how to end an essay about cultural differences

How to Write an Essay About Cultural Differences

How to Write Research Papers From Start to Finish

Starting your cultural differences essay can be a challenging undertaking. After all, the traditions and social expectations of any culture are so broad that it can be difficult to find a starting point. Choosing a specific aspect of two cultures to research narrows down the topic, leaving you one or two issues to focus on in detail.

Pick Your Topic

When writing an essay on cultural differences, the first question to address is which cultures to write about. The assignment you are given may ask you to compare and contrast two different cultures, or to compare your own culture to a culture with which you are unfamiliar. Pick a culture you are interested in, within the constraints of your assignment. This could be a culture that exists side by side with yours in your town or city, or a culture that exists on the other side of the world. If you are already partially familiar with that culture, pick an aspect of the culture you would like to know more about to ensure that you are engaged in your research.

Conduct Your Research

An encyclopedia may be a good place to begin your search. While an encyclopedia does not go in-depth into the particulars of a culture, it provides a general picture of topics you might want to investigate. These reference books often direct you to more specific references on your topic of interest, such as books, journal articles and online sources. You are likely to find, for example, a variety of sources about different levels of formality expectations in two cultures.

While doing your research, try to note whenever an aspect of a culture strikes you as strange, and ask yourself whether it is a bias based on your own assumptions. This is especially important if you are writing about the differences between your culture and another culture; you do not want your biases to creep into your writing. If possible, interview a member of the culture you are studying to get input on perceived differences.

Structure Your Paper

The next step is writing a thesis statement -- a sentence that expresses the argument of your paper. Since you are writing about a cultural difference, your thesis statement should mention what difference you want to highlight or explain in your paper. For example, if you are an American comparing your social norms of privacy to those of British culture, your thesis statement might go like this:

"The differences in British and Americans standards of privacy are evident in each culture's approach to personal openness and humor."

Once you have your thesis statement, you can plan out the rest of your paper. Outline paragraphs that compare and contrast the two cultures in regard to the issues stated in your thesis. Describe and explore similarities and differences. If possible, provide an explanation for what about the two cultures causes the differences to exist.

Write Your Paper

Begin your paper with an introduction paragraph that includes your thesis statement and additional sentences that define specific topics your paper addresses. Think of your introduction as a way of letting your reader know the topics your paper will cover. Following a well-argued body with strong supporting examples, end your essay with a conclusion paragraph that restates your thesis and the most important points of your cultural comparisons. Ensure that you cite your sources according to the style guide requested by your instructor.

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Jon Zamboni began writing professionally in 2010. He has previously written for The Spiritual Herald, an urban health care and religious issues newspaper based in New York City, and online music magazine eBurban. Zamboni has a Bachelor of Arts in religious studies from Wesleyan University.

15 Cultural Differences Examples

Examples of cultural differences include differences in values, norms , beliefs, mores , rituals , mannerisms, and expressions between different societies.

We can also identify cultural differences in eating and drinking habits, religious beliefs, moral beliefs, rituals, time management, sanitation, greeting, gift giving, exchange, conformity , rebelliousness, sports, language, work ethic , marriage, and so on can all be cultural.

It is common to apply Hofstede’s cultural dimensions theory to analyze different dimensions of cultures (Hofstede, 2011).

Cultural Differences Examples

• Kinship – Kinship principles generally form the basis of societal organization. Families consisting of at least one parent and one child are customary in all societies, but there are many differences beyond this.
• Marriage – Marriage and families seem to be human universals, but there is significant variability in customs related to these aspects of social life.
• Sexuality – Interestingly enough, societies vary significantly in the degree to which they encourage or discourage intimacy and its different forms at different stages of life.
• Art – Virtually all societies have some forms of art. Visual art, music, song, dance, literature, etc. of different cultures vary significantly.
• Religion – Religious beliefs and practices are features of all known societies, but they vary significantly between cultures.
• Gender – Categorizing children into the binary categories of female and male is fairly common, but there is significant cultural variability in the toleration of switching categories and the number of genders .
• Sports – Games and sports seem to be human universals, but the types of games and sports played by different cultures vary.
• Dwellings – Different societies, often due to environmental as well as cultural reasons, have very different types of houses or dwellings.
• Celebrations – Cultural celebrations in different cultures include New Years Eve, Chinese new year, birthdays, and Diwali.
• Cultural taboos – While there are some universal taboos, you’ll also notice that some cultures consider certain things you consider ‘normal’ to be very much taboo! For example, some cultures encourage eye contact while other cultures find it offensive.
• Rites of passage – Rites of passage can include the walkabout in Indigenous Australian culture, baptisms in Christianity, school graduation ceremonies, and so forth.
• Worldviews – In broad strokes, Western nations like the modern United States have had a strong history of individualism , while Indigenous cultures often embrace communalism and stewardship of nature.
• Dress codes – When you travel the world, you quickly learn that some cultures encourage conservative dress, such as covering your shoulders and knees in public.
• Food and eating habits ( foodways ) – This includes not only what you eat, but when. Go to Spain, for example, and learn all about very late dinners!
• Educational methods – In 21 st Century Western nations, we are accustomed to formal education in classrooms and standardized testing. But go to Indigenous Australian communities, and we can see that they have their own learning styles heavily reliant on story sharing, symbolism, and non-verbal cues.

Thought Bubble: Are We Really All That Different?

Some anthropologists and biologists have argued against the empirical assumption that cultures are as variable as we might think.

These anthropologists argue that there are cultural universals – concepts that unite all cultures.

Kinship, mourning, birth, the experience of empathy and sympathy, fear, concepts of luck, the use of grammar, exchange, cooperation, competition, aggression, reciprocity, and the biological needs, are some of the constant elements of human experience that go against the assumption that world cultures are fundamentally different (Brown 2004).

Common Categories of Cultural Difference

Unlike many other mammals, human adults rarely live alone. Families are the basic building blocks of any society.

How big these families are and how they are composed varies significantly between cultures.

Consider this example: you are a parent worried about your children no longer living with you when you’re too old for productive work. Some children will grow up and get married. Once they’re married, some children will have to stop living with their parents.

It is, therefore, necessary to decide who lives where. Rules that determine this are called marital residence rules. They differ significantly between cultures (Ember, 2022).

The two most common marital residence rules specify the gender expected to stay and the one expected to leave. When the rule states that the daughter must stay and her husband must move to where her family resides, it is called a matrilocal residence rule.

The inverse is called a patrilocal residence rule. These account for around 85% of the cases social scientists know about, but patrilocal residence is far more common among cultures.

2. Marriage

Different cultures have varying rules for how many people one can be married to simultaneously, what kind of marriage partner one is allowed, and so on.

In virtually all societies known to social scientists today, it is prohibited to marry one’s brother, sister, or parent. Most societies extend this to include the entire kin group.

There are, however, significant cultural differences regarding community exogamy/endogamy, cousin marriage, arranged marriage, polygyny/polyandry, and so on (Ember, 2021).

Let’s take the example of community exogamy and endogamy. Community exogamy refers to marriage with a spouse from another community. Endogamy refers to marriage within the community.

The most common rule is to allow marriage both within and outside of the community, as it is accepted in, for example, European countries. Community exogamy occurs in around 33% of the world’s societies, while endogamy occurs in 7.5% (Kirby et al., 2016).

Another example of cultural variation can be observed in rules concerning the toleration of cousin marriage. Some societies, like the Selk’nam of Tierra del Fuego, are averse to marriage between related people (Gusinde, 1931). Others, like the Komachi of southern Iran, prefer being married to their kin (Bradburd, 1990, p. 115).

There are interesting differences regarding the arts of different cultures that can be seen through analysis.

