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Culture and Pain
CULTURE AND PAIN
Expression of pain generally open and public but can vary. Pain scales helpful to rate discomfort levels. Discuss possible fear of addiction in regard to pain medication.
Offer pain medication as ordered. Pain viewed as necessary part of life to be endured. May be viewed as consequence of "earthly misconduct" or “imbalance” of nature. Expression of pain (moaning or crying) acceptable.
Patient may not complain of pain; be aware of nonverbal cues to assess pain. Offer pain medications instead of waiting for patient to ask for them. Some patients may use acupressure or acupuncture to treat pain and illness.
Culturally acceptable to express feeling of pain. Men may seem hypersensitive; women more tolerant. Understand numerical scale of expressing pain. May fear becoming addicted to narcotics. Prefer not to take medication or to wean off as quickly as possible. Injections viewed as more effective or stronger than tablets. Nonpharmacological methods for pain control often under-utilized.
In general, patients have very low pain thresholds. Whole demeanor changes, very verbal about what is hurting them, sometimes moaning. Usually very vague about location of pain, believing that whole body system is affected; therefore, location of pain is not important since disease travels. Injection the preferred treatment method, followed by elixir, tablets, and finally capsules.
Can be stoic in expression of pain or discomfort. Offer pain medications, as ordered. Some have high pain threshold, but others may refrain from asking for medications. Older generations especially concerned about addiction to medication and may refuse. Others take medication as prescribed, preferring oral medications to injections; may refuse rectal form.
Patients tend not to complain of pain. Assess pain by nonverbal cues. Most prize inner control and self-endurance. For some men, expressing pain shows weakness and possible loss of respect. Expression of pain socially more acceptable in women; however, stoicism common.
May complain of pain in general terms such as “I don't feel so good,” or "Something doesn't feel right." If patient reports being "uncomfortable" and gets no pain relief, patient unlikely to repeat request for assistance. Patient may complain of pain to trusted family member or visitor instead of health care worker. Traditional Native medicine usage may be requested.
May not express pain but will understand numerical scale to quantify pain. Hindu and Sikh patients will usually accept narcotics for pain. Muslim patients may refuse narcotics for mild to moderate pain, as narcotics forbidden in their religion; however, usually accepted for severe pain. Some may prefer home remedies to manage certain acute pain.
(taken from: Culture and Nursing Care: A Pocket Guide. ed by Juliene G. Lipson, Suzanne L. Dibble, Pamela A. Minarik. San Francisco: University of California, San Francisco Nursing Press, 1996.)
MAJOR RELIGIOUS TRADITIONS AND THE DYING PERSON
The following is a summary of some of the religious practices important to the dying person belonging to one of the major world religions. It is important to remember, however, that within each religious group, a number of distinct subgroups exist. These subgroups have beliefs and practices that may differ considerably from those of the main group, necessitating individual assessment. This summary is intended to provide only an overview of some of the dominant practices in each group.
Many branches of the Christian church exist with tremendous variations in practices, and it is important to determine what rituals the dying person desires to follow. Because many Christians believe that death results in a temporary separation of the body and the soul, and that, after Christ's second coming, the righteous will be sent to Heaven to enjoy eternal bliss, and the wicked will be sent to bell for eternal punishment, common practices are for the person to request a visit from a minister or priest during which prayer will be offered, sometimes accompanied by an anointing with oil, communion, or confession. In some cases, caregivers may need to help patients by assisting with arrangements for ritualized confession and reconciliation. Other practices may include prayer and meditation, reading selected portions of the Bible, dietary restrictions (especially for some during specific times of the year), and special articles of clothing. While death is understood to result from failure of body organs, in a larger sense, it may be thought to be due to sin against God. This emphasis on punishment can result inconsiderable fear of death among some Christians, and patients may need reassurance that physical pain and suffering are not necessarily punishments for sin. However, in other cases, death is often approached calmly by those who believe that eternal life is given to those who believe in Jesus as Lord and Savior (such as fundamentalists), or those who believe absolution from sin ensures eternal life (such as Catholics). Other persons, without these beliefs, may conduct an extensive life review to assure themselves that the good they have done is greater than their sins and may need the reassurance of a pastor or another Christian that they are loved and accepted by God. Following death, the body is typically straightened and the hands folded across the chest. The request for an autopsy generally is not resisted, and the body may be buried or cremated, depending on the beliefs and preferences of the person.
