Home Print this page Email this page Small font sizeDefault font sizeIncrease font size
Users Online: 860


Home  | About Us | Editors | Search | Ahead Of Print | Current Issue | Archives | Submit Article | Instructions | Subscribe | Contacts | Login 

Table of Contents
Year : 2011  |  Volume : 1  |  Issue : 2  |  Page : 154-156

Cultural and religious aspects of palliative care

Department of Surgery, Division of Critical Care, Trauma and Burn, The Ohio State University, Columbus, Ohio, USA

Date of Web Publication12-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
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2229-5151.84804

Rights and Permissions

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

How to cite this URL:
Steinberg SM. Cultural and religious aspects of palliative care. Int J Crit Illn Inj Sci [serial online] 2011 [cited 2023 Mar 30];1:154-6. Available from: https://www.ijciis.org/text.asp?2011/1/2/154/84804

   Introduction Top

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 Top

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 Top

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 Top

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.  Back to cited text no. 1
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.  Back to cited text no. 2
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.  Back to cited text no. 3
4.Kinzbrunner BM. Jewish Medical Ethics and End-of-Life Care. J Palliat Med 2004;7:558-73.  Back to cited text no. 4
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.  Back to cited text no. 5
6.Bradley CT. Roman Catholic Doctrine Guiding End-of-Life Care: A Summary of the Recent Discourse. J Palliat Med. 2009;12:373-7.  Back to cited text no. 6
7.Whitman SM. Pain and Suffering as Viewed by the Hindu Religion. J Pain 2007;8:607-13.  Back to cited text no. 7