For example, since egalitarian societies tend to value sameness and stratified societies tend to value hierarchies, the art of egalitarian societies will often contain more repetition than the art of stratified ones (Fischer, 1961).

4. Religion

Religious beliefs and practices vary significantly from culture to culture and change over time.

Different societies have different gods, spirits, types of rituals , and supernatural forces.

Religion itself appears to be common across many cultures, but the specifics are not. According to Émile Durkheim and his followers, religion is the glue that holds societies together (Atran & Henrich, 2010).

The vast body of research conducted by social scientists about human societies and cultures allows us to find, compare, and analyze human cultural universals and differences. If there are different cultures, there are differences between them. It is the task of social scientists to research those differences.

Atran, S., & Henrich, J. (2010). The Evolution of Religion: How Cognitive By-Products, Adaptive Learning Heuristics, Ritual Displays, and Group Competition Generate Deep Commitments to Prosocial Religions. Biological Theory , 5 (1), 18–30. https://doi.org/10.1162/BIOT_a_00018

Baghramian, M., & Carter, J. A. (2022). Relativism. In E. N. Zalta (Ed.), The Stanford Encyclopedia of Philosophy (Spring 2022). Metaphysics Research Lab, Stanford University. https://plato.stanford.edu/archives/spr2022/entries/relativism/

Boas, F. (1940). Race, Language, and Culture . University of Chicago Press.

Bradburd, D. (1990). Ambiguous relations: Kin, class, and conflict among Komachi pastoralists . Smithsonian Institution Press. http://books.google.com/books?id=mgRuAAAAMAAJ

Broude, G. J. (1980). Extramarital Sex Norms in Cross-Cultural Perspective. Behavior Science Research , 15 (3), 181–218. https://doi.org/10.1177/106939718001500302

Broude, G. J. (2004). Sexual Attitudes and Practices. In C. R. Ember & M. Ember (Eds.), Encyclopedia of Sex and Gender: Men and Women in the World’s Cultures Volume I: Topics and Cultures A-K Volume II: Cultures L-Z (pp. 177–186). Springer US. https://doi.org/10.1007/0-387-29907-6_18

Brown, D. E. (2004). Human universals, human nature & human culture. Daedalus , 133 (4), 47–54. https://doi.org/10.1162/0011526042365645

Ember, C. R. (2019). Sexuality . https://hraf.yale.edu/ehc/summaries/sexuality

Ember, C. R. (2021). Marriage and Family . https://hraf.yale.edu/ehc/summaries/marriage-and-family

Ember, C. R. (2022). Residence and Kinship . https://hraf.yale.edu/ehc/summaries/residence-and-kinship

Fischer, J. L. (1961). Art Styles as Cultural Cognitive Maps1. American Anthropologist , 63 (1), 79–93. https://doi.org/10.1525/aa.1961.63.1.02a00050

Gusinde, M. (1931). The Fireland Indians: Vol. 1. The Selk’nam, on the life and thought of a hunting people of the Great Island of Tierra del Fuego . https://ehrafworldcultures.yale.edu/cultures/sh04/documents/001

Hofstede, G. (2011). Dimensionalizing Cultures: The Hofstede Model in Context. Online Readings in Psychology and Culture , 2 (1). https://doi.org/10.9707/2307-0919.1014

Kirby, K. R., Gray, R. D., Greenhill, S. J., Jordan, F. M., Gomes-Ng, S., Bibiko, H.-J., Blasi, D. E., Botero, C. A., Bowern, C., Ember, C. R., Leehr, D., Low, B. S., McCarter, J., Divale, W., & Gavin, M. C. (2016). D-PLACE: A Global Database of Cultural, Linguistic and Environmental Diversity. PLOS ONE , 11 (7), e0158391. https://doi.org/10.1371/journal.pone.0158391

Lenard, P. T. (2020). Culture. In E. N. Zalta (Ed.), The Stanford Encyclopedia of Philosophy (Winter 2020). Metaphysics Research Lab, Stanford University. https://plato.stanford.edu/archives/win2020/entries/culture/

van de Vijver, F. (2009). Types of Comparative Studies in Cross-Cultural Psychology . Online Readings in Psychology and Culture , 2 (2). https://doi.org/10.9707/2307-0919.1017

Tio Gabunia (B.Arch, M.Arch)

Tio Gabunia is an academic writer and architect based in Tbilisi. He has studied architecture, design, and urban planning at the Georgian Technical University and the University of Lisbon. He has worked in these fields in Georgia, Portugal, and France. Most of Tio’s writings concern philosophy. Other writings include architecture, sociology, urban planning, and economics.

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Chris Drew (PhD)

This article was peer-reviewed and edited by Chris Drew (PhD). The review process on Helpful Professor involves having a PhD level expert fact check, edit, and contribute to articles. Reviewers ensure all content reflects expert academic consensus and is backed up with reference to academic studies. Dr. Drew has published over 20 academic articles in scholarly journals. He is the former editor of the Journal of Learning Development in Higher Education and holds a PhD in Education from ACU.

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Navigating Cultural Differences: Overcoming Challenges and Building Collaboration

• August 14, 2023
• Teamwork & Collaboration

One potential objection to the notion of navigating cultural differences and building collaboration is the complexity and challenges inherent in such endeavors. Cultural conflicts can impede effective teamwork, hinder communication, erode trust, and limit opportunities for growth. However, by developing cultural intelligence, empathy, and open-mindedness, individuals and teams can overcome these obstacles. This article aims to explore strategies for managing cultural conflicts, leveraging diversity, and fostering a collaborative culture that enhances decision-making and creates an inclusive work environment.

Table of Contents

Key Takeaways

• Cultural differences on global teams can be complex and contradictory.
• Cultural conflicts can lead to misunderstandings and communication breakdowns.
• Strategies for managing cultural conflicts include fostering inclusivity and respect, encouraging open dialogue and active listening, providing cultural awareness training, and building cross-cultural relationships.
• Leveraging cultural diversity can enhance creativity, innovation, problem-solving abilities, and decision-making, while creating a positive and inclusive work environment.

Understanding the Complexity of Cultural Differences

The complexity of cultural differences on global teams can pose challenges that require understanding and adaptation to foster effective collaboration. Navigating cultural complexities involves uncovering hidden differences that may not be immediately apparent. These differences can include communication styles, decision-making processes, and approaches to conflict resolution. Cultural adaptation is a crucial aspect of navigating these complexities, as it involves striking a balance between assimilation and preservation. Team members must be able to adapt to the cultural norms and values of the team while also preserving their own cultural identities. This requires a high level of cultural intelligence, which encompasses awareness, knowledge, and skills to navigate and bridge cultural gaps. By understanding and adapting to cultural differences, global teams can overcome challenges and work together more effectively.

Overcoming Surprising Cultural Challenges

Surprising cultural challenges can be addressed by developing cultural intelligence and fostering empathy and open-mindedness. Navigating these challenges is essential for overcoming cultural barriers and promoting effective collaboration. When cultural differences are unexpected, they can lead to misunderstandings, communication breakdowns, and hinder productivity on global teams. Resolving these conflicts requires effective communication and conflict resolution skills. Strategies for managing cultural conflicts include fostering a culture of inclusivity and respect for diversity, encouraging open dialogue and active listening, providing cultural awareness training, establishing clear communication channels, and building cross-cultural relationships. Leveraging cultural diversity can bring a variety of perspectives and ideas to the team, enhance creativity and problem-solving abilities, and lead to better decision-making and business outcomes. Building a culture of collaboration involves fostering trust, respect, and teamwork, promoting cross-cultural learning and knowledge sharing, and recognizing and celebrating the contributions of individuals from different cultures.

