1. EELLNNEECC Geriatric Curriculum E L N E C _____ Geriatric Curriculum End-of-Life Nursing Education Consortium SESSION 8: Cultural and Spiritual Considerations at End-of-Life Fairfield University Quinnipiac University School of Nursing ELDER Project

2. EELLNNEECC Geriatric Curriculum Objectives: Upon completion of this session, the learner will be able to… 1.Examine the influence of cultural and spiritual beliefs. 2. Describe beliefs regarding death and dying held by various cultures. 3. Identify the role of interdisciplinary care in respecting cultural and spiritual diversity.

3. EELLNNEECC Geriatric Curriculum Culture Defined Socially transmitted values, customs, arts, behaviors, and beliefs that guide a person’s world viewSocially transmitted values, customs, arts, behaviors, and beliefs that guide a person’s world view A system of shared symbolsA system of shared symbols Provides security, integrity, belongingProvides security, integrity, belonging

4. EELLNNEECC Geriatric Curriculum Components within Culture EthnicityEthnicity RaceRace GenderGender AgeAge Religion and spiritualityReligion and spirituality

5. EELLNNEECC Geriatric Curriculum In order to provide culturally sensitive care to those at the end of life, the first task of the healthcare workers should be to: 1. 1.evaluate the cultural beliefs of co-workers 2. 2.identify one’s own cultural background and values 3. 3.learn to predict how various races deal with end-of-life issues 4. 4.become informed about state laws concerning end-of-life care

6. EELLNNEECC Geriatric Curriculum Self-Cultural Assessment What is your ethnic affiliation and how strong is your ethnic identity?What is your ethnic affiliation and how strong is your ethnic identity? Who makes decisions - you, your family, or a designated family member?Who makes decisions - you, your family, or a designated family member? Is religion an important source of support and comfort?Is religion an important source of support and comfort? What are your health and illness beliefs and practices?What are your health and illness beliefs and practices? What are your past experiences regarding death and bereavement?What are your past experiences regarding death and bereavement? How much do you and your family wish to know about the disease and prognosis?How much do you and your family wish to know about the disease and prognosis? What are your beliefs about the afterlife and miracles?What are your beliefs about the afterlife and miracles? Adapted from:Adapted from: Zoucha, R. (2000). The keys to culturally sensitive care. American Journal of Nursing, 100(2),Zoucha, R. (2000). The keys to culturally sensitive care. American Journal of Nursing, 100(2), 24GG-24II. Reprinted with permission.24GG-24II. Reprinted with permission.

7. EELLNNEECC Geriatric Curriculum Which factor should NOT be considered when assessing the cultural beliefs and practices related to death and dying? 1. 1.how long the client has been in this country 2. 2.the age of the client and family members 3. 3.aspects of spirituality, traditions, rites and rituals 4. 4.specific beliefs about pain, suffering and death

8. EELLNNEECC Geriatric Curriculum Name that Culture! Group Activity Hispanic/LatinoHispanic/Latino African AmericanAfrican American IndianIndian HaitianHaitian JamaicanJamaican RussianRussian VietnameseVietnamese Judaism & IslamJudaism & Islam

9. EELLNNEECC Geriatric Curriculum The palliative care team is caring for a client from Cambodia who has terminal lung cancer. The client does not want to discuss the illness. What should the healthcare worker do? 1. 1.Remind the client that it is important to talk about the illness. 2. 2.Allow the client to remain in denial by not discussing the cancer. 3. 3.Ask the family about their beliefs regarding full disclosure. 4. 4.Refer the client to a mental health professional for evaluation.

10. EELLNNEECC Geriatric Curriculum How has culture influenced your care of dying patients?

11. EELLNNEECC Geriatric Curriculum Cultural Values of the American Health Care System Truth-tellingTruth-telling Patient autonomyPatient autonomy Personal controlPersonal control

12. EELLNNEECC Geriatric Curriculum Group Activity: American views on death Group Activity: American views on death

13. EELLNNEECC Geriatric Curriculum Values in Non-European American Cultures Interdependence, especially among family members, rather than a focus on individual autonomyInterdependence, especially among family members, rather than a focus on individual autonomy Respectful communicationRespectful communication Trust, rather than controlTrust, rather than control

14. EELLNNEECC Geriatric Curriculum Cultural Assessment at the End of Life Communication stylesCommunication styles Decision-makingDecision-making Death ritualsDeath rituals Religious beliefsReligious beliefs Gender /ageGender /age Historical or political factorsHistorical or political factors Community resourcesCommunity resources Lipson & Dibble, 2005; Mazanec & Panke, 2010

15. EELLNNEECC Geriatric Curriculum The healthcare team is teaching a student how to perform a cultural assessment for clients at the end of life. Which of the following statements shows the student understands? 1.“The best strategy for evaluating sexual orientation is to ask clients if they are heterosexual or homosexual.” 2.“To assess spirituality, questions regarding religious affiliation and religious practices are generally sufficient.” 3.“Financial status is an invasive question and should be asked by the social worker.” 4.“Ethnic identity varies within ethnic groups, so ask clients how strongly they identify with a particular group.”

