palliative care in jordan: culturally sensitive practice

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    JOURNAL OF PALLIATIVE MEDICINEVolume 11, Number 10, 2008 Mary Ann Liebert, Inc.DOI: 10.1089/jpm.2008.0166

    Palliative Care in Jordan: Culturally Sensitive Practice

    Mohammad Bushnaq, M.D.

    Dear Editor:

    At the King Hussein Cancer Center in Jordan, we havebeen working since 2004 to implement palliative care for pa-tients with cancer. We have been taught using materials fromthe EPEC Project, the ELNEC Project, and onsite teaching byteams of physicians and nurses from the United States aswell as training at San Diego Hospice and the Institute forPalliative Medicine.

    As part of our implementation, an important questionarose. How do we apply what we learned in palliative carein harmony with our culture? Let me illustrate with a recentcase.

    A 52-year-old man presented with pallor, fatigue, andjaundice due to pancreatic cancer metastatic to the liver. Hewas married and had three daughters. He was a devout Mus-lim.

    After investigation, the oncologist decided there were nocurative measures and he referred the patient to palliativecare. At the time the palliative care team arrived in the pa-tients room, many family members were waiting outside theroom with many questions. They said they hoped they willfind a treatment somewhere else. They asked that the patientnot know anything about his disease to keep up his moraleand spirit. The atmosphere was tense.

    We asked the close family for a family meeting, in whichwe listened to them talking about the disease progression,their feelings, hopes, and their expectations from us. Thenwe shared the disease condition and prognosis.

    In Jordan, based in the Islamic religion and cultural norms,people believe that no matter what you do, when your timecomes to die, it is Gods wish and your destiny. Therefore,it was easy for the family to accept a do-not-resuscitate con-cept. And in the same way, they accepted the fact that it isthe right of the patient to at least have some sense that hisdeath is near, so that he could finish unfinished business,in particular moral and religious duties, so that he may meethis lord free of sins.

    Then, we asked the family to join us to see the patient to-gether. We talked about his cancer, emphasizing that the goalnow will be for symptom control and quality of life. He lis-tened carefully and then he asked: how much time do I have?We answered, We dont have a definite answer, but we dorecommend you balance things. At the same time you havehope to survive for a long time, you really need to get pre-pared. In other words, hope for the best and prepare for theworst. The patient and the family were satisfied with this

    open discussion, and the patient was discharged home withour home palliative care service. Three weeks later the pa-tient died at home peacefully.

    This case illustrates that approaches developed in Europeand the United States can be integrated into traditional Arabculture. We think its clear that values and principles of pal-liative care are the same everywhere, but the way we applyit needs to be tailored to local culture and norms. In this ex-ample, in response to his question, How long have I got?we did not answer with the phrase, Weeks to months aswe might if we had been practicing in California.

    We have the following advice for those working in Araband Muslim culture.

    The family system is strong. Parents, spouses, and elderchildren are involved in making decisions. They need tobe assured that we respect their opinion and input.

    Traditional Muslims believe the patient must attend tosome moral and religious obligations before death.

    When facing suffering and illness, a traditional Muslimaccepts suffering as a way of atonement of ones sins. Thisdoesnt conflict with giving all efforts to relieve suffering.This way of handling suffering helps the Muslim copewith the illness and to die in peace with self, God, andothers.

    When we ask patients if they want to hear the truth whenwe are breaking bad news, most of the people say yes.But, we subsequently discover that they wish they did notask. We discovered most are seeking reassurance and em-pathy rather than information, even though they answeryes. Our approach now is to respond to the patientsquestion with a more oblique answer. We try to switchtheir focus toward quality of life and comfort, without of-fering false hope. In rare occasions, when the patient in-sists to know, we give the answer following the six stepsof breaking bad news advocated by Robert Buckman.

    When asked about prognosis, in our experience, tradi-tional Muslims respond well to euphemisms. Instead ofgiving answers in terms of time, we say that he/she is re-ally in a critical condition, and it is the right time for himto meet his family and to prepare for the hereafter in casehe/she deteriorates. This prompts the family to move intotheir traditional role, sometimes with our help, to stay atthe bedside, reading a chapter from Noble Quran and toprompt gently that the patient speak the shahadah; (bear-ing witness that there is no true God but Allah and Mo-hammad is verily his servant and his messenger).

    Letters to the Editor


    We do not present do-not-resuscitate status as a choice.Patients and families tell us it is a big burden for them tochoose, and many family members said they would feelguilty if they make that decision. Instead, we rely on ourlegal and religious background, and inform the family thisis a medical decision so they only need to be informed,not to decide.

    Muslim people are not familiar with chaplain, since inIslam you can talk directly to God, and you do not needanybody to help you pray. On the other hand, we foundthat it is very useful to have somebody who has the skills

    to address spiritual needs with the patients at this stageof their life.

    Address reprint requests to:Mohammad Bushnaq, M.D.

    Hospice and Palliative Care ConsultantKing Hussein Cancer Center



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