Death and Dying Across Cultures

Gihan ElGindy, RN, MSNGihan ElGindy, RN, MSN

Editor’s Note: Meet Minority Nurse’s cultural competence expert: Gihan ElGindy, RN, MSN, an internationally recognized authority on cross-cultural issues in nursing. Her advice column is designed to answer your questions about incorporating cultural competence into your nursing practice and resolving cultural conflicts in today’s diverse health care workplace.

Death and dying is a universal human experience throughout the globe. Yet human beings’ beliefs, feelings and practices in regard to this experience vary widely between different religions and cultures. As nurses, it is amazing how much we need to learn in order to incorporate sensitivity to unique religious and/or cultural needs into our daily practice. For patients from diverse cultures, quality of care means culturally appropriate care. We need to remember that dying is difficult enough; no one needs to undergo additional stress or suffering as a result of cultural misunderstanding.

As we all learn in nursing school, the patient is the focus of our care. Therefore, patients–and their families–from cultures we may not be familiar with should be viewed as a source of knowledge about their special religious/cultural needs and norms. In many cases, accommodating these needs in a hospital setting is not that difficult, but it definitely requires creativity and just a few extra minutes of our time.

Often, just being aware of our own perceptions and religious/cultural practices, and possessing a degree of openness toward other individuals’ unique needs, is more than enough to lead our basic common sense in caring competently for dying patients from diverse cultural backgrounds during this difficult time.

However, we must resist the temptation to make generalizations or assumptions that all individuals from the same cultural, ethnic or religious background are exactly alike. Within many ethnic populations, such as Hispanics/Latinos, there is a great deal of diversity in terms of cultural practices, geographic origin, etc. Above all, it’s important to realize whether you are dealing with recent immigrants to the U.S. or with first- or second-generation individuals.

Q: As an ICU nurse, I care for dying patients every shift. Often when there is a Hispanic or Latino patient dying or deteriorating, I have to face a crowd of family and friends all day, regardless of the visible visiting hours sign, posted in Spanish. The frustration is mutual. In addition, sometimes the families request to place a special food item in a special location next to the patient’s bed. I know how much this item must mean to them but many of our inflexible unit policies do not promote such practices. What is the best approach to resolve this issue?–Mary John, RN

A: Yes, it is true that America’s health care facilities have many inflexible polices that do not allow much room for promoting diverse cultural/religious rituals or practices. This is a conflict that we nurses face every day and need to work on through ongoing dialog. It can often be difficult to accommodate a patient’s wishes without changing these old, dry polices that ignore many individuals’ needs, even during their last minutes of life.

In the situation you have described, to fully understand these families’ requests we need to understand their culture, too. Hispanics/Latinos are predominantly Christians, yet they encompass varied cultural backgrounds and traditions. Sometimes when a Hispanic/Latino person is sick or dying, close family members such as the spouse, children, parents, etc. may all sit in a circle around a carefully selected food item, such as a fruit dish, placed in the middle of the room. They may spend most of the night praying and conducting special religious practices around this fruit dish. As a result, it becomes a holy dish that holds a great religious significance; the family believes that the holy object can assist their sick or dying loved one. At the end of the night, the family carries the holy fruit dish to the nurse or other care providers, expecting their full compliance in placing it next to the patient to facilitate healing, recovery or a peaceful death.

A simple discussion with the family explaining hospital and unit policies will usually lead nowhere. To please everyone and maintain a positive environment–including compliance with unit policies–the best approach is to place the holy fruit dish or food item in a sealed plastic bag, placing it exactly as the family specifies and explaining to them the perishable item’s time limitation depending on fermentation status and weather conditions. Allowing the item to remain in place for several hours–such as only eight, 10 or 24 hours–will be very much appreciated and calming to everyone. It is very important to remember to ask the family what they want you to do with this item when the time is over.