16. EELLNNEECC Geriatric Curriculum When talking to persons of another culture, the healthcare worker should: 1. 1.use the person’s first name to establish warm rapport 2. 2.determine who makes decisions for the client and family 3. 3.speak primarily to the translator rather than the client or family 4. 4.act as if the client is fully informed of the diagnosis and prognosis

17. EELLNNEECC Geriatric Curriculum Culturally Sensitive Care: General Approaches KnowledgeKnowledge Careful assessment without stereotypingCareful assessment without stereotyping Respect for diverse beliefs and practicesRespect for diverse beliefs and practices Understanding and honoring one’s own valuesUnderstanding and honoring one’s own values

18. EELLNNEECC Geriatric Curriculum Which remark by a palliative care team member shows culturally sensitive end of life care? 1. 1.“I ask the client who he wants to include in conversations about his illness.” 2. 2.“I hold the client’s hand and get physically close to her to show I care.” 3. 3.“I can predict how members of a particular ethnic group will respond to pain.” 4. 4.“I feel it’s our obligation to tell a patient bad news, even if the family objects."

19. EELLNNEECC Geriatric Curriculum Spiritual Considerations

20. EELLNNEECC Geriatric Curriculum A 48-year-old woman recently diagnosed with breast cancer is married and has 3 small children. When is the best time to begin a spiritual assessment? 1.when the patient enters the health care system 2.after chemotherapy is started 3.once the patient asks for spiritual support 4.as soon as the client begins to deteriorate

21. EELLNNEECC Geriatric Curriculum Spiritual Assessment Key Assessment AreasKey Assessment Areas Concept of God or deity Concept of God or deity Sources of hope and strength Sources of hope and strength Important religious practices Important religious practices Relationship between spiritual beliefs and health Relationship between spiritual beliefs and health Sample questionSample question Is religion or God significant to you? Can you describe how?Is religion or God significant to you? Can you describe how? Who do you turn to when you need help? Are they available?Who do you turn to when you need help? Are they available? Are any religious practices important to you?Are any religious practices important to you? Has being sick made any difference in your feelings about God or the practice of your faith?Has being sick made any difference in your feelings about God or the practice of your faith?

22. EELLNNEECC Geriatric Curriculum Spirituality Central idea that defines life’s meaning and purpose Central idea that defines life’s meaning and purpose Feeling of connectedness with oneself, others, nature, God Feeling of connectedness with oneself, others, nature, God Allows people to transcend suffering and despair Allows people to transcend suffering and despair

23. EELLNNEECC Geriatric Curriculum Religion Expression of one’s spirituality through organized, codified beliefs and practicesExpression of one’s spirituality through organized, codified beliefs and practices People can be spiritual without being religiousPeople can be spiritual without being religious Religious beliefs can influence EOL treatment decisions.

24. EELLNNEECC Geriatric Curriculum Group Activity

25. EELLNNEECC Geriatric Curriculum Spiritual Assessment -FICA FaithFaith ImportanceImportance or Influence or Influence CommunityCommunity AddressAddress

26. EELLNNEECC Geriatric Curriculum During a spiritual assessment, which question shows the healthcare workers bias? 1. 1. “What church do you attend?” 2. 2.“Are spiritual beliefs important in your life?" 3. 3.“What aspect of your faith gives your life most meaning?” 4. 4.“How would you like me to address spirituality in your care?”

27. EELLNNEECC Geriatric Curriculum Spiritual Interventions Therapeutic presenceTherapeutic presence Compassion without exhaustionCompassion without exhaustion Prayer, spiritual readings, spiritual ritualsPrayer, spiritual readings, spiritual rituals Opportunities for life reviewOpportunities for life review

28. EELLNNEECC Geriatric Curriculum Life Review: Seeking Meaning in Life and Death Encourages a person to review his/her life, and come to grips with the good and badEncourages a person to review his/her life, and come to grips with the good and bad Confirms the uniquenessConfirms the uniqueness of each person’s life of each person’s life through story-telling through story-telling

29. EELLNNEECC Geriatric Curriculum Life Review:*ACTIVITY* What is the legacy of your life?What is the legacy of your life? What gives you greatest joy in your life?What gives you greatest joy in your life? What regrets do you have?What regrets do you have? Coming to grips with the good and the bad.

30. EELLNNEECC Geriatric Curriculum Spiritual Interventions Encouraging patients toEncouraging patients to use their spiritual use their spiritual strengths strengths Making referrals to chaplains and otherMaking referrals to chaplains and other spiritual caregivers spiritual caregivers

31. EELLNNEECC Geriatric Curriculum The Role of Chaplains and Other Spiritual Caregivers in EOL Care Consistent presence Consistent presence Assisting in meaning-making Assisting in meaning-making Encourage reconciliation Encourage reconciliation Support at death Support at death Follow-up after death Follow-up after death

32. EELLNNEECC Geriatric Curriculum Summary Culture and spirituality are essential parts of EOL care. They can be viewed as barriers or opportunities. Supporting the dying person and family by accepting them and being present can help relieve suffering and bring peace at EOL. Culture and spirituality are essential parts of EOL care. They can be viewed as barriers or opportunities. Supporting the dying person and family by accepting them and being present can help relieve suffering and bring peace at EOL.

33. EELLNNEECC Geriatric Curriculum References City of Hope & the American Association of Colleges of Nursing, 2007; Revised, 2010. The End-of-Life Nursing Education Consortium (ELNEC)- Geriatric Training Program and Curriculum is a project of the City of Hope (Betty R. Ferrell, PhD, FAAN, Principal Investigator) in collaboration with the American Association of Colleges of Nursing (Pam Malloy, RN, MN, OCN, Co-Investigator). D.J. Wilkie & TNEEL Investigators, 2001. Toolkit for Nursing Excellence at End of Life Transition, version 1.0. Cancer Pain & Symptom Management Nursing Research Group; University of Washington. Supported by DHHS/HRSA/BHPR/Division of Nursing Grant # D62HP06858