The Importance of Cultural Intelligence

Understanding the importance of cultural intelligence is crucial for effective collaboration and navigating the complexities of diverse global teams. Cultural intelligence refers to the ability to adapt to different cultural contexts and interact effectively with individuals from diverse backgrounds. It involves being aware of and sensitive to cultural differences, as well as possessing the knowledge and skills to navigate through them. Cultural adaptability and cultural sensitivity training are essential components of developing cultural intelligence.

• Cultural adaptability: Developing the ability to adapt one’s behaviors, communication styles, and problem-solving approaches to suit different cultural contexts.
• Cultural sensitivity training: Providing team members with the knowledge and skills necessary to understand and appreciate cultural differences, as well as to navigate potential cultural conflicts.

Developing Empathy and Open-Mindedness

Developing empathy and open-mindedness facilitates a deeper understanding and appreciation of diverse cultural perspectives. In diverse teams, it is crucial to foster these qualities to navigate cultural differences effectively. Empathy involves putting oneself in another’s shoes, understanding their emotions, and responding with sensitivity. It allows team members to connect on a deeper level and build trust, which is essential for effective collaboration. Open-mindedness, on the other hand, involves being receptive to different ideas, beliefs, and perspectives. It encourages individuals to challenge their own assumptions and biases, leading to more inclusive decision-making processes. In multicultural environments, fostering open-mindedness is particularly important as it allows team members to embrace diversity and respect different cultural norms and values. By developing empathy and open-mindedness, teams can navigate cultural differences with greater ease, fostering a more inclusive and productive work environment.

Impact of Cultural Conflicts on Collaboration

Cultural conflicts can disrupt effective communication and hinder productivity on global teams, leading to missed opportunities and negative outcomes. The impact of cultural conflicts on team dynamics is significant and can have far-reaching consequences. These conflicts arise due to various causes, such as differences in communication styles, values, and norms, as well as misunderstandings and stereotypes. When cultural conflicts occur within a team, they can result in misunderstandings and breakdowns in communication. This can lead to tension, mistrust, and resentment among team members, ultimately hindering collaboration and productivity. Moreover, cultural conflicts may also result in missed opportunities and failed projects. Resolving these conflicts requires effective communication and conflict resolution skills, as well as a willingness to understand and appreciate different cultural perspectives. By addressing cultural conflicts and fostering a positive work environment, teams can overcome these challenges and achieve successful collaboration.

Communication Breakdowns and Mistrust

Communication breakdowns and mistrust can arise in global teams due to cultural conflicts, hindering effective collaboration and productivity. Cultural differences can create communication barriers, such as language barriers, different communication styles, and non-verbal cues that may be misinterpreted. These barriers can lead to misunderstandings, miscommunication, and a lack of trust among team members. Fostering trust is crucial in overcoming these communication barriers. It requires creating an environment that promotes open and honest communication, active listening, and respect for different perspectives. Building trust also involves acknowledging and addressing cultural differences, providing cultural sensitivity training, and encouraging cross-cultural learning and understanding. By fostering trust and effectively managing communication barriers, global teams can enhance collaboration and productivity, leading to successful outcomes.

Resolving Cultural Conflicts Effectively

In order to navigate cultural differences and overcome challenges in global teams, it is essential to address and resolve cultural conflicts effectively. Cultural conflicts can lead to misunderstandings, communication breakdowns, and hinder collaboration and productivity. Resolving these conflicts requires effective communication and conflict resolution skills. Here are three strategies to effectively resolve cultural conflicts:

Foster open and effective communication: Encourage team members to express their thoughts and concerns openly, and create a safe space for dialogue. Active listening and empathy are key in understanding different perspectives and finding common ground.

Develop conflict resolution skills: Provide training and resources on conflict resolution techniques and strategies. This includes negotiation, mediation, and compromise to find mutually beneficial solutions.

Promote cultural intelligence: Foster an environment that values and embraces cultural differences. This includes promoting cultural awareness, sensitivity, and understanding among team members.

Strategies for Managing Cultural Differences

Establishing a culture of inclusivity and respect for diversity is an effective approach in managing and bridging gaps caused by varying cultural backgrounds. One strategy for managing cultural differences is to provide cultural sensitivity training for team members. This training helps individuals develop the knowledge and skills necessary to navigate and understand different cultural norms, values, and communication styles. By fostering an environment that promotes cultural sensitivity, organizations can create an inclusive workplace where individuals feel valued and respected. Additionally, fostering inclusive environments involves creating policies and practices that support diversity and inclusion, such as implementing non-discriminatory hiring practices and providing support systems for individuals from different cultural backgrounds. These strategies help to create a cohesive and collaborative work environment where everyone can contribute their unique perspectives and talents towards achieving common goals.

Leveraging Cultural Diversity for Success

Leveraging cultural diversity on global teams can result in improved decision-making, enhanced creativity, and a broader understanding of global markets and customers. To foster creativity and embrace inclusivity, organizations should consider the following:

Encourage a collaborative and inclusive work environment: By creating a culture that values diversity and promotes inclusivity, individuals from different cultural backgrounds are more likely to contribute their unique perspectives and ideas. This can lead to increased creativity and innovation within the team.

Emphasize the importance of diverse perspectives: Recognizing and valuing the different viewpoints that cultural diversity brings can enhance problem-solving abilities and lead to better decision-making. By embracing these diverse perspectives, teams can gain a deeper understanding of global markets and customers, enabling them to tailor their strategies accordingly.

Provide opportunities for cross-cultural learning and collaboration: By facilitating interactions and knowledge sharing among team members from different cultural backgrounds, organizations can bridge cultural gaps and foster a collaborative environment. This can further enhance creativity and overall team performance.

Building a Collaborative Culture Across Cultures

Developing a culture of trust and respect is essential for fostering effective collaboration across diverse cultural backgrounds. Building a collaborative culture across cultures requires promoting inclusivity and cross-cultural teamwork. To achieve this, it is crucial to create an environment where team members feel valued and respected regardless of their cultural background. Encouraging open dialogue and active listening can help in understanding different perspectives and resolving conflicts. Providing cultural awareness and sensitivity training equips team members with the necessary skills to navigate cultural differences. Establishing clear communication channels and guidelines for conflict resolution promotes effective communication and reduces misunderstandings. Additionally, team-building activities can help bridge cultural gaps and promote collaboration. Recognizing and celebrating the contributions of individuals from different cultures further enhances a collaborative culture. By actively promoting inclusivity and cross-cultural teamwork, organizations can harness the benefits of cultural diversity and achieve successful collaboration.

Frequently Asked Questions

How do cultural differences impact global teams.

Cultural differences impact global teams by introducing complexity and contradictions. They can lead to misunderstandings, communication breakdowns, tension, mistrust, and missed opportunities. Managing cultural clashes requires understanding nuances and fostering inclusivity, open dialogue, and cross-cultural relationships.

What Are Some Common Misunderstandings That Can Arise From Cultural Conflicts?

Common misunderstandings arising from cultural conflicts include misinterpretation of nonverbal cues, differences in communication styles, and assumptions based on stereotypes. Cultural sensitivity and effective cross-cultural communication can help address these misunderstandings.

How Can Effective Communication Help in Resolving Cultural Conflicts?

Effective communication, through open dialogue and active listening, is crucial in resolving cultural conflicts. It helps to build bridges between individuals by fostering cultural sensitivity, understanding different perspectives, and finding common ground for collaboration.

What Are Some Strategies for Fostering Inclusivity and Respect for Diversity?

Creating empathy and promoting cultural awareness are effective strategies for fostering inclusivity and respect for diversity. These approaches encourage understanding and appreciation of different perspectives, ultimately fostering a positive and inclusive work environment.

How Does Cultural Diversity Contribute to Better Decision-Making and Business Outcomes?

