Transcultural Care in End-Of-Life Nursing: Hispanic and Asian Sensitivity Awareness

While transcultural care in end-of-life nursing can hardly be representative of every ethnic or diverse group, which has ventured from the native homeland to the United States or other Westernized nation, there are commonalities in the expectations of what living in a new culture means. Medical care and health beliefs or practices become heightened in intensity particularly towards the end-of-life experience, approaching the profoundly irreversible and seriousness of death. The role of the nurse in a palliative environment naturally involves a close support system of varying interventions, during which spiritual and emotional sensitivity run side-by-side in administration of diagnostic care. The nursing role is critical in these situations and is not merely a matter of solely controlling symptoms and monitoring risk management in the client's physicality. As a key partner in the medical team, the Transcultural Care nurse in a hospice or end-of-life situation becomes intricately woven into the lives of both patients and their families. 

This nursing research investigation explores Transcultural Care aspects during the end-of-life episodes among those clients of Hispanic and Asian cultures. The overall ideological thrust is to compare and/or contrast those health beliefs and health practices – actually more accurately put, the expectations of each group – as relates to nursing care during the last days and moments of life in which serious and terminal illnesses force decedents to pass on. Three primary points shall be addressed herein. The first provides a basis for background as a description of what typical care might look like in the Hispanic or Asian homeland environment. In other words think about the expectations of what a new immigrant must be like. Not exclusively however, because cultural expressions and traditions are deeply ingrained as Leininger's Theory of Cultural Care notes. The second aspect identifies resources in countries of origin in terms of populace usage of hospice care, for example. This may include attendant roles, or professional healthcare worker practices. Thirdly, for each group of either Hispanic or Asian, there shall be 8 nursing interventions listed using the Leininger model theory of Cultural Care or Transcultural Care, as it is also sometimes and interchangeably termed. As the Nursing Theories BlogSpot proclaims about Madeliene Leininger's influence “With direct observations and interactions with clients of diverse cultures, with variety of health conditions, she became conscious that recovery from illnesses and or maintaining health and wellbeing was greatly affected by how health care was provided to them” (“Leininger's Theory of Culture Care”). Obviously this philosophy becomes even more crucial to address diverse clients' needs in the hour of death. Next is a perusal of the Asian cultural aspects for the clinical nursing specialist to be aware of in the process, which may definitely include mental and/or pain treatment practices in a patient's final moments. 

A general description of the Asian health beliefs and culture may be understood by references of practice provided in their homeland. What might be the expectations of a new immigrant from China or Japan, especially during any serious illness wherein the client is most likely to die? Research author Kwang-hee Park wisely discusses a holistic model of elderly care among those accustomed with the perspective of “Traditional Chinese Medicine” (TCM) in which there is a heavy link between mind, body, soul and the social aspects. Park explains the traditional multidimensional aspects of Chinese/Asian healthcare involves insight from religion-inspired beliefs.

Park expresses the details of the Chinese beliefs which can easily be tied to an understanding of healthcare expectations. It is not simply a matter of curing the body, or relinquishing the biological life forces of the physical body during the final episode of death but embracing a universal concept. Park advises “The Chinese believed that everything that exists in the universe is made up of the vital substance of qi” and this reflects both the complementary forces of yin and yang” as well as an integration of the five elements such as fire, earth, wood, and metal (p. 74). The point is that expected healthcare among the Asian rooted clientele assumes these cultural traditions whether the religion is Taoism, Buddhism, or Confucianism. There exists a basic harmony among all nature, and the respect for such envisions a connection between human beings and all the universe. Furthermore, the Asian concept of the preciousness of human life includes a polite respect for morality and education, and almost a graceful acceptance that as Park continues wherein all “is transient and temporary” and eventually “will decay” (p. 75). Naturally then the resources of these various countries of origin, be it China, Japan, Vietnam, or island lands of Indo-Caribbean Hindus have a certain healthcare usage or hospice attendant role among the populace. 

For example, interesting data has been collected by experts in regard to healthcare proxy’s intervention and practitioners among the elderly dying of Indo-Caribbean Hindu culture. Demographic, acculturation, and religiosity studies examined social connections and such that deemed prolonging life artificially as a very negative situation. Attitudes generally were adamantly against this. Authors of journal article “Elderly Indo-Caribbean Hindus and End-of-Life Care: A Community-Based Exploratory Study” Rao, Desphande, Jamoona, and Reid imply potent healthcare belief expectations based upon “Karmic thought holds strong influence over many Hindus' approaches to life and death,” despite a wide variety of “thousands of interpretations that result in the great diversity of cultural rituals and customs” across India (p. 1130). The smart nursing monitor therefore should be sensitive to the fact that even among the Asian culture, there is a wide variance of specifics in terms of one religion or another, yet the gist of attitudes would see artificially extension of the physical body as undignified, negative, or downright insulting.

