Cultural & Religious Considerations in End-of-Life Care & the Donation Decision

1. Cultural & Religious Considerations in End-of-Life Care & the Donation Decision FirstName LastName Title Organization

2. Question to Run on: How comfortable are you with your knowledge of cultures and religions and how does that impact your care? Hospital-MCT_HAguiar

3. Cultural Assumption Hospital-MCT_HAguiar

4. New Perspective Hospital-MCT_HAguiar

5. Objectives By the end of this presentation the learner will: Understand the definitions of culture, race, and ethnicity Recognize nursing theory supporting cultural competence Recognize the risk of cultural assumption and imposition Be empowered to draw upon their professional strengths Be equipped with practical tips to become culturally skilled Hospital-MCT_HAguiar

6. Overview Laying Foundations Need for Multicultural Skills Culturally Sensitive End-of-Life Care Basic Principles Hospital-MCT_HAguiar

7. Laying Foundations Operational Definitions of Culture, Ethnicity, and Race and the Differences Between These Terms Hospital-MCT_HAguiar

8. Laying Foundations • Culture is requires a broad definition and should include: • Ethnographic variables • Demographic variables • Status variables • Affiliation variables Hospital-MCT_HAguiar

9. Laying Foundations – Defining Culture “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 “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) Hospital-MCT_HAguiar

11. Laying Foundations – Defining Race “…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 Hospital-MCT_HAguiar

12. Laying Foundations 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 Hospital-MCT_HAguiar

13. Laying Foundations Important Clarifications: • There are no distinct, pure races today • Religion is very much entwined with ethnicity, shaper of health values, beliefs, and practices Hospital-MCT_HAguiar

14. Thought Question 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”? Hospital-MCT_HAguiar

15. Need for Multicultural Skills Nursing Theory & Regulatory Standards Requiring Multicultural Skills Hospital-MCT_HAguiar

16. Need for Multicultural Skills • Nurse Theorist • PhD in Anthropology • Transcultural Nursing • Transcultural Nursing Society • Journal of Transcultural Nursing • Talks about culturally congruent care Madeleine Leininger Hospital-MCT_HAguiar

17. Need for Multicultural Skills Leininger says that nurses are realizing the critical need to become more culturally competent and knowledgeablein working with individuals of diverse cultures. (Leininger, 1994) Hospital-MCT_HAguiar

18. Need for Multicultural Skills • 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 Hospital-MCT_HAguiar

19. Need for Multicultural Skills • 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) Hospital-MCT_HAguiar

20. Need for Multicultural Skills 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 The Joint Commission definition of cultural competence (cont.): • Cultural competence requires organizations and their personnel to: • value diversity; • assess themselves; • manage the dynamics of difference; • acquire and institutionalize cultural knowledge; and • adapt to diversity and the cultural contexts of individuals and communities served • culturally and linguistically appropriate Hospital-MCT_HAguiar

22. Need for Multicultural Skills “Cultural competence is a journey, not a destination.” (Galanti, 2008) Hospital-MCT_HAguiar

23. Culturally Sensitive End-of-Life Care Cultural Assumptions & Imposition, Cultural Beliefs about EOL & Donation & Cross-Cultural Communication Hospital-MCT_HAguiar

24. Play Video YouTube - Seinfeld. Is he black? Hospital-MCT_HAguiar

25. Culturally Sensitive End-of-Life Care • 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 Culture Assessed by Observation: • Dress • Appearance • Speech • Education Hospital-MCT_HAguiar

27. Culturally Sensitive End-of-Life Care Practices in EOL & attitudes about donation • Preconceived ideas about cultures • African American • Filipino • Hispanic • Asian • Religious background • Jewish • Jehovah Witness • Hindu • Bias vs.. reality Hospital-MCT_HAguiar

28. 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 Cambodia Hospital-MCT_HAguiar

29. Culturally Sensitive End-of-Life Care 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 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 • Belief in Donation • Depends on tribe – generally not supported but this is changing Hospital-MCT_HAguiar

30. 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 • 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 Hmong 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 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 Filipino Hospital-MCT_HAguiar

33. Culturally Sensitive End-of-Life Care 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

34. Culturally Sensitive End-of-Life Care Iranians • 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 Hospital-MCT_HAguiar

35. Culturally Sensitive End-of-Life Care 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 Hospital-MCT_HAguiar

36. Culturally Sensitive End-of-Life Care “Unspoken assumptions regarding meaning of health, illness, and death may affect communication regarding donation.” Dr. Hawryluck & Knickle (n.d.) Hospital-MCT_HAguiar

37. Culturally Sensitive End-of-Life Care 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 • Generalization vs. Stereotyping • Arthur Kleinman’s Explanatory model • Unbiased approach to an individual • Gain the emic perspective versus our etic perspective Hospital-MCT_HAguiar

39. Culturally Sensitive End-of-Life Care 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 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? Hospital-MCT_HAguiar

41. Culturally Sensitive End-of-Life Care 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? Hospital-MCT_HAguiar

42. Culturally Sensitive End-of-Life Care Simple triggers - the 4Cs: • Call • Cause • Cope • Concerns Hospital-MCT_HAguiar

43. Cross-Cultural Communication Skills • Culture & communication connected • Communication – driven by culture • Connection forgotten = risk for misunderstanding Hospital-MCT_HAguiar

44. Cross-Cultural Communication Skills Effective communication is your responsibility 6 barriers to communication: Nonverbals Ethnocentrism Assuming similarities vs. differences • Anxiety • Stereotypes and prejudice • Language problems Hospital-MCT_HAguiar

45. Cross-Cultural Communication Skills • 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 Hospital-MCT_HAguiar

46. Cross-Cultural Communication Skills 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 Hospital-MCT_HAguiar

47. Understand your motives Concerns for the family Concerns for the recipient Turning a negative situation around to be positive Cross-Cultural Communication Skills Hospital-MCT_HAguiar

48. Cross-Cultural Communication Skills • 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 Hospital-MCT_HAguiar

49. Cross-Cultural Communication Skills 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 Hospital-MCT_HAguiar

50. Basic Principles Practical Tips for Working with Various Cultures Hospital-MCT_HAguiar