This article has been cited by
1 Barriers to palliative care in hepatocellular carcinoma: A review of the literature
Mostafa Abasseri, Shakira Hoque, BA Slavica Kochovska, Kim Caldwell, Linda Sheahan, Amany Zekry
Journal of Gastroenterology and Hepatology. 2023;
[Pubmed] | [DOI]
2 (Dis)Agreement with Dysthanasia, Religiosity and Spiritual Experience as Factors Related to Nurses’ Workload during End-of-Life Care
Brankica Juranic, Aleksandar Vcev, Suzana Vuletic, Željko Rakošec, Domagoj Roguljic, Štefica Mikšic, Jelena Jakab, Jasenka Vujanic, Robert Lovric
International Journal of Environmental Research and Public Health. 2023; 20(2): 955
[Pubmed] | [DOI]
3 Resourcefulness and stress among hospice and palliative nurses: the role of positive thinking
Mary Gergis, Abir Bekhet, Maria Kozlowski-Gibson, Cynthia Hovland, Constance Dahlin, Michael Ent, Joan Thoman
International Journal of Palliative Nursing. 2023; 29(2): 91
[Pubmed] | [DOI]
4 Student nurses' knowledge of and attitudes toward palliative care in the Middle East: an integrative review
Domam Alomari, Hana Mohammad Abu-Snieneh
International Journal of Palliative Nursing. 2023; 29(3): 109
[Pubmed] | [DOI]
5 The Good Death Among Black, Indigenous, and/or People of Color: Which Aspects of a Good Death Are Most Important?
Zainab Suntai, Kirsten Laha-Walsh, David L. Albright
OMEGA - Journal of Death and Dying. 2022; : 0030222822
[Pubmed] | [DOI]
6 Coping Strategies Used by Patients After Diagnosis Disclosure in the Transition to Palliative Care: A Cross-Sectional Study
Natália Ubisse Schmauch, Francisca Rego, Luísa Castro, Jahit Sacarlal, Guilhermina Rego
Journal of Palliative Care. 2022; : 0825859722
[Pubmed] | [DOI]
7 End-of-life care for Filipino patients with cancer
Geneva E. Guarin, Edward Christopher Dee, Janine Patricia G. Robredo, Michelle Ann B. Eala, Manuel F. Medina, Kimberson C. Tanco
Palliative and Supportive Care. 2022; : 1
[Pubmed] | [DOI]
8 Comparison of End-of-Life Care Between Recent Immigrants and Long-standing Residents in Ontario, Canada
Bradley I. Quach, Danial Qureshi, Robert Talarico, Amy T. Hsu, Peter Tanuseputro
JAMA Network Open. 2021; 4(11): e2132397
[Pubmed] | [DOI]
9 Association between Bathing and Survival in Patients with Advanced Cancer in Their Last Days of Life: A Prospective Cohort Study
Kiyofumi Oya,Tatsuya Morita,Hidenobu Koga,Masanori Mori,Hideyuki Kashiwagi,Takashi Ohmori,Yaichiro Matsumoto,Eri Matsumoto,Shunsuke Kosugi,Sho Sasaki
Palliative Medicine Reports. 2021; 2(1): 59
[Pubmed] | [DOI]
10 The do not resuscitate order (DNR) from the perspective of oncology nurses: A study in Saudi Arabia
Omar AbuYahya,Sawsan Abuhammad,Bara Hamoudi,Ranjni Reuben,Muawiyah Yaqub
International Journal of Clinical Practice. 2021;
[Pubmed] | [DOI]
11 Transitioning end-of-life care from hospital to the community: case report
Pedro Lino,Mary Williams
British Journal of Nursing. 2021; 30(17): 1010
[Pubmed] | [DOI]
12 Definition and recommended cultural considerations for advance care planning in Japan: A systematic review
Ai Chikada,Sayaka Takenouchi,Kazuko Nin,Masanori Mori
Asia-Pacific Journal of Oncology Nursing. 2021; 0(0): 0
[Pubmed] | [DOI]
13 Definition and recommended cultural considerations for advance care planning in Japan: A systematic review
Ai Chikada,Sayaka Takenouchi,Kazuko Nin,Masanori Mori
Asia-Pacific Journal of Oncology Nursing. 2021; 0(0): 0
[Pubmed] | [DOI]
14 Are Health-Care Providers Well Prepared in Providing Optimal End-of-Life Care to Critically Ill Patients? A Cross-Sectional Study at a Tertiary Care Hospital in the United States
Kartikeya Rajdev,Nina Loghmanieh,Maria A. Farberov,Seleshi Demissie,Theodore Maniatis
Journal of Intensive Care Medicine. 2020; 35(10): 1080
[Pubmed] | [DOI]
15 Cultural thanatology: an exploration of the religious, spiritual, and existential concerns of elderly terminally-ill diasporic Hindus
Veena S. Singaram,Swami Saradaprabhananda
Journal of Religion, Spirituality & Aging. 2020; : 1
[Pubmed] | [DOI]
16 Integration of Palliative and Hospice Care in Physical Therapy
Lubayna Fawcett
Rehabilitation Oncology. 2020; 38(1): E7
[Pubmed] | [DOI]
17 Predictors of Palliative Care Knowledge Among Nursing Students in Saudi Arabia
Journal of Nursing Research. 2020; 28(1): e60
[Pubmed] | [DOI]
18 Dealing with cultural diversity in palliative care
Stefaan Six, Johan Bilsen, Reginald Deschepper
BMJ Supportive & Palliative Care. 2020; : bmjspcare-
[Pubmed] | [DOI]
19 The Relationship Between Death and Do Not Resuscitation Attitudes Among Intensive Care Nurses
