1 Module 5 Cultural and Spiritual Considerations in End-of-Life CareCore Curriculum Module 5 Cultural and Spiritual Considerations in End-of-Life Care

2 Case Example A new nurse at your institution asks you: “Why are we catering to Ms. Smith? She is so difficult to care for; all she wants is more pain medication and lots of attention. When I go in to give her pain medication, I have to wake her up. She is taking all my time.” Ms. Smith is a 40-year-old single, African American woman with sickle cell disease. Both parents have died, no siblings and has been on disability and Medicaid since she was 21-years-old. She was admitted to the ICU two days ago, after having a CVA. She also is in pain. Palliative care will be discussed for this admission. 2

3 How Culture Influences DeathCulture affects: Views of death Social customs Relationships Decision-making

4 Culture Defined System of shared symbolsProvides security, integrity, belonging Constantly evolving Making meaning of illness Not limited to race or ethnicity Influences response to illness

5 Cultural Competence Campinha-Bacote, 2011 Components of CulturalAwareness Knowledge Skill Encounters Desire Campinha-Bacote, 2011 5

6 Cultural Assessment Numerous tools available Cultural attributesVariation within groups Individuals hold varying degrees of adherence to traditional customs within the same community & family Kagawa-Singer et al., 2010 6

7 Components of Cultural AssessmentPatient, family, community Birthplace Ethnic identity Community Decision-making Language and communication

8 Components of Cultural Assessment (cont.)Religion/spirituality Food preferences, prohibitions Economic situation Health beliefs regarding: Death Grief Pain Traditional therapies Care of the body Organ donation

9 Nurse’s Self Assessment of CultureCultural beliefs of co-workers Mazanec & Panke, 2015

10 Cultural Disparities in End-of-Life CareAccess/utilization to hospice services Access to medications for pain and symptom management Gender issues Impact on families with chronic illness 10

11 Vulnerable Populations & Cultural ConsiderationsMinorities Veterans Homeless Prisoners Immigrant & refugee populations Older adults Disabled Sexual orientation 11

12 Cultural Considerations of Spirituality and ReligionMeaning-making Need for purpose, forgiveness, love, hope, relatedness, and religious faith Transcendence Religion “Organized” Institutional beliefs Taylor, 2015

13 FICA: An Example of A Spiritual AssessmentF = Faith I = Importance, influence C = Community A = Address Puchalski, 2014

14 Spiritual Care InterventionsProviding presence Deep listening Bearing witness Putting compassion into action Baird, 2015 14

15 Cultural Considerations of CommunicationConversation style Personal space Eye contact Touch View of healthcare professionals Learning styles 15

16 Cultural Considerations of Communication (cont)Use of interpreters Avoid use of family members Use telephone translation services/or institution’s professional interpreters Speak to patient/family, not to the interpreter 16

17 Language Used at the End of Life“Discontinuation” “DNR” “Withdrawing/withholding”

18 Role of the Family Who is considered family? Who are the caregivers?Who makes decisions? Who is included in discussions? Is full disclosure acceptable? 18

19 Cultural Influences on Decision-MakingBeliefs about autonomy and other values differ Disclosure of diagnosis and prognosis Ascertain desire for disclosure 19

20 When Cultures Clash Clashes occur Assess your reactions Never lieOffer information Use cultural guides 20

21 Case Study Revisited: Patient with Sickle Cell DiseaseCulture clash Opportunity for self-reflection & growth Review issues identified Reflect on cultural considerations and their impact on delivery of palliative care

22 Conclusion Culture is a major influence on end-of-life careMany dimensions of culture Self-assessment of culture Culturally and spiritually sensitive care Interdisciplinary care 22