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| SYMPOSIUM ON END OF LIFE CARE |
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| Year : 2011 | Volume
: 1
| Issue : 2 | Page : 154-156 |
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Cultural and religious aspects of palliative care
Steven M Steinberg
Department of Surgery, Division of Critical Care, Trauma and Burn, The Ohio State University, Columbus, Ohio, USA
| Date of Web Publication | 12-Sep-2011 |
Correspondence Address:
Steven M Steinberg
Vice Chair for Clinical Affairs, Department of Surgery Chief, Division of Critical Care, Trauma and Burn, 395 W. 12th Avenue, Suite 630, Columbus, Ohio 43210
USA
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2229-5151.84804
 Abstract | | |
For most clinicians and patients, the discussion of palliative care is a difficult topic. It is complicated by both the clinician's and patient's belief systems, which are frequently heavily influenced by cultural and religious upbringing. This article discusses the impact of some of those differences on attitudes toward end of life decisions. Several different religions and cultures have been evaluated for their impact on perceptions of palliative care and the authors will share some examples. Keywords: Culture, end-of-life care, palliative care, religion
How to cite this article:
Steinberg SM. Cultural and religious aspects of palliative care. Int J Crit Illn Inj Sci 2011;1:154-6 |
| Introduction | |  |
The consideration of institution of end-of-life care is an emotionally charged issue for the patient, their families and caregivers. Attitudes and approaches to palliative care vary widely amongst religions and cultures. Decisions are influenced by the beliefs of the caregivers, patients and their families. Given the heterogeneity of many societies including our own, it is worthwhile to examine the differences in approaches to palliative care and end-of-life issues in different cultures and religions. Even within individual countries, the manner in which palliative care is delivered varies by culture and religion. Examples of the differences in attitudes on the part of both the caregivers and patients will be presented.
| Materials and Methods | | |
A literature search was performed on palliative care, culture, and several religions (Christianity, Judaism, Islam, Hindu, Buddhism). Articles were selected by the author that seemed representative of mainstream thought within those cultures and religions for presentation in this manuscript.
| Discussion | | |
Cohen and colleagues report on end-of-life attitudes in Latino and Cambodian patients living in the United States in the Boston area. [1] They evaluated the effect of religion, sense of destiny, quality of life, and process preferences regarding end-of-life decision-making. The majority of both groups believed that the inevitability of dying made discussion of advanced directives a moot point. As evidence of this, only 15% of the patients had ever discussed advanced directives with their physician. Both the Cambodian and Latino patients expressed that if quality of life was poor then they saw no point in continuing medical care that would likely only prolong the inevitable. However, when religion was considered there was a significant dichotomy between the two groups. The strong belief in the Latino group was that removing a patient from life support was tantamount to killing them. The Cambodian cohort separated religion from end-of-life decision-making and did not perceive a connection between the two. There were also subtle differences in the two groups as to the involvement of family in end-of-life decisions. The Cambodian group seemed to delegate primarily to their children and spouse, while the Latino patients indicated that a more extended family structure was frequently involved and needed to reach consensus on these sorts of decisions. Both the Latino and Cambodian patients valued the input of their physicians. Cohen and her co-authors concluded that two main themes had emerged from their focus group study of Latino and Cambodian patients. Integration of belief systems and process preferences were both important and that, specifically, emphasis on quality-of-life, the role of destiny and understanding the role of family in end-of-life discussions were extremely important.
Ball and colleagues described the results of a large multi-country and multi-cultural survey on end-of-life care in trauma patients. [2] A survey was sent to trauma surgeons, intensivists, bioethicists, and rehabilitation experts in the United States, Canada, South Africa, Europe, Asia, and Australia/New Zealand. The respondents were a diverse group in relation to country of practice, religion, and cultural background. There were significant differences in practice pattern, with most American respondents classifying themselves as both trauma surgeons and intensivists. Physicians from other regions were more apt to classify themselves as either a trauma surgeon or intensivist, which probably represents a difference in practice in other areas of the world where the intensivist is more likely not to be a surgeon. Most of the physicians indicated that they believed that their views of end-of-life matters were similar to their local colleagues as well as the patients they cared for. The need to transfer a patient to another physician's care because of a conflict over end-of-life issues was quite rare. Except in the United States where the admitting physician was most likely to direct end-of-life discussions with the family, the intensivist was most likely to be the main caregiver involved in those discussions. The respondents indicated that very few were subject to formal medical futility laws to direct their practice. Most clinicians stated that ethics consultation services were available but they were rarely used. When used, the majority of physicians found that they were either "typically" or "occasionally" helpful. Physicians in South Africa and Asia believed that resource limitations affected end-of-life decision-making whereas respondents from other regions rarely thought that was the case.