Nevertheless in the Rao et al., study the majority of subjects reported healthcare roles under the auspices of a locally affiliated clinic and had lived in extended familial situations inclusive of grandchildren, and children. Rao et al., acknowledge that the norm of these population had “a primary care physician” often associated with a “teaching hospital” and had a “mean MMSE score of 27 and were not clinically depressed or functionally dependent” (p. 1131). How might this information shed light upon the Asian patient attitude in poor health, which may be to the point of death? It may be gleaned that in the absence of mental anguish – to the point of clinical depression – many Asian client patients accept the decline of health towards an inevitable death with grace and less stress than do their  many mainstream white counterparts. Referring to the Tao lifestyle beliefs deriving from China, the attitude is to strive for a “harmonious” encounter “with nature,” to allow simplicity to take its course, and beliefs that there is a “sacred power of the natural environment to establish” a balance (p. 76). Funeral rites are one thing, yet since the Chinese believe that spirits of the dead can bless or curse their descendents the process of dying obviously has a spiritual component attached to the end-of-life process. 

It is important for nurses to keep in mind not to perhaps become alarmed if a dying patient in a hospice organization should have a Taoist priest perform religious rites over the client for healing. Although death may be acceptable as part of life, and a natural transition of sorts, does not exclude the willingness for a patient to live. So longevity and immortality promotions are not unusual as such aforementioned priests may “practiced exorcism to bring healing to the sick” (p. 76). Qualitative studies were done in measuring Asian attitudes of people born in China, Japan, and Vietnam who currently were living in Texas by Gloria Duke and reported in a peer-reviewed journal article appearing in the “International Journal of Palliative Nursing.” The findings did show a difference between Asian cultural values by an admittance that there does exist this “dichotomy between Western and Eastern values” as relates to end-of-life matters (p. 77). The data collection was fairly evenly mixed between Japanese, Chinese, and Vietnamese. 

For the Asian group(s) there may be described 8 basic nursing interventions which claim its theoretical model and framework from Madeliene Leininger's Cultural Care, or Transcultural Nursing. They are as follows:

1) Physical care in terms of teaching the Asian client the nursing protocol overstep, interfere with, or assume – as Duke surmises – their “wishes for initiating or discontinuing artificial nutrition or mechanical ventilation” (p. 78). Independently intervene to teach to full array of options. Pay attention to the cognitive levels and needs of the patient if for example, removing a feeding tube.

2) Counseling as an ongoing assessment, and based upon skills nurses are licensed to conduct, should offer counseling yet not assume all Asians are alike. These patients are not a monolith, therefore it helps to distinguish those from a Japanese cultural perspective, for example which may appreciate counseling advice that embraces a nature theme of not prolonging artificial feeding without imparting guilt.

3) Direct care may be performed by nursing end-of-life staff to relieve pain for the client, and directly communicate patient wishes to have loved ones nearby as caregiver life-sustaining measures diminish. Advocate for his or her individual self.

4) Indirect care may be an extension of the above by paying attention to performance of nursing activities away from the patient, but for their behalf. For example, you may be best to phone a priest of the preferred religion or invite such into the dying patient's room to prepare for any pending last rites. Indirect intervention may include placing your nursing responsibilities to show respect to others surrounding the patient by inquiring as to their wishes for the pending decedent.

5) The planning step of the nursing process duties can help alleviate confusion, and make for a smoother transition of flexibility, and customized change that needs to occur in the care and communication process towards the patient and loved ones in attendance.

6) Implementation of the actual nursing performance goes a long way when dealing with Asian clients, as you may utilize sensitivity to culture in the use of language itself. For instance, a gentle thoughtful comment about a small attractive bonsai plant that is bedside will bridge an understanding that a recognition of nature and harmony is appreciated. This is almost common sense yet must be consciously done.

7) Risk reduction in nursing diagnoses should help to lessen the Asian client's risk factors for unwanted medical protocols. Once again discretion, both professionally driven by nursing and humanitarian.

8) When etiologic change factors are involved, and nothing else is imminently possible at the deathbed of your patient, the nurse must choose to treat signs and symptoms. This can be done without violation of Asian cultural values and sensibilities.

Evidence-based guidelines may be useful reference tools. Lunder, Sauder, and Furst proclaim that the nursing professional in an end-of-life, or palliative situation must contend with strategies that go beyond these essentials. Lunder et al., state that is an attitude problem be it from a rich or poor country to deal with diverse cultures, and that despite complaints of resources lack of “little recognition, inadequate buildings,” or the absence of “competent workers” there remains a responsibility “for creating an environment for improvement” (p. 266). Nursing makes the difference. 