There are many structured behaviors and rituals in Judaism and the extent to which a Jewish individual desires to follow these practices will be based primarily on whether the practitioner follows Orthodox, Conservative, or Reform Judaism. Often they will observe days of special religious significance, including the Sabbath, which begins at sundown on Friday with the fighting of candies and lasts until sundown on Saturday, when candies are extinguished. In addition to observing specific holy days, may Jews observe daily prayer, ritual handwashing prior to meals, and strict dietary laws that prohibit pork and shellfish. Some Jews require that food be prepared according to kosher techniques, and more stringent requirements regarding food preparation are often followed on specific holy days, such as Passover. A wide range of beliefs concerning the afterlife exists in Judaism, although the primary focus of concern is on the importance of the current life, emphasizing how life is lived on this earth, instead of events that occur after death and of the possibility of future life, as these events are viewed as being more appropriately left to God. According to Jewish belief, dying patients should be attended almost constantly. Family members and a rabbi frequently read from specific religious texts. Just before death occurs, the dying person is encouraged to make a confession, pray for forgiveness, and repeat specific prayers. When death is believed to have occurred, a feather may be placed over the mouth and nose to assess any signs of breathing. If none are present, the eyes and mouth are closed, the jaw tied up, limbs straightened and arms placed at the sides, and the body is washed and dressed, usually in a white shroud or a plain white sheet. These functions are performed preferably by the deceased's family, and due to special requirements, staff should not attempt to lay out the body without permission from the family. From the time of death until the funeral, especially in the Orthodox tradition, the body is rarely left unattended, and, because most Jews do not believe in embalming or cremation, burial is encouraged within 24 hours of the death. An autopsy or request for organ donation will likely be refused by Orthodox Jews, but may not be resisted by less strict groups.
As with other world religions, diversity of belief and practice is common among various sects of Islam, but for most Muslims (also seen written as Moslem), creation, death, and resurrection are sacred and are inseparably linked. Their holy text, the Koran, describes a barrier that separates the living from the dead, which means the deceased have no way of returning to earth and cannot be reincarnated, and life is viewed as a time of preparing the soul so it is worthy to pass into life after death. Because of this, struggling against death is viewed as resisting the will of Allah, so Muslims tend to be fatalistic about approaching death, often wanting to use their remaining time for prayer and meditation. The practicing Muslim follows a precise code of behavior and practices, including praying five times a day facing Mecca, ritual washing in running water before prayer, observing Friday as the day of worship; fasting during the month of Ramadan (food and fluid may be taken before sunrise and after sunset, although IV medication may be rejected during periods of fasting), following dietary restrictions such as no pork products, exclusion of any fish not having fins and scales, and abstinence from all alcohol including alcohol-based oral medications, and exhibiting modesty through dress and contact with health care professionals only of the same sex. Although the terminally ill person may be exempt from these practices, many will want to continue the rituals as long as possible. After death, the body should be touched only by a Muslim, or, if contact by a non-Muslim is unavoidable, gloves should be worn. The body is straightened, the face is bandaged to keep the mouth and eyes closed, the feet are tied together, the head turned to the right in order to face toward Mecca after burial and the unwashed body is wrapped in a plain white cloth or sheet. Muslims are never cremated and burial usually takes place within 24 hours, which means resistance to autopsies is strong.
Hinduism is an ancient religion and consists of an amalgam of traditions, rituals, devotions, and philosophical systems. Although polytheism is the basis for much Hindu worship, Hindus believe in the essential oneness of ultimate reality, and most Hindu scriptures focus on achieving awareness of the eternal Self and on attaining union with Brahman, often occurring after any number of reincarnations. There are many variations of Hindu beliefs and practices, depending on which god is worshipped, and death is natural and unavoidable, but not actually real; only Atman and Brahman are real. Common Hindu practices include meditation, prayer, exercise such as yoga, purification through bathing in running water, dietary restrictions such as vegetarianism, strict guidelines of food preparation and regular fasting (especially during specific times of year) which can affect pain and symptom control measures. Most exhibit extreme modesty to the extent of not being examined or cared for by a person of the opposite sex, and often there is a request to utilize traditional Hindu (Ayurvedic) medicines. A Hindu priest may be called to facilitate the person's acceptance of death as part of the continual cycle of life, and because of this philosophical view of death, the event of dying is generally faced calmly. As death approaches, religious rites and ceremonies provide support for the dying person. If possible, a son or relative puts water from the Ganges River in the dying person's mouth to bring peace and comfort, and family members and friends chant, sing and read devotional prayers. Because of the variability of Hindu beliefs, the dying person or a family member should be asked if there are any additional religious practices desired. After death occurs, the body is washed, anointed, and dressed in new clothes, and the hair and beard are trimmed. Hindus believe that cremation offers the best way for the soul to begin its journey. After cremation, any remaining bones may be buried or cast into a river. Autopsies are usually rejected as an indication of disrespect for the dead.
