A love of nature and the importance of living a simple, natural life are the basis of Hinduism, a faith that originated in India and is generally acknowledged to be the world’s oldest and third largest religion. Like Buddhism, the Seventh-day Adventist Church and other religions that promote a vegetarian lifestyle, the Hindu faith encompasses a number of health beliefs and dietary practices arising from the idea of living in harmony with nature and having mercy and respect for all of God’s creations.
Followers of the Hindu religion, which is practiced primarily in India, Nepal and Sri Lanka, believe that the body is made up of natural elements: earth, air, fire, water, etc. The proper balance of these elements indicates good health, while an imbalance indicates the opposite. Hindus believe self-control and meditation is the path to health, with prayer to the Almighty God being the last resort. For many Hindus, yoga is a means by which to bring the integration of the body, mind and intellect together in order to achieve perfect harmony or alignment.
The four Vedas (which means “the Wisdom and the Knowledge”) are among the most important of the Hindu holy books. For devout believers, these sacred texts address every aspect of their lives that are controlled by their faith, including their daily practices, their yearly calendar and their use of water in acts of worshipping. For Hindus, water is believed to be a purifier and a rejuvenating agent for religious acts, as evidenced, for example, in the traditional practice of bathing in sacred rivers during pilgrimages.
The Hindu Dietary Code
Devout Hindus believe that all of God’s creatures are worthy of respect and compassion, regardless of whether they are humans or animals. Therefore, Hinduism encourages being vegetarian and avoiding the eating of any animal meat or flesh. However, not all Hindus choose to practice vegetarianism, and they may adhere to the religion’s dietary codes in varying degrees of strictness. For example, some Hindus refrain from eating beef and pork, which are strictly prohibited in the Hindu diet code, but do eat other meats.
Some Hindu Sayings and Beliefs Related to Health and Diet Live a natural, healthy life—i.e., be like the birds and animals. “The treatment is a learning process, but sometimes an old patient is worth more than a young doctor.” In other words, knowledge, wisdom and experience are valuable to the process of staying healthy. Showing care for what you eat can save your body and mind. Eat moderately and consume simple, pure, healthy foods (a Sattvic diet) even when not fasting.
Like Buddhists, Hindus believe that food affects both body and mind. Food is considered to be a source of the body’s chemistry, which affects one’s consciousness and emotions. Thus, expression of the soul depends on the body, which depends on the food. A proper diet is considered vital for spiritual development in Hinduism. The Hindu diet code divides food into three categories, based on the food’s effect on the body and the temperament:
Tamasic food is leftover, stale, overripe, spoiled or other impure food, which is believed to produce negative emotions, such as anger, jealousy and greed.
Rajasic is food that is believed to produce strong emotional qualities, passions and restlessness in the mind. This category includes meat, eggs, fish, spices, onions, garlic, hot peppers, pickles and other pungent or spicy foods.
The most desirable type of food, Sattvic, isfood that is non-irritating to the stomach and purifying to the mind; it includes fruits, nuts, whole grains and vegetables. These foods are believed to produce calmness and nobility, or what is known as an “increase in one’s magnetism.”
Hindus believe that for true service to God, purity of food is necessary to maintain the desirable state of mind that leads to enlightenment. Food is consumed not only to survive but also to stay healthy and maintain mind/body equilibrium. By eating a purer quality of food, such as a Sattvic diet, and regulating food consumption, one can ensure a pure heart, long life, cheerful spirit, strength, health, happiness and delight. Good and pure food promotes a peaceful—not agitated—mind, which is needed to see the Truth as the Truth. Sin, or an agitated state of mind, prevents the journey to moksha (divine supreme knowledge, which leads to freedom from the cycle of birth, life, death and rebirth).
Some specific Hindu dietary customs and practices include the following:
A true devotee will refuse to accept any food that is not offered first to God. Gaining God’s blessing before consuming the food is essential. Hindus may do this is by placing their daily food before the particular deities they worship and by reciting shlokas(prayers). Once the food is offered to God, it is eaten as prasador blessed food.
