Cultural Considerations

END OF LIFE y Refers to issues related to death and dying

Follow with respect the bioethical and cultural beliefs and practices of the client/family/carer
Cultural influences and Advance Directives African American Clients European American Clients Asian American Clients Hispanic American Clients

Religion and End-of-Life Care

CHRISTIANITY Catholic and Orthodox Religions y y Priest anoints the sick Other sacraments before death include reconciliation and holy communion

Protestant y y No last rites are given (anointing of the sick is accepted in some groups) Prayers are given to offer comfort and support

Church of Jesus of Latter-Day Saints (Mormons) y  Cleric may administer a sacrament if the client requests Discourage, oppose, or prohibit cremation

Jehovah Witness y y  Members do not believe in sacraments Members will be excommunicated if they receive a blood transfusion Prohibit organ donation

ISLAM y Second degree male relatives such as cousin or uncles should be the contact person and determine whether the client and/or family should be given information about the client. Client may choose to face Mecca The head should be elevated above the body Discussions about death usually are not welcomed Stopping medical treatment is against Allah s (Arabic word for God) will Grief may be expressed through slapping or hitting the body

y y y y y

y y y

If possible, only a same-sex Muslim should handle the body after death; if not possible, non-Muslim should wear gloves so as not to touch the body Discourage, oppose, or prohibit cremation Prohibit organ donation

JUDAISM y y y Prolongation of life is important ( a client on life support must remain so until death) A dying person should not be left alone (a rabbi s presence is desired) Autopsy and cremation are forbidden

HINDUISM y y  Rituals include tying a thread around the neck or wrist of the dying person, sprinkling the person with special water, or placing a leaf of basil on the person s tongue. After death, the sacred threads are not removed and the body is not washed. Prefer cremation and cast the ashes in a holy river

BUDDHISM y y y y y A shrine to Buddha maybe placed in the client s room Time for meditation at the shrine is important and should be respected Clients may refuse medications that may later their awareness After death, a monk may recite prayers for 1 hour (need not be done in the presence of the body) Buddhist in America encourage organ donation and consider it as an act of mercy

Cultural and religious issues

African American    Organ and blood donation usually are not allowed Members prefer to die at home Members discuss issues with the spouse of older family members

Hispanics and Latino Groups y y y y y y y y y Predominant religion is Roman Catholic Prayer and folk remedies are common, as is the use of religious objects Members may avoid eye contact as a sign of respect Members tend not to complain of pain The family generally makes decision and may request to withhold the diagnosis or prognosis from the client Extended family members often are involved in the end-of-life care (pregnant women may be prohibited from caring for the dying or attending funerals) Several family members may be at the dying client s bedside Vocal expression of grief and mourning is acceptable and expected Members refuse procedures that alter the body, such as organ donation or autopsy

Members prefer to die at home

African American Clients y y y y y y y y Members discuss issues with the spouse or older family members (elders are held in high respect) Family is highly valued and is central to the care of the terminally ill Pain is reported openly Open displays of emotion are common and accepted Organ and blood donation usually are not allowed They are more likely to select aggressive interventions Are less likely than European American of Hispanic American clients to have documented their end-of-life health care wishes Members prefer to die at home

Chinese Americans y y y y y y Family members may make decisions about care and often do not tell the client about the diagnosis or prognosis Members often avoid eye contact because it represents disrespect to persons in authority Personal distances should be maintained Affection between family members rarely is exhibited in public Members may not report pain Dying at home may be considered bad luck

Native Americans y y y y y Eye contact is avoided Personal distances needs to be maintained Family meeting may be held to make decisions about end-of-life and the type of treatments that should be pursued Members may not report pain Some tribes avoid contact with the dying (prefer to die in the hospital)

Issues on Advance directive: European American Clients y y Are more much likely to have written advance directives than members of other cultures Select no code more than do Hispanic American or African American clients but less than do Asian American clients

Asian American Clients y y Select no code more than do all other groups Are less likely to have advance directives

Hispanic American Clients y Are least likely of all groups to select no code

Legal and Ethical Issues y y Outcomes related to care during illness and the dying experience should be based on the client s wishes Issues for consideration may include organ and tissue donations, advance directives or other legal documents, withholding or withdrawing treatment, and cardiopulmonary resuscitation.

Palliative care y y y Focuses on caring interventions and symptom management rather than cure for disease that no longer respond to treatment A pain-controlled and symptom controlled environment is established ( the dying client should be as pain-free and as comfortable as possible) Hospice care provides support and care for clients in the last phases of incurable diseases so that they might live as fully and as comfortable as possible; client and family needs are the focus of any intervention.

Nursing Care 1. Assessment of the client a. Assessment should be limited to obtaining essential data b. Frequency of assessment depends on the client s stability (at least every 8 hours); as changes occur, assessment needs to be done more frequently. c. Avoid repeated, unnecessary assessments on the dying client 2. Physical care for the dying client a. Pain i. Administer pain medication ii. Do not delay or deny pain medication b. Dyspnea i. Elevate the head of the bed or position on the side ii. Administer supplemental oxygen iii. Suction fluids from airway as needed c. Skin i. Assess color and temperature ii. Assess for breakdown iii. Implement measures to prevent breakdown d. Dehydration i. Maintain regular oral care ii. Encourage taking of ice chips and sips of fluids iii. Do not force the client to eat or drink iv. Use moist cloths to provide moisture to the mouth v. Apply lubricant to the lips and oral mucus membranes e. Anorexia, nausea, and vomiting i. Provide antiemetics before meals

ii. Have family members provide the client s favorite food iii. Provide frequent small portions of favorite foods f. Elimination i. Monitor urinary and bowel elimination ii. Place absorbent pads under the client and check frequently g. Weakness and fatigue i. Provide rest periods ii. Assess tolerance for activities iii. Provide assistance and support as needed for maintaining bed or chair positions h. Restlessness i. Maintain a calm soothing environment ii. Do not restrain iii. Limit the number of visitors at the client s bedside iv. Allow a family member to stay with the client i. 3. Psychosocial care a. Monitor for anxiety and depression b. Monitor for fear Fear associated with Dying Fear of Pain o Fear of pain may occur based on anxieties related to dying o Do not delay or deny pain relief measures to a terminally ill client y Fear of Loneliness and Abandonment o Allow family members to stay with the client o y Fear of Meaningless o Client may feel hopeless and powerless o Encourage life reviews and focus on the client s positive aspect of their life Encourage the client and family to express feelings Provide support and advocacy for the client and family Provide privacy for the client and family Provide a private room for the client Maintain respect and dignity for the client y

c. d. e. f. g.

4. Postmortem care a. Maintain respect and dignity for the client b. Determine whether the client is an organ donor, if so, follow appropriate procedures related to the donation c. Consider cultural rituals, state laws, and agency procedures when performing postmortem care d. Prepare the body for immediate viewing by the family e. Provide privacy and time for the family to be with the deceased person General Postmortem Procedures y Close the client s eyes y Replace dentures y Wash the body

y y y

Place pads under the perineum Remove tubes and dressings Straighten the body and place a pillow under the head in preparation for family viewing