Many different forms of Buddhism exist, but most believe that, through multiple rebirths and the accumulation of knowledge enabling the person to follow the Buddha's teachings more fully, the Buddhist gradually moves toward a state of perfection or nirvana, and although Buddhist death practices vary greatly from country to country, there is general agreement that a dying person's state of mind is of great importance. There are variations in rituals and practices, based on the form of Buddhism followed, and it is important to ask what practices the dying person wishes to follow. Some of the more common practices are meditation preceded by washing, and dietary restrictions such as vegetarianism. Although the relief of pain is important, a higher need is to maintain a clear awareness. For those deeply involved in meditation practices, pain medications may be refused unless the dying person can be assured that the dosage will lessen pain but not affect the senses; for others, good symptom control is appreciated because it enhances the ability to focus on peaceful calming of the spirit instead of bodily distress. Buddhists, like Hindus, often place high value on modesty and personal hygiene, and they may prefer caregivers of the same gender. To help the dying patient achieve peace, family and friends often surround the dying person, reading and chanting from religious texts, and, when nearing death, the patient may desire a visit from a Buddhist monk or sister; contacting a local Buddhist center usually results in a rapid response to this request. After death occurs, the body is washed and dressed in burial clothes chosen by the family or wrapped in a plain sheet; it is believed that any pattern or emblems may disrupt the consciousness as it departs the body. If the family is not immediately available, Buddhist families often ask that a patient's corpse remain untouched for as long as possible after death so its spirit can make a peaceful transition to the next world. The body is then cremated, with a service usually conducted by a monk or sister. Because some Buddhists believe the dead person's conscious soul remains in or around the body for several days, monks are also invited to chant sacred texts to assist the dead person's passage to the spiritual world and to relieve the mourners' fears. There is strong opposition to autopsies because the body would be violated and perhaps not seen as whole.
CARING FOR OTHER RELIGIOUS FAITHS, AND DYING PERSONS WITH VARYING SPIRITUAL BELIEFS OR NO RELIGIOUS COMMITMENT
When interacting with dying persons, it is likely that the professional caregiver at some time will have contact with persons of religious or spiritual beliefs other than these five groups (such as Taoism, Sikhism, and traditional Native American). It is difficult to have a working knowledge of the practices of every religion, but effort should be made to become familiar with the beliefs and rituals of the groups most likely to be encountered within the locality served. Provision of spiritual care measures, individualized to meet the needs of the dying person, will provide comfort to that person and family during a time of change and loss.
For the dying person who has no religious commitment and who declines offers of spiritual comfort or a final opportunity to talk with a spiritual counselor, providing spiritual comfort may be interpreted as providing comfort for the psychosocial needs of the person. The person will need reassurance of love from significant others and confirmation that his or her life has been meaningful. Efforts to compel the person to experience a "deathbed conversion" are likely to result in psychosocial discomfort for the person, rather than comfort.
(Sources: Aspen Reference Group. “Palliative Care Patient and Family Counseling Manual," Aspen Publishing Inc., Gaithersburg, Md; 1997; American Academy of Hospice and Palliative Medicine. "Unipac 2: Alleviating Psychological and Spiritual Pain in the Terminally Ill,” AAHPM, Gainsville, Fl; 1997; Taylor, Andrew and Box, Margaret. "Multicultural Palliative Care Guidelines," Palliative Care Council of South Australia; 1999 (this source contains additional specifies with 20 different language groups and their religions, and can be downloaded from http://www.pallcare.asn.au).
CULTURAL DIVERSITY OF DYING
REFERENCES AND RECOMMENDED READING
Academy for Guided Imagery. "ATS/4B-Interactive Guided Imagery with Death, Dying, Loss, and Transformation," A.G.I., Inc., P.O. Box 2070, Mill Valle, Ca. 94942; 1998.
American Academy of Hospice and Palliative Medicine. "Unipac 2: Alleviating Psychological and Spiritual Pain in the Terminally Ill," AAHPM, Gainsville, Fl; 1997.
Aspen Reference Group. "Palliative Care Patient and Family Counseling Manual" Aspen Publishing Inc., Gaithersburg, Md; 1997.
Aspen Reference Group, Weavers, Simon, Ed. "Pain Management Patient Educational Manual;" Aspen Publishing, Inc.; Gaithersburg, Md. 1999.
Barley, Nigel. Grave Matters: A Lively History of Death Around the World, Henry Holt, NY; 1995.
Buckman, Robert. How To Break Bad News: A Guide for Health Care Professionals, The John Hopkins University Press, Baltimore; 1992.
Carr-Gomm, Philip. The Elements of The Druid Tradition, Element Books, Inc., Rockport, MA; 1991.
Dershimer, Richard. Counseling the Bereaved, Perganon Press, NY; 1990.
Grof, Stanislav. Books of the Dead-Manuals for Living and Dying, Thames & Hudson, Inc, NY; 1994.
