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. Practices related to death and dying vary in different cultures although the feelings of loss and grief are universal.In the United States two forces converge on the patient and family near the time of death that isolates them from their traditional support systems . First:. most deaths over age
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1. Diverse Cultural Beliefs and Practices About Death and Dying in the Elderly Article by: Marjorie Kagawa-Singer, PhD, MN, RN Presented by: Barbara DiStefano RN, BSN
2. Practices related to death and dying vary in different cultures although the feelings of loss and grief are universal.
In the United States two forces converge on the patient and family near the time of death that isolates them from their traditional support systems
3. First: most deaths over age 65 occur in the hospital.
The human experience of dying is decontextualized from cultural, tradition, lineage, and accepted dogma.
Death is adverse to the mission of health care.
Culture of hospitals is based in the positivist scientific approach.
Health care practitioners are trained to divest health care from the spiritual aspects of life in the name of science.
Focus is on highly technical, objective measures to ensure longevity is incongruous with acceptance of death as a natural event
4. Second: The social value of the aged . We highly value change, newness, energy, and the beauty and independence of the young.
American culture holds far less value in tradition, change through evolution, or wisdom which comes from having lived many years.
We avoid the old. At death many elderly are peripheral to families and younger community members.
Social death occurs before biological death. "Graying of America".
In contrast, elderly are held in a position of esteem by many other cultures and ethnic groups within the US. They are central to community life.
5. Objective: to define a paradigm for dying within a hospital milieu which would reintegrate the isolated process of dying back into a context of living
6. Social and Cultural Practices: identify the "elderly
Bearers and teachers of culture
defined by life stages and social function than chronological age. Ex., American Indians consider age 45 or even younger, if warranted by impaired health and functional abilities.
Elders in Japan (60 years old) symbolically pass family caretaking to the next generation absolving themselves of adult responsibilities and return to the joys of childhood.
In contrast American culture, ones social value seems to be directly proportional to ones earning potential.
mandatory retirement age.
Post-retirement social role in America is still evolving.
7. Rituals of Death and Dying Members of a cultural group go through predictable transitions in life such as birth, first communion, adulthood, marriages, and death
8. VanGennep (1960) Rites of Passage
life transitions require the relinquishment of one set of beliefs about ones social role, the development of a new set of role responsibilities and identity. Death rituals re-establish emotional synchrony and sense of equilibrium for the dying and the bereaved, and ensure group welfare and continuity Rite of Aggregation
two stages Expression of grief Breaking emotional ties with the deceased
9. All societies express grief, bereavement, and mourning in response to the loss created by death
Grief is subjective individual response to an objective loss
Bereavement is similar to grief, sense of being stripped, robbed or deprived of a loved one
Mourning is the social response to the loss
10. Worden (1982) four tasks 1-Accepting the reality of the loss 2-Experiencing the pain of grief 3-Adjusting to the new environment which no longer contains the deceased member of the family such as social roles and family roles 4-Withdrawal of emotional energy from the loved one
11. Accommodating to the loss does not mean forgetting the deceased, but it does require redirection of ones energy into a world without that individual
12. Rituals for Bereavement Religious funerary practices assist practitioners to achieve the first and second steps of Wordens resolution of grief
13. Judaism - someone must be present with the dying individual at all times, individual must not be alone at the moment of death or the soul would feel abandoned when it leaves
14. Rural Greek-Orthodox-
mourn for five years
burial is done with great expressions of grief and sorrow through singing of laments.
Immediate family remains in a liminal state of being until the bones are exhumed on the fifth anniversary. Greeted as though they have returned home, reburied in the village ossuary. The family can then rejoin the life of the community
five annual holidays continue to recognize the deceased. Degree of decomposition of the body reaffirmation proper social conduct, white bones and completely decomposed tissue confirm that the soul is finally at rest in paradise, black bones or partially decomposed body indicates that the deceased or someone in the family has transgressed the moral code of the community and the soul is destined to remain in purgatory
15. Buddhist Hmong, Vietnamese, Chinese and Japanese- believe each individual has three souls Vegetative- consists of body functions Animal- the instinctual responses Spiritual- the essence of the individual and remains with the ancestors Each leave the body at different times Vegetative- the first day Instinctual- the seventh day Spiritual- the 49th day A religious service is held in the community temple on each of these significant days Audible crying is highly unusual, tears are restricted to the immediate family Memorial services are held at different intervals throughout the 50th year. A shrine is placed in the home and the ancestors are greeted every morning and evening Vietnamese Buddhist are different from Japanese Buddhist, loud crying and wailing are acceptable, professionals may be hired
16. Moslems - first morning prayer begins with the contemplation of ones own death, Allah decides when death will occur, must be in the right mind to accept it. Grief behavior of loved ones requires loud wailing and keening to indicate how much pain the loss of the loved one has cost the bereaved
17. Hindus- believe the soul resides in heaven until the rebirth occurs in the ongoing cycles of life. Individuals can escape the cycle of rebirth if they are truly pure.