Cultural diversity contributes to better decision-making and business outcomes through cultural synergy, which enhances creativity, innovation, and problem-solving abilities. It allows for a broader understanding of global markets and customers, leading to positive business growth.

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Research: How Cultural Differences Can Impact Global Teams

• Vasyl Taras,
• Dan Caprar,
• Alfredo Jiménez,
• Fabian Froese

And what managers can do to help their international teams succeed.

Diversity can be both a benefit and a challenge to virtual teams, especially those which are global. The authors unpack their recent research on how diversity works in remote teams, concluding that benefits and drawbacks can be explained by how teams manage the two facets of diversity: personal and contextual. They find that contextual diversity is key to aiding creativity, decision-making, and problem-solving, while personal diversity does not. In their study, teams with higher contextual diversity produced higher-quality consulting reports, and their solutions were more creative and innovative. When it comes to the quality of work, teams that were higher on contextual diversity performed better. Therefore, the potential challenges caused by personal diversity should be anticipated and managed, but the benefits of contextual diversity are likely to outweigh such challenges.

A recent survey of employees from 90 countries found that 89 percent of white-collar workers “at least occasionally” complete projects in global virtual teams (GVTs), where team members are dispersed around the planet and rely on online tools for communication. This is not surprising. In a globalized — not to mention socially distanced — world, online collaboration is indispensable for bringing people together.

• VT Vasyl Taras is an associate professor and the Director of the Master’s or Science in International Business program at the University of North Carolina, Greensboro, USA. He is an associate editor of the Journal of International Management and the International Journal of Cross-Cultural Management, and a founder of the X-Culture, an international business competition.
• DB Dan Baack is an expert in international marketing. Dan’s work focuses on how the processing of information or cultural models influences international business. He recently published the 2nd edition of his textbook, International Marketing, with Sage Publications. Beyond academic success, he is an active consultant and expert witness. He has testified at the state and federal level regarding marketing ethics.
• DC Dan Caprar is an Associate Professor at the University of Sydney Business School. His research, teaching, and consulting are focused on culture, identity, and leadership. Before completing his MBA and PhD as a Fulbright Scholar at the University of Iowa (USA), Dan worked in a range of consulting and managerial roles in business, NGOs, and government organizations in Romania, the UK, and the US.
• AJ Alfredo Jiménez is Associate Professor at KEDGE Business School (France). His research interests include internationalization, political risk, corruption, culture, and global virtual teams. He is a senior editor at the European Journal of International Management.
• FF Fabian Froese is Chair Professor of Human Resource Management and Asian Business at the University of Göttingen, Germany, and Editor-in-Chief of Asian Business & Management. He obtained a doctorate in International Management from the University of St. Gallen, Switzerland, and another doctorate in Sociology from Waseda University, Japan. His research interests lie in international human resource management and cross-cultural management.

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Cultural Awareness—How to Be More Culturally Aware & Improve Your Relationships

Wendy Wisner is a health and parenting writer, lactation consultant (IBCLC), and mom to two awesome sons.

Ivy Kwong, LMFT, is a psychotherapist specializing in relationships, love and intimacy, trauma and codependency, and AAPI mental health.  

The Importance of Cultural Awareness

How to be more culturally aware, what if i say the wrong thing, cultural awareness and sensitivity in intercultural/interracial relationships, can i ask someone to help me learn about their culture, pitfalls of not developing cultural awareness.

Cultural awareness, sometimes referred to as  cultural sensitivity , is defined by the NCCC (National Center for Cultural Competence) as being cognizant, observant, and conscious of the similarities and differences among and between cultural groups.

Becoming more culturally aware is a continual process and it can help to have curiosity, an open mind, a willingness to ask questions, a desire to learn about the differences that exist between cultures, and an openness to becoming conscious of one’s own culturally shaped values, beliefs, perceptions, and biases.

The Value of Cultural Awareness

Cultural awareness is important because it allows us to see and respect other perspectives and to appreciate the inherent value of people who are different than we are. It leads to better relationships, healthier work environments, and a stronger, more compassionate society.

Read on to learn more about cultural awareness, including the impacts it can have, how to become more culturally aware, how to approach conversations about cultural awareness, and how to address cultural awareness in intercultural relationships.

Cultural awareness involves learning about cultures that are different from your own. But it’s also about being respectful about these differences, says  Natalie Page  Ed.D., chief diversity officer at Saint Xavier University in Chicago. “It’s about being sensitive to the similarities and differences that can exist between different cultures and using this sensitivity to effectively communicate without prejudice and racism,” she explains.

5 Reasons Why Cultural Awareness Is Important

Here are five reasons why it’s important to become more culturally aware:

• When you strive to become more culturally aware, you gain knowledge and information about different cultures, which leads to greater cultural competence, says Dr. Page
• Engaging in cultural awareness makes you more sensitive to the differences between cultures that are different than your own, Dr. Page says; you also become less judgmental of people who are different than you.
• Studies have found that greater cultural awareness in the workplace leads to an overall better workplace culture for everyone involved.
• Research has found that cultural awareness creates better outcomes for people in healthcare environments, and in other environments where people are receiving care from others.
• According to Nika White, PhD, author of Inclusion Uncomplicated: A Transformative Guide to Simplify DEI , cultural awareness can improve your interpersonal relationships. “Just like any other relationship, you must understand their culture to truly understand someone’s lived experiences and how they show up to the world,” Dr. White describes.

Knowing about the importance of being more culturally aware is one thing, but actually taking steps to do so is something else.

It’s about being sensitive to the similarities and differences that can exist between different cultures and using this sensitivity to effectively communicate without prejudice and racism.

Here are a few tips for how to go about becoming more culturally aware.

Understand That It’s a Process

“Becoming culturally aware is a process that is fluid, birthed out of a desire to learn more about other cultures,” says Dr. Page.

She says it can be helpful to study the model laid out by Dr. Ibram Kendi, the author of How To Be An Antiracist . Dr. Kendi says that there are basically three paths to growing cultural awareness:

• “The first is moving from the fear zone, where you are afraid and would rather stay in your own culture comfort zone,” Dr. Page describes.
• Next is moving into the learning zone, where you strive to learn about different cultures, how people acquire their cultures, and culture's important role in personal identities, practices, and mental and physical health of individuals and communities. The learning zone can also include becoming more aware of your own culturally shaped values, beliefs, and biases and how they impact the way you see yourself and others.
• “The last phase is the growth zone, where you grow in racial advocacy and allyship,” says Dr. Page.

Ask Questions

Dr. White says that asking questions is a vital part of becoming more culturally aware. You can start by asking yourself some important questions, such as: “How is my culture affecting how I interact with and perceive others?” Dr. White suggests.

You can also respectfully ask others about their lives. But make sure the exchanges aren’t one-sided, she recommends: when you ask others about their cultures, tell them about yours, too. “Tell your own stories to engage, build relationships, find common ground, and become more culturally aware of someone from a different culture,” she says.

Educate Yourself and Do the Work

There’s no way around it: if you want to become more culturally aware, you need to take action and educate yourself.

“Don’t lean on assumptions,” says Dr. White. “Actually research cultures different from yours.” This can help you become more aware of how culture affects every aspect of your life and the lives of others. In addition to research, educating yourself often involves seeking and participating in meaningful interactions with people of differing cultural backgrounds. “Expand your network to include people from different cultures into your circle,” Dr. White recommends.

Study the Cultural Competence Continuum Model

The Cultural Competence Continuum Model is an assessment tool that helps us understand where people are on their journey to becoming more culturally competent.

Different people fall into various categories along the continuum. Categories include cultural destructiveness, cultural incapacity, cultural blindness, cultural pre-competence, cultural competence, and cultural proficiency.