Harrison, Connie. In Times Of Grief, Quest Books, Weaton, Il.; 1995.
Irish, Donald, Lundquist, & Nelsen, eds. Ethnic Variations in Dying, Death, and Grief, Taylor & Francis, Inc., Washington, D.C.; 1993.
Johnson, Christopher, McGee, Marsha, eds. How Different Religions View Death and Afterlife, The Charles Press, Inc., Philadelphia; 1998.
Kalish, Richard, ed. Death and Dying: Views from Many Cultures, Baywood Pub. Co., NY; 1972.
Kramer, Kenneth. The Sacred Art of Dying: How World Religions Understand Death, Paulist Press, Mahwah, N.J.; 1988.
Metcalf, Peter and Huntington, Richard. Celebrations of Death-The Anthropology of Mortuary Ritual, Cambridge University Press, Cambridge, UK; 1991.
Parkes, Colin, Laungani, & Young. Death and Bereavement Across Cultures, Routledge, NY; 1997.
Parry, Joan and Ryan, Angela, eds. A Cross-Cultural Look At Death, Dying, and Religion, Nelson-Hall Pub., Chicago; 1995.
Phipps, Etienne, et al. "Approaches to End of Life Care in Culturally Diverse Communities," lastacts newsletter, 14 page printout-posted 7/07.
Rando, Therese. Grief, Dying, and Death, Research Press Co., Illinois; 1984.
Rinpoche, Sogyal. The Tibetan Book of Living and Dying, Harper, San Francisco; 1992.
Rosen, Elliott. Families Facing Death, Jossey-Bass Pub., San Francisco; 1998.
Smith, Douglas. Spiritual Healing, Psycho-Spiritual Pubs., Madison, Wis; 2000.
Stroebe, Margaret, Stroebe, & Hansson. Handbook of Bereavement, Cambridge U. Press, NY; 1993.
Taylor, Andrew and Box, Margaret. “Multicultural Palliative Care Guidelines," Palliative Care Council of South Australia; 1999 (this source contains additional specifics with 20 different language groups and their religions, and can be downloaded from http://www.pallcare.asn.au).
Walter, Tony. On Bereavement: The Culture of Grief, Open U. Press, Pa.; 1999.
Wrede-Seaman, Linda. Symptom Management Algorithms: A Handbook for Palliative Care, Intellicard, POB 8255, Yakima, Wa. 98908; 1999.
A THOROUGH CULTURAL ASSESSMENT CAN TAKE MANY HOURS, BUT CAREGIVERS RARELY HAVE THAT LUXURY. AT A MINIMUM, THE FOLLOWING LIST SHOULD BE CONSIDERED FOR INCLUSION IN THE CULTURAL ASSESSMENT OF ANY PATIENT:
--WHERE WAS THE PATTENT BORN?
IF AN IMMIGRANT, HOW LONG HAS THE PATIENT LIVED IN THIS COUNTRY?
--WHAT IS THE PATIENT'S ETHNIC AFFILIATION?
HOW STRONG IS PATIENT'S ETHNIC IDENTITY?
--WHO ARE THE PATIENT'S MAJOR SUPPORT FAMILY: FAMILY MEMBERS, FRIENDS?
DOES THE PATIENT LIVE IN AN ETHNIC COMMUNITY?
--WHAT ARE TBE PRIMARY AND SECONDARY LANGUAGES?
SPEAKING AND READING ABILITY?
--TO WHAT DEGREE DOES THE PATIENT APPEAR TO UNDERSTAND HIS/HER CONDITION AND TREATMENT RECOMMENDATIONS?
--HOW WOULD YOU CHARACTERIZE THE NONVERBAL COMMUNICATION STYLE?
--WHAT IS THE PATIENT'S RELIGION, ITS HAPORTANCE IN DAILY LIFE AND CURRENT PRACTICES? DOES IT DIFFER FROM THAT OF THE SUPPORT FAMILY?
--WHAT ARE THE PATIENT'S FOOD PREFERENCES AND PROHIBITIONS?
--DOES THE PATIENT HAVE ANY OTHER PROHIBITIONS IN REGARD TO CARE?
--WHAT ARE THE PATIENT'S BELIEFS AND PRACTICES AROUND HEALTH AND ILLNESS?
--WHAT ARE THE PATIENTS'CUSTOMS AND BELIEFS AROUND DEATH?
TO WHAT DEGREE DOES THE PATIENT ADHERE TO THEM?
(This assessment is based on the following source: Aspen Reference Group, Weavers, Simon, Ed. 'Pain Management Patient Educational Manual;" Aspen Publishers, Inc.; Gaithersburg, Md. 1999; Chpt. 6, pg. 60).