Before starting any daily meal, a devout Hindu first sprinkles water around the plate as an act of purification.
Five morsels of food are placed on the side of the table to acknowledge the debt owed to the devta runa (divine forces) for their benign grace and protection.
For a child’s birthday celebration, the sacred symbol “OM” is added onto the birthday cake along with “Happy Birthday.” Also, a lamp is lit instead of having the child blow out the candles. In the Hindu faith, lighting a lamp is symbolic of new life, a new beginning or the spreading of knowledge.
The Practice of Fasting
Some Hindus practice the tradition of fasting during special occasions, such as holy days, new moon days and festivals. As is also the case in a number of other religions, fasting is seen as a way of staying close to God and attaining a close mental proximity to Him. Hindus fast in various ways, depending on the individual: They may choose to not eat at all during the fasting period, or to eat only once, eat only fruits or restrict themselves to a special diet of simple foods.
Fasting is believed to help reinforce control over one’s senses, squelch earthly desires and guide the mind to be poised and at peace. Hindus also believe that when there is a spiritual goal behind fasting, it should not make the body weak, irritable, or create an urge to later indulge. Rather, rest and a change of diet during the fasting time is considered to be very good for the digestive system and the entire body. The idea is that every system needs a break and an occasional overhaul to work at its best.4
Health Considerations of the Vegetarian Diet
There is a myth that vegetarians suffer from vitamin deficiencies. The truth is that all needed nutrients are found in vegetables, fruits and nuts when eaten in sufficient amounts; the only exception is vitamin B12. To overcome this potential deficiency, which can cause anemia and other disorders, vegetarians need to markedly increase their protein intake. According to the recommendation of the American Dietetic Association (ADA), vegetarians should increase their consumption of rice milk, soy milk, yeast extracts and breakfast cereals to ensure a sufficient intake of vitamin B12.
Ask the Cultural Competence Expert Minority Nurse’s cultural competence expert, Gihan ElGindy, MSN, RN, is an internationally recognized authority on cross-cultural issues in nursing. This 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. Do you need advice on how to provide culturally sensitive care to patients from a particular ethnic or religious background? Are you looking for ways to increase understanding and acceptance of cultural differences in your work environment? Our expert can help! Send your Cultural Competence Q&A questions to [email protected].
Some vegetarians refrain from eating meat, fish or fowl but do consume eggs and/or dairy products. In contrast, a vegan diet is a total vegetarian diet that excludes any and all animal products (i.e., no meat, eggs and dairy). Therefore, vegans generally have a lower calcium intake than non-vegetarians, but they may have lower calcium requirements as well. Vegans are advised to increase their intake of Omega-3 fatty acids found in flax seed, walnuts, soybeans and dark green vegetables.
The ADA is just one example of a major health organization that recognizes that a well-planned vegetarian or vegan diet can reduce the risk of many chronic conditions, such as heart disease, obesity, diabetes, asthma, high blood pressure and cancer. Because vegetarians are less susceptible to major diseases, they can live healthier, longer and more productive lives, with fewer visits to doctors, fewer dental problems and lower medical bills.
Here are some additional health benefits of the vegetarian diet:
Food is easier to digest, provides a wider ranger of nutrients and requires less effort to purify the body from its wastes.
Vegetarians’ immune systems are stronger, their skin is less flawed and their bodies are more pure and refined.
Finally, because meat is expensive compared to fruits, vegetables, etc., a vegetarian diet can also have financial benefits for low-income populations. Unfortunately, lack of sufficient access to food stores that sell good quality fresh produce continues to be a serious health problem in disadvantaged communities.
Editor’s Note: Previous articles in the culturally competent dietary assessments series, including “Meeting Jewish and Muslim Patients’ Dietary Needs” and “Understanding Buddhist Patients’ Dietary Needs,” are available online.
Because immigrants from Asian countries with large Buddhist populations are a rapidly growing minority group in the U.S., it’s important for nurses to understand Buddhist patients’ beliefs about health, illness and food.
