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_____Geriatric
Curriculum
End-of-Life Nursing Education Consortium
SESSION 8:
Cultural and Spiritual
Considerations at End-of-Life
Fairfield University
Quinnipiac University
School of Nursing ELDER Project
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Objectives: Upon completion of this
session, the learner will be able to…
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Examine the influence of cultural and spiritual
beliefs.
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Describe beliefs regarding death and dying held
by various cultures.
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Identify the role of interdisciplinary care in
respecting cultural and spiritual diversity.
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Culture Defined
• Socially transmitted values, customs,
arts, behaviors, and beliefs that
guide a person’s world view
• A system of shared symbols
• Provides security, integrity,
belonging
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Components within Culture
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Ethnicity
Race
Gender
Age
Religion and spirituality
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In order to provide culturally sensitive care to those
at the end of life, the first task of the healthcare
workers should be to:
1. evaluate the cultural beliefs of co-workers
2. identify one’s own cultural background and values
3. learn to predict how various races deal with end-of-life
issues
4. become informed about state laws concerning end-of-life
care
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Self-Cultural Assessment
• What is your ethnic affiliation and how strong is your
ethnic identity?
• Who makes decisions - you, your family, or a designated
family member?
• Is religion an important source of support and comfort?
• What are your health and illness beliefs and practices?
• What are your past experiences regarding death and
bereavement?
• How much do you and your family wish to know about the
disease and prognosis?
• What are your beliefs about the afterlife and miracles?
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Adapted from:
Zoucha, R. (2000). The keys to culturally sensitive care. American Journal of Nursing, 100(2),
24GG-24II. Reprinted with permission.
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Which factor should NOT be considered when
assessing the cultural beliefs and practices related to
death and dying?
1. how long the client has been in this country
2. the age of the client and family members
3. aspects of spirituality, traditions, rites and
rituals
4. specific beliefs about pain, suffering and
death
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Name that Culture!
Group Activity
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Hispanic/Latino
African American
Indian
Haitian
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Jamaican
Russian
Vietnamese
Judaism & Islam
The palliative care team is caring for a client from
Cambodia who has terminal lung cancer. The client
does not want to discuss the illness. What should the
healthcare worker do?
1. Remind the client that it is important to talk about the
illness.
2. Allow the client to remain in denial by not discussing the
cancer.
3. Ask the family about their beliefs regarding full
disclosure.
4. Refer the client to a mental health professional for
evaluation.
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How has culture influenced
your care of dying patients?
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Cultural Values of the American
Health Care System
• Truth-telling
• Patient autonomy
• Personal control
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Group Activity:
American views on death
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Values in Non-European American
Cultures
• Interdependence, especially
among family members,
rather than a focus on
individual autonomy
• Respectful communication
• Trust, rather than control
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Cultural Assessment at the End of Life
• Communication styles
• Decision-making
• Death rituals
• Religious beliefs
• Gender /age
• Historical or political
factors
• Community resources
Lipson & Dibble, 2005;
Mazanec & Panke, 2010
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The healthcare team is teaching a student how to
perform a cultural assessment for clients at the end
of life. Which of the following statements shows the
student understands?
1. “The best strategy for evaluating sexual orientation is to
ask clients if they are heterosexual or homosexual.”
2. “To assess spirituality, questions regarding religious
affiliation and religious practices are generally sufficient.”
3. “Financial status is an invasive question and should be
asked by the social worker.”
4. “Ethnic identity varies within ethnic groups, so ask clients
how strongly they identify with a particular group.”
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When talking to persons of another culture, the
healthcare worker should:
1. use the person’s first name to establish warm rapport
2. determine who makes decisions for the client and family
3. speak primarily to the translator rather than the client or
family
4. act as if the client is fully informed of the diagnosis and
prognosis
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Culturally Sensitive Care:
General Approaches
• Knowledge
• Careful assessment without stereotyping
• Respect for diverse beliefs and practices
• Understanding and honoring one’s own
values
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Which remark by a palliative care team
member shows culturally sensitive end of life
care?
1. “I ask the client who he wants to include in conversations
about his illness.”
2. “I hold the client’s hand and get physically close to her to
show I care.”
3. “I can predict how members of a particular ethnic group
will respond to pain.”
4. “I feel it’s our obligation to tell a patient bad news, even if
the family objects."
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Spiritual Considerations
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A 48-year-old woman recently diagnosed with
breast cancer is married and has 3 small
children. When is the best time to begin a
spiritual assessment?
1. when the patient enters the health care
system
2. after chemotherapy is started
3. once the patient asks for spiritual support
4. as soon as the client begins
to deteriorate
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Spiritual Assessment
• Key Assessment Areas
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Sample question
• Concept of God or deity
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Is religion or God significant to
you? Can you describe how?
• Sources of hope and strength
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Who do you turn to when you need
help? Are they available?
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Are any religious practices
important to you?
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Has being sick made any difference
in your feelings about God or the
practice of your faith?
Important religious practices
• Relationship between spiritual
beliefs and health
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Spirituality
• Central idea that
defines life’s meaning
and purpose
• Feeling of
connectedness with
oneself, others, nature,
God
• Allows people to
transcend suffering
and despair
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Religion
• Expression of one’s spirituality
through organized, codified beliefs
and practices
• People can be spiritual without being
religious
Religious beliefs can influence EOL treatment
decisions.
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Group Activity
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Spiritual Assessment -FICA
• Faith
• Importance
or Influence
• Community
• Address
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During a spiritual assessment, which question
shows the healthcare workers bias?
1. “What church do you attend?”
2. “Are spiritual beliefs important in your life?"
3. “What aspect of your faith gives your life most
meaning?”
4. “How would you like me to address spirituality in
your care?”
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Spiritual Interventions
• Therapeutic
presence
• Compassion
without exhaustion
• Prayer, spiritual readings, spiritual
rituals
• Opportunities for life review
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Life Review:
Seeking Meaning in Life and Death
• Encourages a person to review
his/her life, and come to grips with
the good and bad
• Confirms the uniqueness
of each person’s life
through story-telling
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Life Review:*ACTIVITY*
• What is the legacy of your life?
• What gives you greatest joy in your life?
• What regrets do you have?
Coming to grips with the good and the bad.
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Spiritual Interventions
• Encouraging patients to
use their spiritual
strengths
• Making referrals to
chaplains and other
spiritual caregivers
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The Role of Chaplains and Other
Spiritual Caregivers in EOL Care
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Consistent presence
Assisting in meaning-making
Encourage reconciliation
Support at death
Follow-up after death
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Summary
Culture and spirituality are essential parts
of EOL care. They can be viewed as
barriers or opportunities. Supporting the
dying person and family by accepting them
and being present can help relieve suffering
and bring peace at EOL.
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References
City of Hope & the American Association of Colleges of Nursing, 2007;
Revised, 2010. The End-of-Life Nursing Education Consortium
(ELNEC)- Geriatric Training Program and Curriculum is a project of
the City of Hope (Betty R. Ferrell, PhD, FAAN, Principal Investigator)
in collaboration with the American Association of Colleges of Nursing
(Pam Malloy, RN, MN, OCN, Co-Investigator).
D.J. Wilkie & TNEEL Investigators, 2001. Toolkit for Nursing Excellence
at End of Life Transition, version 1.0. Cancer Pain & Symptom
Management Nursing Research Group; University of Washington.
Supported by DHHS/HRSA/BHPR/Division of Nursing
Grant # D62HP06858
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