It also seems that one's perception of God may correlate with patients' coping mechanisms in end-of-life situations. Van Laarhoven and his colleagues surveyed Dutch patients with cancer who had entered the palliative care period as to their image of God and their coping strategies. [3] A non-personal image of God may include such beliefs as "God is unknowable" or "something higher", both of which imply the God surpasses all of our powers of imagination. Comparatively, a personal image of God is one in which the individual views God as interacting with individuals. The authors found that patients who had a more non-personal image of God were more likely to be subject to denial and were more likely to use the coping mechanisms of seeking advice and information from others, and seeking moral support while they were less likely to rely on a sense of humor. Those patients who had a personal image of God were most likely to use religion as a coping mechanism. Those who thought that God was unknowable were not likely to use any of the coping mechanisms.
The issues become even more complex when specific religions are considered, both from the perspective of the patient and the caregivers. Kinzbrunner discusses Jewish medical ethics as they pertain to end-of-life. [4] Clearly, in Judaism, suicide, assisted-suicide, and euthanasia are not permitted. Withdrawal of care that has already been instituted is also usually not allowed. However, the Jewish religion recognizes that life is of limited duration and that in end-of-life situations, treatments to provide comfort are permitted even if they have some risk of shortening life. There is no requirement for a Jewish patient to accept any treatment not viewed as curative. Pain and suffering should be minimized even if there is some risk of shortening life.
Similarly, Babgi describes in great detail the organization of Islamic society and beliefs in Saudi Arabia as they relate to health care and end-of-life issues. [5] In Saudi Arabia, its constitution and legal system is based on Shari'a, the system of Islamic law. Islamic law also views life as sacred but finite in duration. Similar to Judaism, suicide, assisted-suicide and euthanasia are prohibited. Interestingly, Do Not Resuscitate (DNR) orders are allowable, but only under certain very proscribed conditions. The family is not consulted as they are viewed as unqualified to make such decisions. Three qualified physicians, who sign the DNR form, must make the determination. Living wills and advanced directives are not recognized in Islamic law, as it is believed that only Allah can make decisions on life and death.
Bradley presents an essay on Roman Catholic Doctrine as it pertains to end-of-life matters. [6] The Catholic church makes a distinction between ordinary and extraordinary treatment and care. As an example, the provision of nutrition and hydration to patients in persistent vegetative states is considered ordinary care and therefore must be administered. Euthanasia is not permitted and Catholic doctrine addresses "euthanasia by omission" and clearly states that this is prohibited. Otherwise, Catholicism gives a rather wide berth for accepting or refusing other treatments. Treatments are viewed as disproportionate or extraordinary when they either do not offer a reasonable hope of benefit or are excessively burdensome to patient or community.
The Hindu view of pain and suffering is summarized by Whitman. [7] It is very different than the Western concepts presented above. Pain and suffering are viewed as part of karma, which is the unfolding of events based on a person's current and previous lives. Put succinctly, pain and suffering are viewed as the state the individual is supposed to be in. The two Hindu concepts that are most operational for patients with either acute or chronic pain are "acceptance" and "detachment". Acceptance is the accepting of suffering as a natural consequence of karma along with the realization that suffering is temporary and not solely negative. Detachment from the world, with its pain and suffering, in order to concentrate on God, is the ultimate goal.
In summary, culture and religion at least partially affect one's perception of palliative care and the decision-making that occurs at end-of-life. It is important to realize that there is an entire system at play that includes the patient, their family, their physicians, and other healthcare providers. In order to provide the best possible care to patients and families in end-of-life situations, it is important to understand their cultural constructs as well as their individual preferences. It is also important for each caregiver to realize that we each bring our own set of biases to these discussions based on our cultural and religious background and personal experiences.
| References | | |
| 1. | Cohen MJ, McCannon JB, Edgman-Levitan S, Kormos WA. Attitudes toward Advance Care Directives in Two Diverse Settings. J Palliat Med 2010;13:1427-32. 
[PUBMED] [FULLTEXT] |
| 2. | Ball CG, Navsaria P, Kirkpatrick AW, Vercler C, Dixon E, Zink J, et al. Impact of Country and Culture on End-of-Life Care for Injured Patients: Results From an International Survey. J Trauma 2010;69:1323-33.
[PUBMED] [FULLTEXT] |
| 3. | van Laarhoven HW, Schilderman J, Vissers KC, Verhagen CA, Prins J. Images of God in Relation to Coping Strategies of Palliative Cancer Patients. J Pain Symptom Manage 2010;40:495-501.
[PUBMED] [FULLTEXT] |
| 4. | Kinzbrunner BM. Jewish Medical Ethics and End-of-Life Care. J Palliat Med 2004;7:558-73.
[PUBMED] [FULLTEXT] |
| 5. | Babgi A. Legal Issues in End-of-Life Care: Perspectives from Saudi Arabia and the United States. Am J Hosp Palliat Care 2009;26:119-27.
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| 6. | Bradley CT. Roman Catholic Doctrine Guiding End-of-Life Care: A Summary of the Recent Discourse. J Palliat Med. 2009;12:373-7.
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| 7. | Whitman SM. Pain and Suffering as Viewed by the Hindu Religion. J Pain 2007;8:607-13.
[PUBMED] [FULLTEXT] |
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