The love of nature and maximum enjoyment of what nature provides us is necessary in order to live a truly natural life. This is the main belief in many Asian cultures, such as those of China, Japan, Taiwan, Korea, Tibet, Sri Lanka, Thailand, India and the Philippines. While Christianity is the dominant religion in many of these countries, there are also significant numbers of Buddhists, along with Muslims, Hindus and atheists.
In the Buddhist faith, life revolves around nature with its two opposing energy systems, known in Chinese philosophy as yin and yang energy. Examples of these opposing energy forces, which are cyclical, include heat/cold, light/darkness, good/evil and sickness/health. Although a simple illness, such as a cold or flu, may be considered an imbalance of yin and yang energy, many Buddhists-though not all-believe that the best way to live a healthy life is to be a vegetarian.
The Buddhist tradition of vegetarianism has gained a great deal of popularity around the globe, as both a diet and a way of life. In the United States alone, there are about 20 million vegetarians. At the same time, in certain Asian cultures there has been a strong movement away from the traditional strict vegetarian diet as a result of these countries’ exposure to Islam and Christianity.
Part of being a culturally competent health care professional is being careful not to make blanket generalizations about patients from unfamiliar cultures-such as assuming that if a patient is an immigrant from an Asian country, he must be a Buddhist. Even if it is known for a fact that the patient’s religion is Buddhism, this does not necessarily mean that he or she strictly follows all Buddhist religious practices to the letter. It is vitally important for nurses to initiate dialogue with patients and their families in order to determine what, if any, cultural/religious needs and dietary restrictions must be accommodated to ensure the best possible healing process for the patient.
Understanding Buddhist Beliefs
The Buddha was born in what is now Nepal and founded Buddhism in India during the sixth century B.C. After Buddha’s death, his followers considered him a divine entity with the ability to lead them to Heaven.
This is a faith of supreme optimism that teaches self-control as a means to search for true happiness. Buddhists practice yoga and meditation as a means to reach spiritual emancipation or true liberation. Through mastering self-control, a Buddhist can reach full potential toward a journey of self-improvement during this life in order to achieve reincarnation, or rebirth after life. The rebirth process requires a desirable state of freedom or purity from primitive human desires and wishes.
The Buddhist code of morality is set forth in the Five Moral Precepts, which are:
1. Do not kill or harm living things.
2. Do not steal.
3. Do not engage in sexual misconduct.
4. Do not lie.
5. Do not consume intoxicants such as alcohol, tobacco or mind-altering drugs.
Buddhists believe that being careful in selecting the food one eats correlates with the amount of light in one’s body and the degree of power necessary to climb up the spiritual ladder-i.e., to reach the desirable state of relaxation and of being sincere to oneself and others. By following this path, one’s soul reaches harmony, the desirable spiritual status and/or the power of virtue necessary to attain the reincarnation process.
Buddhist Dietary Practices
In the teachings of Buddha, this concept of making the right food choices for spiritual enlightenment is exemplified by the “Five Contemplations While Eating.” Essentially, this means that Buddhists are exercising a special force related to “stopping and thinking” about the food they are eating.
(Interestingly, it is believed that the Buddha himself actually died from food poisoning.) A Buddhist asks himself these five basic but essential questions:
1. What food is this? = The origin of the food and how it reached me.
2. Where does it come from? = The amount of work necessary to grow the food, prepare it, cook it and bring it to the table.
3. Why am I eating it? = Do I deserve this food or not? Am I worthy of it?
4. When should I eat and benefit from this food? = Food is a necessity and a healing agent because I am subjected to illness without food.
5. How should I eat it? = Food is only received and eaten for the purpose of realizing the proper way to reach enlightenment.