Studying this model can help us become more aware of the process of moving toward more cultural sensitivity, and become more patient with ourselves and others as we move through the process.

Acknowledge Your Own Bias

We all have our own biases when it comes to cultural awareness, because we all begin by looking at the world and at others through our own cultural lens.

It is important to acknowledge this as it can help us see how our cultural  biases  may prevent us from being as culturally sensitive as we wish to be.

Often, people don’t want to address topics having to do with culture or race because they are afraid they will say the wrong thing or make a mistake while talking to someone.

The truth is, most people make mistakes on their journey toward cultural awareness, and that’s understandable, says Dr. Page.

“If you make a mistake, simply apologize and let the person that you may have offended know that you are learning and be open to any suggestions they may have,” she recommends. Sometimes it even makes sense to apologize in advance, if you are saying something you are unsure of. You can say, “I may have this wrong, so I apologize beforehand but…” Dr. Page suggests. “The key is to be sincere in your conversations and always open to learning from others,” she says.

Making mistakes is a necessary part of the learning process and it is important to approach these topics and conversations with shared respect, compassion, and grace.

If you are in a relationship with someone who is of a different race or culture than you, it’s important to have open, honest discussions about this. “If a person is going to grow in interracial and intercultural relationships, you have to step out of your cultural comfort zone and seek an understanding about other cultures,” says Dr. Page.

Questions to Ask Someone to Learn About Their Culture

Having a genuine discussion with someone about your differences can feel awkward, and it can be helpful to kick-start the conversation with a few open-ended questions. Dr. White shared some helpful questions:

• Can you tell me about your culture?
• Tell me a little something about how you were raised?
• What role does religion play in your life?

Here are some additional questions that could be asked with respect and consent, to another (and also to yourself!):

• What holidays and celebrations are important in your culture?
• What customs and etiquette are important in your culture?
• What is your favorite food in your culture?
• Is religion an important part of life in your culture? If so, what religion do people practice most often and why do you think that is?
• How do you express your cultural identity?
• What stereotypes or misconceptions do people from your culture often face and what do you wish more people knew?
• Is there anything about your culture that you find challenging?
• How has your culture changed over time?
• How do you think your culture has influenced your personal values and beliefs?
• What is the importance of family in your culture?

One of the important ways to develop culture awareness is to educate yourself about other cultures. Learning directly from people of different cultures is a fantastic way to get authentic information. But it’s important to engage in conversations with others about their cultures in respectful , appropriate manners.

When you decide to ask others about their culture, be mindful that they may not want to answer, and know that that’s okay, says Dr. White. It’s also important to make the conversation a two-way street. Don’t just ask them about their culture—talk about your culture as well. “Share your culture first to model the behavior and let others know it is safe to talk about their culture,” Dr. White suggests.

Finally, make sure to take it upon yourself to do some of the work. “Once you learn of someone’s culture you wish to cultivate a relationship with, do your homework to learn as much as you can,” Dr. White says. Don't simply rely on others to educate you—this may be seen as insensitive, Dr. White says.

The main pitfalls of not developing cultural awareness is that we don’t expand our understanding of other cultures, we don’t deepen our relationship with people who are different than we are, and that we risk continuing to have a narrow view of the world around us. 

“We live in an ever-changing diverse world,” Dr. Page says. “We rob ourselves when we only hang out with people from our cultural groups. We have to branch out and experience the beauty that others bring.”

Angelis T. In search of cultural competence . Monitor on Psychology. 2015;46(3):64.

Shepherd SM, Willis-Esqueda C, Newton D, et al. The challenge of cultural competence in the workplace: perspectives of healthcare providers . BMC Health Services Research. 2019;19:135. doi:10.1186/s12913-019-3959-7

Kaihlanen AM., Hietapakka L, Heponiemi T. Increasing cultural awareness: qualitative study of nurses’ perceptions about cultural competence training . BMC Nursing. 2019;18(38). doi:10.1186/s12912-019-0363-x

Calkins H. How You Can Be More Culturally Competent . Good Practice. 2020:13-16.

Center for Substance Abuse Treatment. Improving Cultural Competence .

By Wendy Wisner Wendy Wisner is a health and parenting writer, lactation consultant (IBCLC), and mom to two awesome sons.

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Chapter 27 Sections

• Section 1. Understanding Culture and Diversity in Building Communities
• Section 3. Healing from the Effects of Internalized Oppression
• Section 4. Strategies and Activities for Reducing Racial Prejudice and Racism
• Section 5. Learning to be an Ally for People from Diverse Groups and Backgrounds
• Section 6. Creating Opportunities for Members of Groups to Identify Their Similarities, Differences, and Assets
• Section 7. Building Culturally Competent Organizations
• Section 8. Multicultural Collaboration
• Section 9. Transforming Conflicts in Diverse Communities
• Section 10. Understanding Culture, Social Organization, and Leadership to Enhance Engagement
• Section 11. Building Inclusive Communities
• Main Section

Relationships are powerful. Our one-to-one connections with each other are the foundation for change. And building relationships with people from different cultures, often many different cultures , is key in building diverse communities that are powerful enough to achieve significant goals.

Whether you want to make sure your children get a good education, bring quality health care into your communities, or promote economic development, there is a good chance you will need to work with people from several different racial, language, ethnic, or economic groups. And in order to work with people from different cultural groups effectively, you will need to build sturdy and caring relationships based on trust, understanding, and shared goals.

Why? Because trusting relationships are the glue that hold people together as they work on a common problem. As people work on challenging problems, they will have to hang in there together when things get hard. They will have to support each other to stay with an effort, even when it feels discouraging. People will have to resist the efforts of those who use divide-and-conquer techniques--pitting one cultural group against another.

Regardless of your racial, ethnic, religious, or socioeconomic group, you will probably need to establish relationships with people whose group you may know very little about.

Each one of us is like a hub of a wheel. Each one of us can build relationships and friendships around ourselves that provide us with the necessary strength to achieve community goals. If each person builds a network of diverse and strong relationships, we can come together and solve problems that we have in common.

In this section, we are going to talk about:

• Becoming aware of your own culture as a first step in learning about other people's culture.
• Building relationships with people from many different cultures.

But first let's talk about what culture is . Culture is a complex concept, with many different definitions. But, simply put, "culture" refers to a group or community with which we share common experiences that shape the way we understand the world . It includes groups that we are born into, such as race, national origin, class, or religion. It can also include groups we join or become part of. For example, we can acquire a new culture by moving to a new region, by a change in our economic status, or by becoming disabled. When we think of culture this broadly we realize we all belong to many cultures at once. Do you agree? How might this apply to you?

How do you learn about people's cultures?

Start by becoming aware of your own culture..

It may seem odd that in order to learn about people in other cultures, we start by becoming more aware of our own culture. But we believe this is true. Why?

If you haven't had a chance to understand how your culture has affected you first hand, it's more difficult to understand how it could affect anyone else or why it might be important to them. If you are comfortable talking about your own culture, then you will become better at listening to others talk about theirs. Or, if you understand how discrimination has affected you, then you may be more aware of how it has affected others.

Here are some tips on how to becoming more aware of your own culture:

What is your culture?

Do you have a culture? Do you have more than one? What is your cultural background?

Even if you don't know who your ancestors are, you have a culture. Even if you are a mix of many cultures, you have one. Culture evolves and changes all the time. It came from your ancestors from many generations ago, and it comes from your family and community today.

In addition to the cultural groups we belong to, we also each have groups we identify with, such as being a parent, an athlete, an immigrant, a small business owner, or a wage worker. These kinds of groups, although not exactly the same as a culture, have similarities to cultural groups. For example, being a parent or and an immigrant may be an identity that influences how you view the world and how the world views you. Becoming aware of your different identities can help you understand what it might be like to belong to a cultural group.