Moving on to the Hispanic culturally inclined perspective an initial description of healthcare expectations which may flow from various Latin homelands can be ascribed as the following. Keep in mind it is not merely the factor of newly introduced immigrants who must negotiate the cultural exchange, but older Latinos certainly hold time-honored traditional beliefs just as strongly. In terms of comfort and end-of-life planning among this Latino population authors Heyman and Gutheil conducted a study which purpose was to determine how interventions delivered in Spanish would influence the end-of-life experience. 

If overall a comparison and contrast were to be drawn between the differences of Asian and Hispanic culturally driven needs and perspectives one might deduct the following. Asian cultural attention and patterns of behavior are deeply concerned with harmonious ties to nature, and ancestral influences from the dead spirit world – generally – while the end-of-life scores among Hispanics involve several aspects. Hispanic culture seems to have varying ethnic groups, yet at times with a language barrier and/or perhaps in situations of less educational access research suggest according to Heyman and Gutheil that “Latinos may not fully understand the health care proxy form or what it means to designate a health care agent” in quoting Hauser (p. 17). Heyman and Gutheil continue to explain that in terms of the literature “there has been little research on the effectiveness of providing end-of-life information in Spanish as one way of helping older people in their end-of-life planning” (p. 17). Language can be a bridge or a barrier. If you have ever visited another country or part of the world where your own language was not widely spoken, or spoken at all, then you can sensitively relate to the factor that it feels almost as if you found a friend when someone in a foreign land speaks your native tongue. 

In studying these older Latino end-of-life individuals, Heyman and Gutheil developed a six-point Comfort Scale via interviews with patients ranging from choices of very comfortable to very uncomfortable. Some of the sample questions included occurred as follows: “How comfortable are you talking with your doctor about treatments? How comfortable are you discussing dying with someone you would trust to make medical decisions for you?” and on and on similar inquiries were made (p. 20). Social support is vitally important for Hispanics who experience hospice yet the statistics reflect that Hispanics, in terms of their specified ethnicity, were “significantly less likely to use hospice” facilities according to Lackan, Ostir, Freeman, Kuo, Zhang, and Goodwin (p. 970). Researchers did admit to the small sample sizes which derived the data, nevertheless the study compared hospice usage among Latinos as contrasted with non-Hispanic white populations in and around Los Angeles, San Francisco, and New Mexico. The core group of older dying women were aged 67 years of age. The study indicated that it excluded Medicare subjects that “switched in and out of Medicare managed care during the 24 months prior to death” (p. 972). This indicates that during end-of-life situations Hispanics culturally may be more inclined to prefer and have family in attendance of their last moments. 

Availability of resources in any Latin or Hispanic country of origin varies widely, and time does not permit a prolonged investigation of this nature. Suffice it to say that despite any professional healthcare practitioners among the nursing attendants during the final stages of life, would do well to be especially sensitive to a high respect and honoring of family participation and concern among both young and old. 

In consideration of the Hispanic end-of-life patient cultural experience, there have been some findings accrued. Grudzen, Stone, Mohanty, Asch, Lorenz, Torres, Morrison, Ortiz, and Timmermans in their peer-reviewed professional journal article entitled “'I Want To Be Taking My Own Last Breath': Patients' Reflections on Illness When Presenting to the Emergency Department at the End of Life” say that there is a basic given. That generality suggests according to Grudzen et al., that “Because decisions regarding the use of life-sustaining technology are often made in the ED [Emergency Department], this further emphasizes the importance of this venue as a site to deliver palliative care services,” and that  patients in their study “because of the severity of their symptoms, as well as the inability to access other sites of care, not because they were seeking aggressive or invasive procedures or testing that are available in most” Emergency Departments (p. 296). Therefore family support would be critical.

Some of the very unique challenges that Hispanics and Latinos face in dealing with the medical system especially during times of complications, and impending deathbed scenarios include a highly involved integration into the public health and medical systems agencies. This is born out with confirmation from authors reporting from data collected from the Minnesota Network of Hospice & Palliative Care program of Opening Doors to Multicultural Communities. The Hispanic experience and Latino community overall has traditionally been under-served as an entire population, so the conscientiously nurse must fully be aware of the matter to efficiently and effectively address the needs of this patient.

Clinic experiences then are very well, and not surprisingly, the norm. The bi-lingual nature of the Hispanic culture drives obvious differences among their patient population and the protocol for excellence in nursing delivery would value the Spanish language as a way of respecting the highest level of trusted communication among particularly the end-of-life clients. The ability to guidelines for caring for all age groups is particularly useful in dealing with Latino patients.