A Buddhist GlossaryVegetarianism: A diet that includes no meat. In the Buddhist religion, eating a vegetarian diet is a natural and logical ramification of the moral precept against the taking of life. Veganism: A philosophy of life that should be thought of as entirely separate from vegetarianism. It is concerned with an entire lifestyle rather than just a dietary regime. Veganism prohibits not only the eating of animals, animal products and their derivatives-including milk, cheese and honey-but also the use of animal furs, leathers, skins, etc. Vegans believe these products-and even their by-products-must be avoided at both the physical and mental levels to ensure true liberation that facilitates the attaining of enlightenment.Ahimsa: The act of not killing or harming. It refers to the compassionate, non-violent treatment of living things and the acknowledgment of all sentient creatures’ right to live and be reborn. Practicing ahimsa will keep the Buddhist on the right spiritual path and enforces “a better life and better health.”Karma: A sort of spiritual bank account that is accumu-lated through one’s actions in life. Good karma occurs for those who follow Buddhism’s moral precepts; it will lead to being reborn as a higher being, such as a god or wealthy human. Bad karma, which can result from forbidden acts such as killing living things, can cause one to be reborn as a lesser being, such as an animal, insect or demon. Once you pay off your karmic “debts,” you can be reborn as human.
Buddhists who are strict adherents to their faith depend not only on these Five Contemplations but also on the Five Moral Precepts to determine which foods are appropriate to consume and which are considered forbidden. In general, Buddhism prohibits the eating of any and all meat, because (1) the killing of animals violates the First Moral Precept and (2) meat is considered an intoxicant to the body, which violates the Fifth Moral Precept.
According to the Fifth Precept, consuming any type of intoxicants will reflect negatively on a Buddhist’s life and afterlife in the following ways:
o Effects on Self: It will distort and cloud one’s samadhi-i.e, it will hinder one’s judgment and decrease proper concentration necessary for meditation, which is the path to enlightenment.
o Effects on Others: It will increase one’s susceptibility to commit crimes and do wrong to others, which means loss of the desirable self-control.
o Religious/Spiritual Effects: It can cause bad karma (see Glossary) that harms other sentient beings and later on will haunt the original being.
Buddhists believe that whoever lives only for pleasure loses his soul’s harmony and the power of virtue. According to the “no killing” precept, whoever kills animals or eats meat will lose the “purity of both body and mind”-i.e., one gets all mixed up with the meat one eats and loses purity, clarity and the power of self-control. Buddhists also believe that causing the suffering of living creatures just to satisfy our taste buds is not a justifiable reason to eat meat. In Buddhists’ eyes, hunger is the minimal expression of compassion that can be offered and becoming a vegetarian is a choice-i.e., choosing not to kill animals (out of kindness) and not to eat them (out of compassion).
In addition to the physical suffering of animals, Buddhists believe that eating meat also causes another type of suffering: bad karma. Killing a sentient being forces it to begin a painful process of rebirth. Since Buddhists believe it is possible for animals to attain enlightenment, killing them deprives them of that chance. Eating a vegetarian diet helps ensure that the cycle of karmic retribution will be purified:
If you don’t eat animals, they won’t eat you. If you don’t kill them, they won’t kill you.
Other foods that may fall into the “forbidden” category include “the Five Pungent Spices.” This refers to onions, scallions, chives, garlic, etc. Traditionally, Buddhists have believed that a person who eats these foods will suffer the following ill effects:
His blood and flesh will be rejected by the gods, and the heavens will distance themselves far from him.
His breath is always foul; therefore, all gods and saints will reject him.
If eaten cooked, these foods will arouse lust and cause explosive temper.
If eaten raw, they will increase one’s anger and cause bad body odor that will not please the gods but will stimulate interested “hungry ghosts” who will hover around and kiss one’s lips. Being near ghosts is believed to hinder one’s enlightenment.
Today, however, many vegetarians around the world, including some Buddhists, may eat the Five Pungent Spices without reservation. For Buddhists, this depends on such factors as the person’s degree of adherence to their faith, whether they are practicing Buddhism along with other faiths, and their geographic location.
Health Benefits of the Buddhist Diet
Examples of permitted foods that are staples of the traditional Buddhist diet in many Asian cultures include:
1. Boiled or stir-fried noodles flavored with aromatic spices. Raw or cooked vegetables, seaweed and home-prepared dried food items can also be added.