Exercise: Try listing all the cultures and identities you have: (This is just a list of suggestions to get you started. Add as many as you think describe you.) What is your: Religion Nationality Race Sexual identity Ethnicity Occupation Marital status Age Geographic region Are you: A female A male Nonbinary or genderqueer Disabled From an urban area From a rural area A parent A student Have you ever been: In the military Poor In prison Wealthy In the middle class In the working class

Did this help you think about your identities and cultures? How have these different cultures and identities affected your life?

How do you build relationships with people from other cultures?

There are many ways that people can learn about other people's cultures and build relationships at the same time. Here are some steps you can take. They are first listed, and then elaborated upon one at a time.

• Make a conscious decision to establish friendships with people from other cultures.
• Put yourself in situations where you will meet people of other cultures.

Examine your biases about people from other cultures.

• Ask people questions about their cultures, customs, and views.
• Read about other people's culture's and histories

Listen to people tell their stories

• Notice differences in communication styles and values; don't assume that the majority's way is the right way

Risk making mistakes

• Learn to be an ally.

Make a conscious decision to establish friendships with people from other cultures

Making a decision is the first step. In order to build relationships with people different from yourself, you have to make a concerted effort to do so. There are societal forces that serve to separate us from each other. People from different economic groups, religions, ethnic groups, and races are often isolated from each other in schools, jobs, and neighborhoods. So, if we want things to be different, we need to take active steps to make them different.

You can join a sports team or club, become active in an organization, choose a job, or move to a neighborhood that puts you in contact with people of cultures different than your own. Also, you may want to take a few minutes to notice the diversity that is presently nearby. If you think about the people you see and interact with every day, you may become more aware of the cultural differences that are around you.

Once you have made the decision to make friends with people different from yourself, you can go ahead and make friends with them in much the same way as with anyone else. You may need to take more time, and you may need to be more persistent. You may need to reach out and take the initiative more than you are used to. People who have been mistreated by society may take more time to trust you than people who haven't. Don't let people discourage you. There are good reasons why people have built up defenses, but it is not impossible to overcome them and make a connection. The effort is totally worth it.

Put yourself in situations where you will meet people of other cultures; especially if you haven't had the experience of being a minority, take the risk.

One of the first and most important steps is to show up in places where you will meet people of cultures other than your own. Go to meetings and celebrations of groups whose members you want to get to know. Or hang out in restaurants and other gathering places that different cultural groups go. You may feel embarrassed or shy at first, but your efforts will pay off. People of a cultural group will notice if you take the risk of coming to one of their events. If it is difficult for you to be the only person like yourself attending, you can bring a buddy with you and support each other in making friends. At these events, it is important to participate, but make sure you do not become the center of the event in order to lift up the voices and actions of the people leading the event.

We all carry misinformation and stereotypes about people in different cultures. Especially, when we are young, we acquire this information in bits and pieces from TV, from listening to people talk, and from the culture at large. We are not bad people because we acquired this; no one requested to be misinformed. But in order to build relationships with people of different cultures, we have to become aware of the misinformation we acquired.

An excellent way to become aware of your own stereotypes is to pick groups that you generalize about and write down your opinions. Once you have, examine the thoughts that came to your mind and where you acquired them.

Another way to become aware of stereotypes is to talk about them with people who have similar cultures to your own. In such settings you can talk about the misinformation you acquired without being offensive to people from a particular group. You can get together with a friend or two and talk about how you acquired stereotypes or fears of other different people. You can answer these kinds of questions:

• How did your parents feel about different ethnic, racial, or religious groups?
• What did your parents communicate to you with their actions and words?
• Were your parents friends with people from many different groups?
• What did you learn in school about a particular group?
• Was there a lack of information about some people?
• Are there some people you shy away from? Why?

Ask people questions about their cultures, customs, and views

People, for the most part, want to be asked questions about their lives and their cultures. Many of us were told that asking questions was nosy; but if we are thoughtful, asking questions can help you learn about people of different cultures and help build relationships. People are usually pleasantly surprised when others show interest in their cultures. If you are sincere and you can listen, people will tell you a lot.

Read about other people's cultures and histories

It helps to read about and learn about people's cultures and histories. If you know something about the reality of someone's life and history, it shows that you care enough to take the time to find out about it. It also gives you background information that will make it easier to ask questions that make sense.

However, you don't have to be an expert on someone's culture to get to know them or to ask questions. People who are, themselves, from a culture are usually the best experts, anyway.

Don't forget to care and show caring

It is easy to forget that the basis of any relationship is caring. Everyone wants to care and be cared about. Caring about people is what makes a relationship real. Don't let your awkwardness around cultural differences get in the way of caring about people.

If you get an opportunity to hear someone tell you her life story first hand, you can learn a lot--and build a strong relationship at the same time. Every person has an important story to tell. Each person's story tells something about their culture.

Listening to people's stories, we can get a fuller picture of what people's lives are like--their feelings, their nuances, and the richness of their lives. Listening to people also helps us get through our numbness-- there is a real person before us, not someone who is reduced to stereotypes in the media.

Additionally, listening to members of groups that have been discriminated against can give us a better understanding of what that experience is like. Listening gives us a picture of discrimination that is more real than what we can get from reading an article or listening to the radio.

Exercise: You can informally ask people in your neighborhood or organization to tell you a part of their life stories as a member of a particular group. You can also incorporate this activity into a workshop or retreat for your group or organization. Have people each take five or ten minutes to talk about one piece of their life stories. If the group is large, you will probably have to divide into small groups, so everyone gets a chance to speak.

Notice differences in communication styles and values; don't assume that the majority's way is the right way.

We all have a tendency to assume that the way that most people do things is the acceptable, normal, or right way. As community workers, we need to learn about cultural differences in values and communication styles, and not assume that the majority way is the right way to think or behave.

Example: You are in a group discussion. Some group members don't speak up, while others dominate, filling all the silences. The more vocal members of the group become exasperated that others don't talk. It also seems that the more vocal people are those that are members of the more mainstream culture, while those who are less vocal are from minority cultures. How do we understand this? How can this be resolved? In some cultures, people feel uncomfortable with silence, so they speak to fill the silences. In other cultures, it is customary to wait for a period of silence before speaking. If there aren't any silences, people from those cultures may not ever speak. Also, members of some groups (women, people of low income, some racial and ethnic minorities, and others) don't speak up because they have received messages from society at large that their contribution is not as important as others; they have gotten into the habit of deferring their thinking to the thinking of others. When some people don't share their thinking, we all lose out. We all need the opinions and voices of those people who have traditionally been discouraged from contributing. In situations like the one described above, becoming impatient with people for not speaking is usually counter-productive. However, you can structure a meeting to encourage the quieter people to speak. For example, you can: Have people break into pairs before discussing a topic in the larger group. At certain times have each person in the circle make a comment. (People can pass if they want to.) Follow a guideline that everyone speaks once, before anyone speaks twice. Invite the quieter people to lead part of the meeting. Talk about the problem openly in a meeting, and invite the more vocal people to try to speak less often. Between meetings, ask the quieter people what would help them speak, or ask them for their ideas on how a meeting should be run. A high school basketball team has to practice and play on many afternoons and evenings. One team member is a recent immigrant whose family requires her to attend the birthday parties of all the relatives in her extended family. The coach is angry with the parents for this requirement, because it takes his player away from the team. How do we understand this? How can this be resolved? Families have different values, especially when it comes to family closeness, loyalty, and responsibility. In many immigrant and ethnic families, young people are required to put their family's needs first, before the requirements of extra-curricular activities. Young people from immigrant families who grow up in the U.S. often feel torn between the majority culture and the culture of their families; they feel pressure from each cultures to live according to its values, and they feel they have to choose between the two. As community workers, we need to support and respect minority and immigrant families and their values. It may already be a huge concession on the part of a family to allow a teenager to participate in extracurricular activities at all. We need to make allowances for the cultural differences and try to help young people feel that they can have both worlds--instead of having to reject one set of values for another. As community builders, it helps to develop relationships with parents. If a young person sees her parents have relationships with people from the mainstream culture, it can help her feel that their family is accepted. It supports the teen in being more connected to her family and her community--and also, both relationships are critical protective factors for drug and alcohol abuse and other dangerous behaviors. In addition, in building relationships with parents, we develop lines of communication, so when conflicts arise, they can be more easily resolved.

