences Between These Terms

Spring2011


Laying Foundations

Spring2011

• Culture is requires a broad definition and should

include:

─ Ethnographic variables

─ Demographic variables

─ Status variables

─ Affiliation variables


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)


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


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


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


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”?


Need for Multicultural Skills

Nursing Theory

&

Regulatory Standards

Requiring Multicultural Skills

Spring2011



• Nurse Theorist• PhD in Anthropology• Transcultural Nursing• Transcultural Nursing

Society• Journal of Transcultural

Nursing• Talks about culturally

congruent care

Spring2011

Madeleine Leininger

http://rds.yahoo.com/_ylt=A2KJkIWCdcVNhAsA4ZyjzbkF/SIG=1300bl2o9/EXP=1304815106/**http:/www.e-contentmanagement.com/uploads/Image/cnj/Madeleine_Leininger.JPG



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



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



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)



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



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



Spring2011

“Cultural competence is

a journey,

not a destination.”(Galanti, 2008)


Culturally Sensitive End-of-Life Care

Cultural Assumptions & Imposition,

Cultural Beliefs about EOL & Donation &

Cross-Cultural Communication

Spring2011


Play Video

YouTube - Seinfeld. Is he black?

Spring2011

http://www.youtube.com/watch?v=-M5G2nWP3xY



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?



Spring2011

Culture Assessed by Observation:

• Dress

• Appearance

• Speech

• Education



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


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



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



– 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



– 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



– 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



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


• 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




Spring2011

“Unspoken assumptions regarding

meaning of health, illness, and

death may affect communication

regarding donation.”

Dr. Hawryluck & Knickle (n.d.)



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)



Spring2011

• Generalization vs. Stereotyping

• Arthur Kleinman’s Explanatory model

• Unbiased approach to an individual

• Gain the emic perspective versus our etic perspective



Spring2011

Anthropological terminology:

• Emic perspective –

insider’s perspective

• Etic perspective –

outsider’s perspective

• Both perspectives –

most effective vantage point



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?



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?


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


• Effective communication is your responsibility

• Anxiety

• Stereotypes and prejudice

• Language problems

• 6 barriers to communication:

• Nonverbals

• Ethnocentrism

• Assuming similarities vs.

differences





• 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



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



• Understand your motives

– Concerns for the family

– Concerns for the recipient

– Turning a negative situation

around to be positive



• 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



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



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?


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….”


Basic Principles

Spring2011

Beware of hand gestures, some examples:


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

Questions ?

Thank you for your attention!

cultural & religious considerations in end-of-life care & the donation decision

Documents

terms spring2011hospitalmct

haguiar9 culture

shared values

key facet of culture

cultural competencerecognize

cultural history

risk of cultural assumption

common ancestry