2. Rice, which can be cooked and flavored in many different ways-e.g., salty, sweet, neutral, sticky, colored or mixed with vegetables.
3. Soy sauce is an essential tasty ingredient that is added to almost every dish, in much the same way as Americans flavor many of their foods with butter and/or salt.
4. Sesame oil is also used heavily in preparing food. Unlike soy sauce, it contains no sodium.
5. Buddhists who are not strict vegetarians will eat fish on an almost daily basis and/or will add it to many of their meals.
6. Herbal tea is a popular and healing drink that originates from various types of tea plants.
For centuries Buddhists have believed that when meat is eaten it accumulates in the body, turning into harmful toxins. Today, modern medicine seems to be proving them right. A number of recent scientific studies have discovered a high incidence of cancer within populations that consume large amounts of meat. Other negative health consequences that have been linked with eating meat include arterial sclerosis, heart disease, high blood pressure, encephalitis, stroke, gallstones and cirrhosis of the liver. All of these conditions are directly related to consuming fat and cholesterol.
According to the Encyclopaedia Britannica, meat does in fact contain wastes and toxins, such as uric acid, that have negative effects on blood and body tissues. In contrast, vegetable proteins obtained from nuts, beans and legumes are decidedly healthier and safer. Furthermore, meat, meat products, poultry and seafood all spoil easily within a few hours, but most vegetables stay fresh for several days. Although beans may become rancid relatively quickly, the deterioration is much easier to detect and recognize compared to spoilage in meat, which may not always be detectable by smell or taste.
Cultural Competence Tips for Nurses
When caring for patients who are followers of the Buddhist religion, nurses need to understand that the patient’s main goal is to bring back the body’s yin/yang equilibrium that was disrupted because of illness. It is helpful to first discuss the patient’s illness and care plan in relation to this concept before volunteering a medical or patho-physiological explanation. Because of the supreme importance of nature in Buddhists’ lives, a culturally sensitive medical team will want to prescribe both herbal medicine and pharmaceutical medications, if appropriate. Remember, in these patients’ eyes the goal is not curing but rather maintaining peace of body and mind that will ensure the rebirth process after death.
In terms of dietary assessments, the first step is obviously to find out whether the patient is a vegetarian, how strict or liberal he/she is in following the traditional vegetarian diet and whether there are any other dietary restrictions the patient must observe. The risk of vitamin B12 deficiency among pure vegetarians can be managed by increasing their daily intake of the different types of vegetable proteins.
Buddhist patients staying in a hospital that only serves American-style food may appreciate being provided with a bottle of soy sauce that they can keep in their room to flavor their meals in the way they are accustomed to. The rule of thumb is: When in doubt, ask the patient what he or she would prefer. Be sure to check the labels on different soy sauce products for their sodium content, which can range from 300 grams to as much as 1,080 grams.
Gihan ElGindy, MSN, RN, is an educator and independent consultant on health, nursing, cultural competence, education and business entrepreneurship issues. She is the executive director of the Transcultural Education Center (TEC) in McLean, Virginia. For more information about TEC, visit www.tecenter.org.
As a Chinese American patient neared death in a nursing home, her family members wanted to follow their Buddhist tradition of gathering around their loved one to chant for 12 hours before and four hours after her passing.
It was an unusual request for the nursing home, but hospice nurse Saijing Xu, RN, CHPN, made sure the family’s wishes were honored. She worked with the facility’s staff to move the patient to a private, single room where her relatives could be alone with her before and after death. For the family, this was priceless. They believed the chanting would help their loved one’s soul pass to heaven and bless the younger generation.
As a case manager and nursing liaison for Beacon Hospice in Boston, Xu helps terminally ill patients achieve the best quality of life possible in their last months, weeks and days. She also plays an important role in reaching out to diverse communities. Numerous studies have shown that Americans of color are far less likely to use hospice care than the Caucasian majority population. Minority nurses such as Xu, who speaks Mandarin and Cantonese, can help bridge the gap by providing culturally and linguistically competent care that is sensitive to these patients’ customs and beliefs about death and dying.