As you are building relationships with people who have different cultural backgrounds than your own, you will probably make mistakes at some point. That happens. Don't let the fear of making mistakes keep you from going ahead and building relationships.

If you say or do something that is insensitive, you can learn something from it. Ask the affected person what bothered or offended them, apologize, and then go on in building the relationship. Don't let guilt bog you down.

Learn to be an ally

One of the best ways to help you build relationships with people of different cultures is to demonstrate that you are willing to take a stand against discrimination when it occurs. People will be much more motivated to get to know you if they see that you are willing to take risks on their behalf.

We also have to educate ourselves and keep informed so that we understand the issues that each group faces and we become involved in their struggles--instead of sitting on the sidelines and watching from a distance. Educate yourself about other cultures by doing your own research, don't ask others to do it for you. There are many resources in this chapter to help you learn. 

Friendship is powerful. It is our connection to each other that gives meaning to our lives. Our caring for each other is often what motivates us to make change. And establishing connections with people from diverse backgrounds can be key in making significant changes in our communities.

As individuals, and in groups, we can change our communities. We can set up neighborhoods and institutions in which people commit themselves to working to form strong relationships and alliances with people of diverse cultures and backgrounds. We can establish networks and coalitions in which people are knowledgeable about each other's struggles, and are willing to lend a hand. Together, we can do it.

Online Resources

Brown University Training Materials :  Cultural Competence and Community Studies: Concepts and Practices for Cultural Competence  The Northeast Education Partnership provides online access to PowerPoint training slides on topics in research ethics and cultural competence in environmental research. These have been created for professionals/students in environmental sciences, health, and policy; and community-based research. If you are interested in receiving an electronic copy of one the presentations, just download their Materials Request Form (found on the main Training Presentations page under "related files"), complete the form, and email it to [email protected] .

The Center for Culturally and Linguistically Appropriate Services  collects and describes early childhood/early intervention resources and serves as point of exchange for users.

Chapter 8: Respect for Diversity in the "Introduction to Community Psychology" explains cultural humility as an approach to diversity, the dimensions of diversity, the complexity of identity, and important cultural considerations.

Culture Matters  is a cross-cultural training workbook developed by the Peace Corps to help new volunteers acquire the knowledge and skills to work successfully and respectfully in other cultures.

Diverse Teams Feel Less Comfortable — and That’s Why They Perform Better from the Harvard Business Review.

Exploring Community-led Racial Healing Models to Deepen Partnerships between Community Development and Healthcare  from the Build Healthy Places Network.

The International & Cross-Cultural Evaluation Topical Interest Group , an organization that is affiliated with the American Evaluation Association, provides evaluators who are interested in cross-cultural issues with opportunities for professional development.

The Multicultural Pavilion  offers resources and dialogue for educators, students and activists on all aspects of multicultural education.

The National Center for Cultural Competence  at Georgetown University increases the capacity of health care and mental health programs to design, implement and evaluate culturally and linguistically competent service delivery systems. Publications and web links available.

National Public Radio's Life Kit project  discusses the importance of having parents talk about social identities with their children.

SIL International makes available " The Stranger’s Eyes ," an article that speaks to cultural sensitivity with questions that can be strong tools for discussion.

Study, Discussion and Action on Issues of Race, Racism and Inclusion : a partial list of resources utilized and prepared by Yusef Mgeni.

Unpacking the Invisible Knapsack : Reflect on how your privilege allows you to walk through the world in order to better connect with others in this essay by Peggy McIntosh.

Organizations:

Center for Living Democracy 289 Fox Farm Rd PO Box 8187 Brattleboro, VT 05304-8187 (802) 254-1234

National Coalition Building Institute (NCBI) 1835 K Street, N.W., Suite 715 Washington, D.C. 20006 (202) 785-9400

Re-evaluation Counseling 719 Second Avenue North Seattle, WA 98109 (206) 284-0113

Southern Poverty Law Center 400 Washington Ave. Montgomery, AL 36104

Print Resource

Axner, D. (1993).  The Community leadership project curriculum . Pomfret, CT: Topsfield Foundation.

Banks, J. (1997).  Educating citizens in a multicultural society . New York, NY: Teachers College Press.

Brown, C.,& Mazza, G. (1997).  Healing into action . Washington, DC: National Coalition Building Institute.

DuPraw, M.,& Axner, M. (1997).  Working on common cross-cultural communication challenges . In Martha McCoy, et. al., Toward a More Perfect Union in an Age of Diversity. Pomfret, CT: Topsfield Foundation, 12-16.

Ford, C. (1994).  We can all get along: 50 steps you can take to end racism . New York, NY: Dell Publishing.

Kaye, G., & Wolff, T. (1995).  From the ground up: A workbook on coalition building and community development . Amherst, MA: AHEC/Community Partners. (Available from Tom Wolff and Associates.)

McCoy, M.,&  et al. (1997).  Toward a more perfect union in an age of diversity: A guide for building stronger communities through public dialogue . Pomfret, CT: Topsfield Foundation.

McIntosh, P. (1988).  White privilege and male privilege: A personal account of coming to see correspondences through work in women's studies . Wellesley, MA: Center for Research on Women, Wellesley College.

Okihiro, G. (1994).  Margins and mainstreams: Asians in American history and culture . Seattle, WA: The University of Washington Press.

Takaki, R. (1993).  A different mirror: A history of multicultural America . Boston: Little, Brown and Company.

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The farewell: culture’s role in how we approach end-of-life.

In the movie, The Farewell, we’re introduced to Billi—a young Chinese-American woman who is conflicted when her family refuses to tell her terminally grandmother, Nai Nai, that she is dying of lung cancer. Wanting to honor her grandmother, Billi is inclined to reveal the truth to Nai Nai but is challenged by her family who says that within Eastern culture one’s life belongs to a whole; that it is the duty of the family to protect the ailing person even if it means withholding the truth. This fascinating movie enlightens viewers as it reminds us that how we deal, discuss and engage with death/dying is deeply influenced by our culture. We are called by this movie to consider how one’s culture greatly informs the way they approach issues of end-of-life care.

Below are stories from two of The Conversation Project’s team members. In their personal narratives, they share a few thoughts about how their ethnicity and culture has played a role in how they think of, engage with and discuss end-of-life.

Naomi’s Experience as a Haitian-American Woman

Mama Bo was ninety-six years old when she passed. Full of wit and cognition before she died, she told her daughters that she did not want any extensive measures taken if her health were to severely decline. When it did, her children honored her wishes by letting the rising and lowering of her chest slowly stop on its own.

My great-aunt’s death underscored a lot of things I already knew about my Haitian family: when it came to death, we did not really have a common agreement about how to grapple with it. There were members of our family who were irate that Mama Bo’s children didn’t do “everything they could” to extend her life (i.e. taking extra medical measures to elongate her days) and there were others who believed it was the right time to let go.

