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Clinical Work with Culturally Diverse Dying Patients

"...the health care team consisting of the doctor, nurse, and social worker, and their patient may come from four very different cultures."

Elaine P. Congress, DSW

Acting Associate Dean and Director of the Doctoral Program, Fordham University Graduate School of Social Service

Working with terminally ill patients arouses strong feelings even for the most seasoned long-term health care professional. Professional caregivers have all had life experiences which influence their beliefs about life, death and the treatment of the terminally ill. These beliefs stem from their personal beliefs, socioeconomic status, cultural background, and, religious heritage.,The first step in providing culturally sensitive service to patients is for professionals to recognize and understand their own beliefs about these sensitive issues.

With the metropolitan New York City becoming increasingly culturally diverse, the likelihood of the health care professional treating a terminally ill person from another culture has greatly increased. Sometimes the health care team consisting of the doctor, nurse, and social worker, and their patient may come from four very different cultures. Not only must health professionals be aware of their own cultural beliefs about death and dying, but also seek to understand the beliefs of their patients. Sometimes this information can be sought directly from the patient; at other times families and relatives can promote greater cultural understanding.

Focusing on advance directives, especially for the seriously ill, requires that health care professionals initiate discussion about these issues with their patients. Yet there is evidence to suggest that clients from some cultures may not be receptive to this. For example, African Americans are more likely to believe that patients should be informed if they have metastatic cancer and should know their options about life support treatments than are Korean and Mexican Americans. It is essential that the health care professionals learn from their patients their beliefs about advance directives.

Religion may be a source of solace to the dying patient. Not only must the health care professional be receptive to calling in clergy members as requested by the dying patient, but also to talking with clients about their spiritual beliefs. Health care professionals, however, may be critical of clients' attitudes when they choose to leave their fate up to God and Insist that they take an active role in fighting to live as long as possible. This health care professional may encourage the dying patient to pursue aggressive treatment when the client may prefer palliative care. The health care professional may stress quality of life issues, such as autonomy, when working with the older person yet fail to support DNR orders when they conflict with their own cultural and religious beliefs. Furthermore, the health care professional may insist that the dying client make independent health care decisions negating that individual's lifelong history of being dependent on family when making all minor and major life decisions.

There are individual and cultural differences in terms of pain management. Some patients may want constant pain medication, while others will stoically deny the need for any pain medication. The role of the health care provider is to help patients advocate for what feels appropriate for them within their cultural context. Understanding the patient may be difficult when patients are from different cultures and speak languages disparate from that of the health care provider. The responsible health care professional seeks out staff members, as well as family or friends with whom the dying patient can communicate. Patients should be allowed to freely express their questions and/or fears about their impending deaths even when such conversations are uncomfortable for the professional.

Often impending death may seem to negate any thought of what the person was and Is apart from the terminal illness. All symptoms and behaviors may be erroneously seen as related to the terminal illness, as this example Illustrates: An 85 year old Puerto Rican terminally ill woman barely touched her food. The social worker interpreted this loss of appetite as caused by her illness. The patient's sister visited from Puerto Rico and brought rice and beans to eat and the patient was observed eating and enjoying a large portion. The social worker learned that the woman's loss of appetite was due to her dislike of institutional food, not her illness.

Terminally ill, culturally diverse people may want to surround themselves continually with relatives of all ages, while health care professionals may be concerned that patients should have more quiet time and that children should not be exposed to terminally ill people. This desire to surround oneself with family of all ages may stem from a by-gone American era or from a very current practice in other countries, where terminally ill people end their days at home not in hospitals or nursing homes.


  1. Understand one's own personal and cultural values about life, death, and dying.
  2. Strive to facilitate communication with the terminally ill person through verbal and nonverbal communication.
  3. Accept that the client's understanding and desire for advance directives may differ from that of the health professional.
  4. Recognize and accept the patient's need for closeness or distance.
  5. Acknowledge the patient's decisions about the use of pain medications.
  6. Understand the patients need to have contact with family members of all ages.
  7. Avoid interpreting all behavior as stemming from the patient's terminal illness.
  8. Be available for the patient when this is desired.

Because patients come from many diverse backgrounds and there is risk of stereotyping certain cultural groups, this article purposefully does not focus on specific cultural, beliefs about death and dying. For a further discussion of diverse cultural beliefs the reader is referred to the following books: A Cross Cultural Look at Death, Dying and Religion by Joan Parry and Ann Shen Ryan (Nelson-Hall, 1995) and Caring for Patients from Different Cultures by Geri Ann Galanti (University of Penn. Press, 1991).

Congress, E. P. (1997). Clinical work with culturally diverse dying patients. Ethics Network News, 4( 3), 5-6.

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Posted 7/24/99