Hospice and palliative care nurses provide pain management and comprehensive, holistic care in the final stages of life. They work as members of interdisciplinary teams with physicians, chaplains and social workers to address patients’—and their families’— physical, social, emotional and spiritual needs as they face terminal illness and bereavement.
This specialty encompasses a broad spectrum of nursing professionals—from nursing assistants to advanced practice nurses—and their numbers are growing rapidly. Membership in the Hospice and Palliative Nurses Association (HPNA) has tripled in the last seven years, says the association’s CEO, Judy Lentz, MSN, RN, NHA. She estimates that 20,000 nurses currently work in the specialty, including 14,000 who are Certified Hospice and Palliative Care Nurses (CHPNs). The hospice care movement in the United States began about 30 years ago and has evolved slowly. “In America, people don’t like to talk about dying,” Lentz says. “Less than 30% of terminally ill patients receive hospice care, and those who do receive it are getting an average of only five to six weeks. Medicare covers hospice care for the last six months of life.”
With the government defining hospice care as the last six months of life, the newer specialty of palliative care emerged about 10 years ago to address the needs of patients who are who have incurable, progressive illnesses but are not yet ready for hospice. It is aimed at providing comfort and symptom relief rather than a cure. “What palliative care is all about is the patient and [his or her] significant others defining what they want as their goals for the remainder of life,” Lentz explains. “It’s not what medicine tells you [should be done], but what the patient wants.”
Hospice nurses provide care in patients’ homes, long-term care facilities or in hospice units. Palliative care nurses practice in hospitals, nursing homes and rehabilitation units. Nurses in both specialties may also work as end-of-life care educators and researchers.
Breaking Down the Barriers
A variety of issues have led to the disproportionately low use of hospice care in communities of color. Among patients who died while in hospice care in California, the most ethnically diverse state in the nation, only 4% were Asian American, 6% were African American and 15% were Hispanic, according to reports commissioned by the California HealthCare Foundation. The vast majority—74%—was white.
To help Latino families remember their loved ones who have passed away, Central Texas Medical Center Hospice celebrates the traditional Mexican Day of the Dead holiday.
The researchers found that many black and Hispanic patients wanted aggressive, life-prolonging treatment, which is often not covered while patients are in hospice care. Some minority patients mistrust the health care system, fearing that hospice and palliative care may be a form of discrimination because it does not focus on a cure. Cultural differences also play a role. “We [Latinos] take a lot of pride in taking care of our elders and our sick,” says Linda Lopez, MSHP, MSN, RN, director of the Central Texas Medical Center (CTMC) Hospice. Many Latinos, she explains, don’t want outsiders taking away their role as caregivers. Sometimes family members refuse the services available through hospice because they feel like they are the ones who should provide that care.
Language differences can also create barriers. For example, according to a recent report on National Public Radio, there is currently no word for “hospice” in Spanish. Furthermore, recent immigrants may be unfamiliar with the U.S. health care system, and with the concept of hospice care in particular.
“For Chinese patients and their families, hospice is new,” Xu says. “A lot of them do not know that hospice services are available.”
A growing number of hospice and palliative care programs are working hard to reach out to diverse communities—and minority nurses are playing a key role in these efforts.
About 40% of the population in San Marcos, Texas, where CTMC Hospice is based, is Latino. Lopez, a retired college educator, is hiring more bilingual caregivers and educating her staff about cultural beliefs and traditional health practices, such as the use of herbs and folk remedies. Some Latino families, for instance, believe that receiving shocking news can result in a “fright illness” called susto. The remedy requires a ceremony in which a healer, often the eldest female member of the family, prays over the person and brushes the body with a bouquet of fresh herbs, such as basil.
When nurses demonstrate cultural knowledge, it lets the patients know their ways are accepted, Lopez believes. “If they know we understand, the relationship is stronger, which can only be a benefit to the patient and family.”