Farzaneh Safari Malak-Kolaei, Akram Sanagoo, Bagher Pahlavanzadeh, Forouzan Akrami, Leila Jouybari, Reza Jahanshahi
OMEGA - Journal of Death and Dying. 2020; : 0030222820
[Pubmed] | [DOI]
20 Nurses’ Opinions on Do-Not-Resuscitate Orders
Senay Gül, Gülcan Bagcivan, Miray Aksu
OMEGA - Journal of Death and Dying. 2020; : 0030222820
[Pubmed] | [DOI]
21 Integration of a palliative approach into heart failure care: a European Society of Cardiology Heart Failure Association position paper
Loreena Hill,Tal Prager Geller,Resham Baruah,James M. Beattie,Josiane Boyne,Noemi Stoutz,Giuseppe Di Stolfo,Ekaterini Lambrinou,Anne K. Skibelund,Izabella Uchmanowicz,Frans H. Rutten,Jelena Celutkiene,Massimo Francesco Piepoli,Ewa A. Jankowska,Ovidiu Chioncel,Tuvia Ben Gal,Petar M. Seferovic,Frank Ruschitzka,Andrew J.S. Coats,Anna Strömberg,Tiny Jaarsma
European Journal of Heart Failure. 2020;
[Pubmed] | [DOI]
22 Power from indirect pain: a historical phenomenology of medical pain management
Domonkos Sik
Continental Philosophy Review. 2020;
[Pubmed] | [DOI]
23 Advancing Nutrition and Dietetics Practice: Dealing With Ethical Issues of Nutrition and Hydration
Denise Baird Schwartz,Mary Ellen Posthauer,Julie O’Sullivan Maillet
Journal of the Academy of Nutrition and Dietetics. 2020;
[Pubmed] | [DOI]
24 Investigating the attitude of healthcare providers, patients, and their families toward “do not resuscitate” orders in an Iranian Oncology Hospital
MohammadReza Fayyazi Bordbar,Keyvan Tavakkoli,Mahsa Nahidi,Ali Fayyazi Bordbar
Indian Journal of Palliative Care. 2019; 25(3): 440
[Pubmed] | [DOI]
25 Predictors of advance directives among nursing home residents with dementia
Hsiu-Li Huang,Yea-Ing Lotus Shyu,Li-Chueh Weng,Kang-Hua Chen,Wen-Chuin Hsu
International Psychogeriatrics. 2018; 30(3): 341
[Pubmed] | [DOI]
26 Regional Differences in Palliative Care Utilization Among Geriatric Colorectal Cancer Patients Needing Emergent Surgery
Danielle R. Heller,Raymond A. Jean,Alexander S. Chiu,Shelli I. Feder,Vadim Kurbatov,Charles Cha,Sajid A. Khan
Journal of Gastrointestinal Surgery. 2018;
[Pubmed] | [DOI]
27 “Will You Remember Me?”
Maryland Pao,Margaret Rose Mahoney
Child and Adolescent Psychiatric Clinics of North America. 2018;
[Pubmed] | [DOI]
28 Perspectives of Singaporean patients and caregivers towards quality of life or quantity of life with disease-modifying treatment in the end-of-life setting
David Sng,Liang Qi Lee,Keson Tay,Rachel Jiayu Lee,Rukshini Puvanendran,Lalit Kumar Krishna Radha
Proceedings of Singapore Healthcare. 2017; 26(1): 11
[Pubmed] | [DOI]
29 Factors that influence advance directives completion amongst terminally ill patients at a tertiary hospital in Kenya
Stephen Omondi,John Weru,Asim Jamal Shaikh,Gerald Yonga
BMC Palliative Care. 2017; 16(1)
[Pubmed] | [DOI]
30 Beyond cultural stereotyping: views on end-of-life decision making among religious and secular persons in the USA, Germany, and Israel
Mark Schweda,Silke Schicktanz,Aviad Raz,Anita Silvers
BMC Medical Ethics. 2017; 18(1)
[Pubmed] | [DOI]
31 Dying among older adults in Switzerland: who dies in hospital, who dies in a nursing home?
Xhyljeta Luta,Radoslaw Panczak,Maud Maessen,Matthias Egger,David C. Goodman,Marcel Zwahlen,Andreas E. Stuck,Kerri Clough - Gorr
BMC Palliative Care. 2016; 15(1)
[Pubmed] | [DOI]
32 Nursing Staff’s Perception of Barriers in Providing End-of-Life Care to Terminally Ill Pediatric Patients in Southeast Iran
Sedigheh Iranmanesh,Marjan Banazadeh,Mansoure Azizzadeh Forozy
American Journal of Hospice and Palliative Medicine®. 2016; 33(2): 115
[Pubmed] | [DOI]
33 Working bi-culturally within a palliative care research context: the development of the Te Arai Palliative Care and End of Life Research Group
Merryn Gott,Tess Moeke-Maxwell,Tessa Morgan,Stella Black,Lisa Williams,Michal Boyd,Rosemary Frey,Jackie Robinson,Julia Slark,Gabriella Trussardi,Susan Waterworth,Rawiri Wharemate,Whio Hansen,Eliza Smith,Kiripai Kaka,Kohi Henare,Eileen Henare,Manaaki Poto,Eliza Tipene-Carter,Devi-ann Hall
Mortality. 2016; : 1
[Pubmed] | [DOI]
34 The Relationship between Nursesć Perception of Barriers Magnitude and their Demographic Characteristics
Sedigheh Iranmanesh,Marjan Banazadeh,Mansoure Azizzadeh Forozy
i-manager’s Journal on Nursing. 2015; 5(1): 11
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
    Materials and Me...

 Article Access Statistics
    PDF Downloaded172    
    Comments [Add]    
    Cited by others 34    

Recommend this journal