Q: I recently encountered my first Jehovah’s Witness patient, a child who was dying from a simple bleeding condition. It was very painful to watch his parents repeatedly refusing a blood transfusion that could easily save the boy’s life. Then I heard the physician trying to obtain a court order that would enable him to act as the child’s guardian so he could administer the needed blood transfusion. What a relief, he was able to save the child’s life. But I still do not fully understand why the parents were so angry. Will you kindly explain this, and why they were refusing a simple treatment that has saved millions of lives? –B.B., Kansas.

A: It is very hard and often very painful for care providers to have to watch the process of slow death, or to do nothing for a dying patient whom they think they can save. Many times, we tend to forget that there is a limit to our role and that we need to realize and accept this.

To help you understand why this young patient’s parents were so resistant to the child being given a blood transfusion, let me first explain the significance of blood in the Jehovah’s Witness faith. Jehovah’s Witnesses believe blood is sacred, representing life. Because of the Bible’s command to “keep abstaining from. . .blood,” their religion prohibits the ingestion of blood and the transfusion of blood and/or blood products. Some artificial blood products may be permissible but never natural human blood or its byproducts.

Often, Jehovah’s Witnesses who require medical or surgical treatment will request the use of nonblood alternatives. To be a culturally competent care provider means recognizing that adult patients have a right to make this choice. Therefore, obtaining the patient’s clear written permission before performing any auto-transfusion procedure is the safest practice for both the provider and the receiver. Failure to do so constitutes violating the patient’s bill of rights and can lead to litigation or legal actions.
However, under U.S. law, providing care to a Jehovah’s Witness patient who is a minor (as in the case you describe) differs from caring for a Jehovah’s Witness adult. For minors, the physician can obtain a court order allowing administration of blood or blood products against the parents’ will if he or she knows the procedure can and will save the child’s life. The reason behind the physician’s action is to protect the minor’s life until he/she becomes an adult and can make his/her own faith decision. Of course, when physicians take this action it is not surprising that care providers, especially nurses, will face angry parents.

In future, to resolve this issue easily and safely for everyone, it would be helpful for you to learn about the bloodless treatment alternatives that are available for Jehovah’s Witness patients. If the facility where you work is unable to provide these alternatives, be aware of the health care centers in your area that are specialized and authorized to manage Jehovah’s Witness patients. Contacting the Witnesses’ Hospital Liaison Committee in your area to obtain more information on bloodless treatment options, patient transfers and/or consultation can also be very helpful. This service is available 24 hours a day, seven days a week.

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Q: I had a dying Muslim patient. I tried to provide her with spiritual support but instead I made her upset. I told her, innocently, that I would call the priest for her. Her tears and facial expressions were alarming enough to send a message of pain. Will you please explain what went wrong? In the future, how can I provide appropriate assistance to Muslims patients who are dying?–Linda

A: Before answering your questions, I need to explain an Islamic concept/principal first. In Islam there is no religious figure, such as a priest or rabbi, through which one communicates with Allah (God) on one’s deathbed. Muslims communicate directly with Allah anytime and anywhere as they wish. In other words, they don’t need a human religious figure to act as a spiritual “middleman.” Nor do they need to give confession to absolve their sins before they die.

Secondly, while it was culturally inappropriate in itself to offer to send a Catholic priest to comfort a Muslim patient, what really made this patient upset was probably that she perceived your action as a message that she was about to die. After death, Islam, like many other religions, requires conducting a prayer for the dead, asking for Allah’s mercy and forgiveness before burial takes place. This prayer may be performed by an Imam–a respected member of the community who, through his memorizing of the Quran (Muslim holy book), leads prayers–or by a Shiekh, or Islamic Scholar, who is a knowledgeable person who spent most of his life studying Islam and usually earns a PhD degree in Islamic Shariah (or “Islamic Laws Jurisprudence”). Therefore, even if you had offered to call an Imam or Shiekh instead of a priest, the patient would probably still have been upset, because she would have interpreted this as meaning that her death was imminent.

In the future, the most culturally appropriate way to assist a dying Muslim patient is to offer them the Quran and to facilitate their prayers.