To help Latino families cope with bereavement, CTMC Hospice celebrates the Day of the Dead (Dia de los Muertos), a traditional Mexican holiday in which families remember their loved ones who have passed away. Last year the hospice partnered with the Hispanic Chamber of Commerce and local restaurants to sponsor altars where community members could place artifacts representing the lives of their loved ones. The event helps educate the community about hospice and allows people to express their feelings, Lopez says.
Beacon Hospice, the largest provider of end-of-life services in New England, began a concerted outreach effort to local minority communities two years ago. The hospice opened an office in Roxbury, a primarily African American neighborhood in Boston, and staffed it with mostly African American nurses and home health aides. Beacon also hired more bilingual nurses to provide linguistically competent care in Asian, Latino, Portuguese and French-speaking communities. “When someone is at the end of life, the patient should not have to struggle to understand the nurse. The nurse should understand the patient,” says Betty Brennan, the hospice’s president and CEO.
As more minority families become aware of the benefits of hospice, they help spread the word. Stephanie Harriston-Diggs, who is African American, began volunteering for Beacon Hospice after her grandmother received care there. She spoke passionately about the service to friends and is now the hospice’s public relations director and president of its Lighthouse Foundation.
Hospice Nursing in Indian Country
In the Midwest, Hospice of Siouxland has been working to reach out to local American Indian communities. The hospice serves a 60-mile radius around Sioux City, Iowa, including two Indian reservations in Nebraska. But until recently, very few of its patients were tribal members.
With grant funding from the Nebraska Department of Health and Human Services, the hospice partnered with the Omaha and Winnebago tribes to create a culturally sensitive palliative care program. Before the program existed, tribal members with serious chronic diseases made frequent trips to the hospital emergency room. But when palliative care became available, they were able to manage their diseases better. The number of hospital visits dropped and the patients’ quality of life improved.
The hospice’s staff learned about the cultures of the tribes and worked with local hospitals to help accommodate tribal customs and rituals. For instance, when tribal members wanted to perform a smudging ceremony—a ritual purification that involves burning cedar, sage or other herbs and is believed to create a more peaceful transition to death—for a patient in a hospital ICU, hospice nurses explained the cultural reasons for the ceremony to the hospital staff and persuaded them to temporarily relax their fire safety rules so that the ceremony could take place.
“The team really became advocates,” recalls Hospice of Siouxland director Linda Todd, RN, BA.
There is a great need for more Native nurses who can work in palliative and hospice care programs in Indian Country, Todd adds. Her hospice is now working with Briar Cliff University in Sioux City to create scholarship opportunities for Indian students interested in nursing or social work.
“The Heart of Hospice”
Hospice and palliative nursing isn’t for everyone. Nurses who want to focus on end-of-life care must be mature enough to have come to terms with their own mortality and to have had some experience with death and dying.
“[At Beacon], we really look for people who have what we call ‘the heart of hospice,’” says Brennan. “It’s an element that goes beyond being a caregiver. It’s a real desire to promote the highest quality of living in the last days of life.”
Lucia Stevens, RN, CHPN, began her nursing career in cardiac surgery, then worked as a nursing director at a nursing home. But because she yearned to care for patients in a more holistic way, she became a hospice nurse for Beacon. “Hospice addresses everything that’s going on with the patient—spiritually, psychosocially and physically,” she says.
Resources on the WebHospice and Palliative Nurses Association http://www.hpna.orgNational Resource Center on Diversity in End-of-Life Care http://www.nrcd.comPalliative Care: One Vision. One Voice. http://www.palliativecarenursing.netEnd-of-Life Nursing Education Consortium (ELNEC) http://www.aacn.nche.edu/elnec
Nurses in this specialty form strong bonds with patients and their families. Stevens, who is African American, recalls one patient, a woman from Barbados who came to the U.S. with her husband for medical treatment and had no family nearby. Stevens cared for her for six months. “She was around the age of my mom, and we bonded so quickly. She started calling me her daughter.”
In her current position as account manager for Beacon’s South Boston office, Stevens meets with community members in the Roxbury and Dorchester areas to educate them about the benefits of hospice care.
