E L N E C _____ Geriatric Curriculum End-of-Life Nursing Education Consortium

1. E L N E C _____Geriatric CurriculumEnd-of-Life Nursing Education Consortium SESSION 8: Cultural and Spiritual Considerations at End-of-Life Fairfield University Quinnipiac University School of Nursing ELDER Project

2. Objectives: Upon completion of this session, the learner will be able to… • Examine the influence of cultural and spiritual beliefs. 2. Describe beliefs regarding death and dying held by various cultures. 3. Identify the role of interdisciplinary care in respecting cultural and spiritual diversity.

3. 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

4. Components within Culture • Ethnicity • Race • Gender • Age • Religion and spirituality

5. In order to provide culturally sensitive care to those at the end of life, the first task of the healthcare workers should be to: • evaluate the cultural beliefs of co-workers • identify one’s own cultural background and values • learn to predict how various races deal with end-of-life issues • become informed about state laws concerning end-of-life care

6. 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? • Adapted from: • Zoucha, R. (2000). The keys to culturally sensitive care. American Journal of Nursing, 100(2), • 24GG-24II. Reprinted with permission.

7. Which factor should NOT be considered when assessing the cultural beliefs and practices related to death and dying? • how long the client has been in this country • the age of the client and family members • aspects of spirituality, traditions, rites and rituals • specific beliefs about pain, suffering and death

8. Hispanic/Latino African American Indian Haitian Jamaican Russian Vietnamese Judaism & Islam Name that Culture! Group Activity

9. 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? • Remind the client that it is important to talk about the illness. • Allow the client to remain in denial by not discussing the cancer. • Ask the family about their beliefs regarding full disclosure. • Refer the client to a mental health professional for evaluation.

10. How has culture influenced your care of dying patients?

11. Cultural Values of the American Health Care System • Truth-telling • Patient autonomy • Personal control

12. Group Activity: American views on death

13. Values in Non-European American Cultures • Interdependence, especially among family members, rather than a focus on individual autonomy • Respectful communication • Trust, rather than control

14. 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

15. 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? • “The best strategy for evaluating sexual orientation is to ask clients if they are heterosexual or homosexual.” • “To assess spirituality, questions regarding religious affiliation and religious practices are generally sufficient.” • “Financial status is an invasive question and should be asked by the social worker.” • “Ethnic identity varies within ethnic groups, so ask clients how strongly they identify with a particular group.”

16. When talking to persons of another culture, the healthcare worker should: • use the person’s first name to establish warm rapport • determine who makes decisions for the client and family • speak primarily to the translator rather than the client or family • act as if the client is fully informed of the diagnosis and prognosis

17. Culturally Sensitive Care:General Approaches • Knowledge • Careful assessment without stereotyping • Respect for diverse beliefs and practices • Understanding and honoring one’s own values

18. Which remark by a palliative care team member shows culturally sensitive end of life care? • “I ask the client who he wants to include in conversations about his illness.” • “I hold the client’s hand and get physically close to her to show I care.” • “I can predict how members of a particular ethnic group will respond to pain.” • “I feel it’s our obligation to tell a patient bad news, even if the family objects."

19. Spiritual Considerations

20. 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? • when the patient enters the health care system • after chemotherapy is started • once the patient asks for spiritual support • as soon as the client begins to deteriorate

21. Spiritual Assessment • Key Assessment Areas • Concept of God or deity • Sources of hope and strength •  Important religious practices • Relationship between spiritual beliefs and health • Sample question • Is religion or God significant to you? Can you describe how? • Who do you turn to when you need help? Are they available? • Are any religious practices important to you? • Has being sick made any difference in your feelings about God or the practice of your faith?

22. 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

23. 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.

24. Group Activity

25. Spiritual Assessment -FICA • Faith • Importance or Influence • Community • Address

26. During a spiritual assessment, which question shows the healthcare workers bias? • “What church do you attend?” • “Are spiritual beliefs important in your life?" • “What aspect of your faith gives your life most meaning?” • “How would you like me to address spirituality in your care?”

27. Spiritual Interventions • Therapeutic presence • Compassion without exhaustion • Prayer, spiritual readings, spiritual rituals • Opportunities for life review

28. 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

29. 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.

30. Spiritual Interventions • Encouraging patients to use their spiritual strengths • Making referrals to chaplains and other spiritual caregivers

31. The Role of Chaplains and Other Spiritual Caregivers in EOL Care • Consistent presence • Assisting in meaning-making • Encourage reconciliation • Support at death • Follow-up after death

32. 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.

33. References City of Hope & the American Association of Colleges of Nursing, 2007; Revised, 2010. TheEnd-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