Male family members prepare and cremate the body, women are not allowed at the cremation, must remain at home to mourn.
If a husband dies the widows social identity dies as well. She can no longer wear bright colors or go to temple and participate in religious services, she is no longer allowed to participate in community celebrations
18. Tibet- the ground is extremely hard and rocky, body of commoners is taken into the mountains after the funeral for sky burials. Bodies are dismembered and the vultures devour the remains so that the soul can fly to heaven
19. Toraja of Indonesia mummify the body and "bury" it in the limestone cliffs, once a year the body is removed and the family holds the body and mourns the loss of the loved one
20. Hispanic cultures- Dios de Los Metros (Day of the Dead) November 1 and 2. Community procession to the graveyard, celebrations and picnics are held. Death is accepted as a part of daily life
21. Christianity- unique in its extremely short formalized period of mourning and public acknowledgement of death.
Period of mourning is about one month, memorial and funeral service (may be on the same day) occurs within a week of the death and is the only religious ceremony.
Family is allowed to mourn for a period of one to two years
22. Facilitating the Readjustment of Social and Family Roles Two differences between mainstream American culture and the practice of other cultures
First- time is allotted to break social ties with the deceased and make the transition to a new identity (third or Wordens four stages of resolution)
Wordens fourth and final step- withdrawal of emotional energy from the loved one to reenter the world without that individual- is made finite in time. Time for this transition is considerably longer than in the US, most cultures it occurs gradually over several years and religious ceremonies acknowledge that the pain of losing a loved one lasts a lifetime.
23. Asia- ancestors exert influence on daily living
Toraja and Hispanics formally mourn their loved ones in a community ceremony on a yearly basis- the painful emotions associated with the loss of a loved one is never healed
African cultures- believe as long as the individual is remembered and missed, the continued spiritual existence of the deceased is assured
24. Transition of the bereaved to a new identity for the family as a group and for individuals takes two to three years.
Bereavement support groups and counseling practice allows the bereaved to acknowledge that they need not forget the loved ones
Second difference- breaking ties with deceased loved ones is in the expression of grief itself. The "natural" practice of various cultures would often conflict with hospital "culture".
Grief is socially confined to the immediate family, allowing them privacy may also isolate the family from care. Another isolation is the restriction of visitors and visiting hours
25. Culture: A fundamental Integrative Concept Common themes across cultures to cope with death A cultures patterns of belief and rules for behavior enable its members to maintain some behavioral consistency and predictability
26. Tapestry analogy- patterns which emerge from each group of people are culturally identifiable.
Concepts of beauty, for example, color balance, symmetry, and subjects chosen to display in the tapestries are culturally defined and symbolically express the ethos of the culture
Two functions of a culture , the integrative and functional, are like the warp and woof of a cultural fabric, and specific beliefs and behaviors are the individual threads
A thread can be taken out and compared across cultural groups for its inherent structure, such as grief behavior, but its function and integrity are not comprehensible unless seen within the pattern of the entire cultural fabric from which it came
Taken in isolation or out of context, anothers cultural belief or behavior may be misinterpreted or even disregarded as unnecessary or maladaptive, especially if evaluated against a different standard
27. The Meaning of Death Euro- Western- Linear image of life from birth through death to the hereafter
Judiasm- places greater emphasis on life
Christians and Moslems view life as prepatory for eternal life in heaven
Other cultures conceive life and death as an ongoing circular process of rebirths (Asian, Hinduism)
American Indian tribes- parallel view of the worlds of the living and the dead
28. Implications for Health Care Practitioners
Major objective:
Assist both the patient and family to find meaning in dying and in death
To assist survivors to reestablish their sense of equilibrium
Acute care setting- poses significant barriers to the incorporation of needed rituals
Inclusion of extended family networks
Desired mode of expression of grief for all patients
29. Strategies to support the dying and grieving process redefining the family to include extended family or the unit of care, patient- identified family
Structure of the health care system and the identification and acknowledgement of its Euro-American cultural foundation, recognize these as differences. Modify our procedures and policies to accommodate individual needs and provide culturally appropriate and acceptable care
30. American health care system with its emphasis on patient rights, informed consent, and advance directives. Disclosing the diagnosis of cancer is felt to be unethical. Elderly may have grown up not feeling comfortable discussing the diagnosis or participating in their treatment decisions
Incorporating different views on the value of autonomy and self-determination. In other cultures than Euro-American the individual responsible to make the end of life decisions is often not the patient. Rules and policies must be flexible enough to accommodate these variations in need, if at all feasible, without compromising standards of care and patient and family safety
31. Establishment of standards of care. Interventions on issues of death and dying. Goal: facilitate and support positive adaptation. Training must include cross-cultural information
Health care professionals must rethink, retrain, and restructure our health care system to care for the dying
32. Reference Kagawa-Singer, M. (1994). Diverse cultural beliefs and practices about death and dying in the elderly. Cultural diversity and geriatric care,15,101-116.