Many people assume that working in end-of-life care would be depressing for nurses because their patients die. Certainly, hospice nurses do grieve. But the emphasis is really about making the most of life.
“You’ve got to live as if this is your last day—patients teach us that every day,” Lopez says. “We’re very blessed [to be caring for these patients] because they teach us so much about living.”
For Xu, the reward comes from knowing she made the most difficult time in someone’s life a little easier. “[It’s good to know] I helped a person leave this world with some comfort,” she says. “I know I made a difference in not only the patient’s life but also in the family’s life.”
Hospice and Palliative Nursing 101
Betty Davies, PhD, RN, CT, FAAN, will never forget the first time one of her patients died. Davies was a second-year nursing student working in a hospital, and a woman who had lung cancer died during her shift.
Nothing in her schooling had prepared her for this. Not knowing what to do, Davies lowered the head of the bed because she had seen nurses do that on TV, and then went to get help.
She later thought, “If caring for people who are dying is part of nursing, why aren’t nursing schools teaching it?”
For many years, nursing curricula did not emphasize end-of-life care. But that’s starting to change. There are currently 10 master’s degree programs around the country that focus on palliative and hospice nursing, as well as many certificate programs in the specialty, says Judy Lentz, MSN, RN, NHA, who is CEO of the Hospice and Palliative Nurses Association (HPNA).
In 2000, the American Association of Colleges of Nursing (AACN), in partnership with City of Hope National Medical Center of Los Angeles, launched the End-of-Life Nursing Education Consortium (ELNEC) project, a national “train the trainer” initiative designed to provide nursing school faculty and other nurse educators with training in end-of-life care so that they can teach this information to nursing students and practicing nurses. As of April 2007, over 3,700 nurses coast to coast have received ELNEC training.
Davies, who has spent much of her career researching and working in end-of-life care, is now a professor in the Department of Family Health Care Nursing at the University of California, San Francisco, which recently started a new acute care pediatric nurse practitioner program with an emphasis on palliative care. She says the school recognized that many pediatric NPs were getting jobs in hospitals but didn’t have the training for acute care. Because most children who die do so in the hospital, nurses working in these settings need to know how to address end-of-life issues.
“Nurses play a critical role in how families deal with the death of a child,” Davies explains. “Just by what they say and do, they can send a family on a course of bereavement that’s either helpful or not. If anyone needs to know about death and dying, it’s nurses.”
Excelsior College, an online college based in Albany, N.Y., recently launched a Hospice and Palliative Care Certificate Program with a strong focus on cultural competency and serving the needs of diverse communities. In creating the program, which was funded by a grant from the U.S. Department of Labor, the school contacted hospices around the country to learn which concepts should be included in the curriculum. “One of the [most important ones] was culture,” says Deborah Sopczyk, PhD, RN, director of the college’s Health Sciences Programs. “This was something hospices told us again and again.”
Excelsior staff and faculty also visited hospices that provide exemplary care to minority populations, such as Hospice of Siouxland and the Central Texas Medical Center Hospice. The certificate program includes case studies and video clips based on these hospices’ best practices to teach students about the importance of addressing cultural issues at the end of life.
“We were very careful not to use a cookie-cutter approach,” Sopczyk says. Students are taught to not make assumptions that all members of a particular ethnic group share the same beliefs.
For instance, the Omaha and Winnebago Indian tribes served by Hospice of Siouxland take opposite approaches to grief. The Omaha tribe believes tears help the passage of loved ones to the next world. They often cry and wail to express their grief in the presence of their loved ones, says faculty member Linda F. Kennelly, PhD, RN. The Winnebago, however, try not to cry, because they believe tears may block the dying person’s passage into the next world.
Excelsior College has also worked with the Rainbow Access Initiative to teach nurses how to provide hospice care that is sensitive to the needs of gay, lesbian and transgendered patients and their loved ones.
See Our Champions of Nursing Diversity
Sign up now to get your free digital subscription to Minority Nurse