A unique quality about Latinos in the United States places their multicultural context within a long history of generational immigrants that are very close knit. These close knit family ties include the involvement of many family members from the very youngest infants to the most elderly great grandmother and grandfather extended family members. The male figures and men of the family as heads of households are very fiercely protective and provide for their loved ones at all costs. You can easily perceive that the cherishing of one's partners and children in the Spanish community is one filled with courage, honesty, and respect. They deserve to be acknowledged by the attending nursing professional in like manner. 

A relaxed family atmosphere then is most appreciated as the culture is warm, inviting and family-oriented. Family members in the Hispanic community tend toward strong protection of an ill relative and do not necessarily wish to burden the sick or dying family member with the knowledge of their impending death. It is important for the nurse not to develop compassion fatigue and to abide by their desired confidences and respect the head of household greatly in terms of decision-making authority. Never for example address the elders by their first name but rather use the formal manner such as Mr., Mrs., or Miss.

Pay attention to non-verbal communications and incorporate them into the 8 nursing interventions for Hispanic culturally inclined patients as follows.

1) Physical care teaching should be done very respectfully with the greatest of politeness.

2) Counseling as an ongoing assessment should be re-affirmed to be the wishes of the patient and family members.

3) Direct care may be introduced after a handshake, both among women and men.

4) Indirect care in nurse performance on the patient behalf should adhere to whether they wish to let the family know of the patient condition or vice versa.

5) Planning a step in the nursing process should be discreet and sensitive instead of blurting things right out; Warm them up in your communication style, using language like wanting to make them feel more “comfortable”

6) Implementation of actual nursing performance should be done with their religious values in place, such as a sensitivity to the Roman Catholic beliefs.

7) Risk reduction should be clearly and respectfully diagnosed to lessen client fears while treating risk factors

8) When etiologic change factors occur, and the nurse has done all he or she can, simply make sure to ask family member who they would like to include in the end-of-life discussions while proceeding to treat signs and symptoms.

All and all these considerations will help to distinguish between Asian and Hispanic culturally driven perceptions and assist the astute nursing professional to do his or her job accordingly. As society is increasingly diverse it makes good practitioner sense to keep aware. There is one further recommendation for Hispanic end-of-life patients in the case of relatives being far away from the dying client's bedside, and that is “Patient care decisions may come to a stop when geographically distant relatives are not present or do not understand the facts. Long-distance telephone conference calls are often helpful to ensure continuous care” (p. 6). The key is to cater to each patient as human beings with feelings of importance and value of their respective cultures in end-of-life situations. 

References

Coolen, P. R. (2012, May 1). Cultural relevance in end-of-life care. [Data file] Retrieved from http://ethnomed.org/clinical/end-of-life/cultural-relevance-in-end-of-life-care  

Duke, G. (2013). Attitudes regarding life-sustaining measures in people born in Japan, China, and Vietnam and living in Texas. International Journal of Palliative Nursing, 19(2), 76-83.

Grudzen, C. R., Stone, S. C., Mohanty, S. A., Asch, S. M., Lorenz, K. A., Torres, J. M., & ... Timmermans, S. (2011). 'I Want To Be Taking My Own Last Breath': Patients' Reflections on Illness When Presenting to the Emergency Department at the End of Life. Journal of Palliative Medicine,14, (3), 293-296. doi:10.1089/jpm.2010.0306  

Heyman, J. C., & Gutheil, I. A. (2010). Older Latinos' attitudes toward and comfort with end-of-life planning. Health & Social Work, 35(1), 17-26.

Lackan, N. A., Ostir, G. V., Freeman, J. L., Kuo, Y., Zhang, D. D., & Goodwin, J. S. (2004). Hospice use by Hispanic and non-Hispanic white cancer decedents. Health Services Research, 39(4p1), 969-984. doi:10.1111/j.1475-6773.2004.00267.x

Lunder, U. Sauter, S., & Furst, C. (2004). Evidence-based palliative care: Beliefs and evidence for changing practice. Palliative Medicine, 18(4), 265-266. doi:10.1191/0269216304pm900ed

Minnesota Network of Hospice & Palliative Care – Opening Doors to Multicultural Communities. (2013). Serving Latino/Hispanic patients & families in end-of-life care: A guide for hospice and palliative care providers [Data file] Retrieved from ab&q=hispanic+beliefs+death+nursing+hospice+end+of+life+mexico

Nursing Theories. (2012). Leininger's theory of culture care [Data file] Retrieved from http://nursingtheories.blogspot.com/2011/07/leiningers-theory-of-culture-care.html  

Park, K. (2011). Asian medicine and holistic aging. Pastoral Psychology, 60(1), 73-83.doi:10.1007/s11089-010-0305-8

Rao, A. S., Desphande, O. M., Jamoona, C., & Reid, C. M. (2008). A community-based exploratory study. Journal of The American Geriatrics Society, 56(6), 1129-1133. doi:1111/j.1532-5415. 2008.01723.x