What I’ve repetitively seen in my family and within my community is overly aggressive treatment given to people who are clearly living on the brink of death. While my American purview is inclined to reprimand those who view this approach as reasonable, my Haitian roots humbly remind me of an island of people who do not have easy access to quality care or healthcare at all. So, those of us who are living in the States, when given the opportunity, tap into the what seems like an endless stream of healthcare interventions.

Similar to Billi in Farewell , I am sometimes conflicted by the way my community handles the issue of death. But I also recognize that my perspective is not to be exalted as it has been refined by my hyphened identity: Haitian-American (emphasize American). Beyond my personal experiences, there are that of other’s that greatly influence how they view death and dying.

Antonella’s Experience Within Her Filipino Community

When I think about Filipino culture, it is fundamentally about storytelling. Filipinos often live in a culture of shared experiences, which makes it easier to connect in community with fellow Filipinos around the world. I first learned to treasure storytelling from my parents, who often share stories about growing up in the Philippines. These stories were my connection with a place beyond what I knew and helped me understand what I valued in life.

My dad loves to tell stories in both Tagalog and English. The stories he tells me are rich in historical context and measured emotion that come from his unique experiences as a Filipino immigrant living in America. Although I can only understand his stories in English, I can tell how warm the Philippines has been in his heart and why it was important for me and my sister to grow up as culturally-aware Filipino-Americans.

So, when I wanted to talk to my dad about death and dying, I didn’t ask him directly about it because I know it wouldn’t be a simple answer. I know that many Filipinos traditionally believe in family harmony and a life as more than one’s own. In this case, I asked him what he thought of the movie The Farewell . My dad suggested that the central lie was a sensible choice: “They’re easing the burden for her. In the East, we value family harmony, and it’s assumed that the family should keep this in mind.”

He then tells me the story about his dad, my Lolo, who passed away when I was young. “I wasn’t able to physically be there for him,” he said. “But I could feel he was there when you woke up in the middle of the night and cried for a moment.” Filipinos are superstitious, and my dad believed that this moment was when my Lolo came to say goodbye.

This was the first of many conversations we had about something as complex as the end-of-life. I have come to understand the complexities of the Filipino experience as a result of diaspora, multigenerational differences, and multicultural influence. This makes considering what my family would want at the end-of-life seem complex, but it gives me a sense of how I have chosen to live: as a part of the Filipino community.

In my Filipino-American culture, the stories we share with each other help us understand the nuanced experiences among us. The impact of culture on one’s life looks different for everyone, but it is becoming more apparent that it is important for patients, providers, families, and communities to acknowledge the importance of cultural context.

We want to hear your story. Email us: how has your culture and/or ethnicity influence the way you approach the topic of death and dying? Send us your story and it will possibly be featured in our upcoming Culture Series.

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3 Responses

As Community Engagement Manager at Hospice of Santa Barbara, I am responsible for a monthly “Learn at Lunch” presentation. this year, I am have a series of 8 presentations on “Death and Dying from Different Religious perspectives.

this article today and the comments were very timely me and it has me thinking about presentations also based on cultural traditions – although religion and culture can be intermingled.

I have not seen the movie “Farewell” but it sounds as though I need to put this on my immediate “to do” list. Thank you for this newsletter and the monthly webinars! Jeanne

From a longer blog posting I wrote three months after my 92-year old father’s death:

https://ignatiusbau.com/2012/12/19/what-my-father-taught-me-about-health-and-health-care-about-life-and-death/

Death is difficult topic in many cultures. In our American culture, which values individual autonomy, agency, and “freedom”, we are only beginning to use documents such as durable powers of attorney for health care decisions, advance health care directives, and physician orders for life-sustaining treatment to discuss, and then document a patient’s wishes about his or her end-of-life care. In traditional Chinese and many other cultures, these decisions are not to be made just by the patient, but collectively as a family, often with the family elder (or the one with the earliest birth order, like the oldest son), being the final decision-maker. Without these discussions and this type of documentation, both health care providers and family members are left trying to second-guess the wishes of the patient, and when there are differences of opinion, trying to reconcile those differences when they literally have life and death consequences.

What my father taught me and my family in the last year of his life was that he knew exactly what he wanted and needed for his comfort – and for his eventual death. He was able to communicate to us both verbally (in remarkably direct ways, given how quiet and often not very communicative he had been all his life), and non-verbally, what he wished. He was surprising blunt about his advance directive and physician orders for life-sustaining treatments. He didn’t want his life to be artificially prolonged, he didn’t want to go to the emergency department or hospital, he wanted to die at home.

For many months, my father resisted the idea of us bringing a hospital bed into his bedroom because when we had brought one to the same bedroom for my mother 38 years ago, she died a few days later. My father was not ready to die, so he was not ready for the hospital bed. But exactly two weeks before he eventually did die, he agreed to have a hospital bed brought in. Having the hospital bed meant he was much more comfortable and made our caregiving much easier in those last weeks, but it also was his way of telling us that he was ready to die.

We decided to use the outpatient services of a hospice organization, which immediately sent a nurse and a social worker out to my father’s house once they were called. They prescribed and monitored anxiety and pain medication to make sure my father would be comfortable. They sent a home health aide to help change and bathe him. Perhaps most useful, they had a phone advice line available 24 hours/7 days a week to answer our questions about how best to care for my father in his last days.

In the last days of my father’s life, I would often spend long hours with him, sometimes staying awake through the night. I never have been a parent, but had a few nights of waking up every hour to check on a loved one. In those last days, our roles as parent and child were totally reversed as I fed my father, changed him, tried my best to comfort him. I am grateful that two days before he died, after a long bout of restlessness and discomfort, I was finally able to get him calmed down and tucked in. My father then said to me (in Chinese) “thank you, I am comfortable now.” Those were the last words my father said to me before he slipped into unconsciousness, and then passed away. I now appreciate that even those last words from my father was his last gift to me – of reassurance, of gratitude, of permission to let go…

I am half Native American, living in Michigan. As someone privileged to work for my tribe in the health care setting, I have seen many variations of end-of-life situations. Not all tribes are the same, but I think most of my people, especially the elders, face death and dying as something natural. After being the recipients of the federal government’s “care” for generations, there is a deep distrust of keeping secrets. I would not hesitate to introduce the discussion with any of them, being sensitive to whatever place the individual was in at that time.

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February 27, 2020

The Farewell: On Cultural Differences in Death and Narrative Control

A poignant film asks viewers to consider challenging questions of medicine and morality

By Yoshiko Iwai

Getty Images

This article was published in Scientific American’s former blog network and reflects the views of the author, not necessarily those of Scientific American

My mother has been living with stage IV lung cancer for over five years now, and for me, Lulu Wang’s film The Farewell, partially based on the director’s own experiences, touched something that felt undeniably true. I have been trying to reckon with my own inability of saving her and the constant state of unknowing that shrouds our every day. These last five years have been a tug-of-war between the reality I want and the reality I get, and one of the hardest parts is the little power I have in framing my own narrative. There are many essays, books, films and songs that try to capture the unpredictabilities of illness— of life —and The Farewell was one that successfully rendered those tensions for me. I believe there are different stories that are effective for each of us; that strike a cord and raise a flurry of ethical quandaries we wouldn’t have otherwise entertained.

The Farewell begins as Wang’s grandmother, who lives in China, is diagnosed with stage IV lung cancer . Her family has been told by doctors that she has three months to live, and the family decides not to tell the grandmother—the holder of the illness and diagnosis—saying no good could come of disclosing the cancer or prognosis. Instead, Wang’s family arranges an elaborate wedding banquet to reunite family members back in their hometown of Changchun, with the covert intention of gathering everyone for their dying matriarch—a marital procession turned fake funeral. The film, which premiered at the Sundance Festival in January 2019, remains a rich source of discussion, particularly in the realm of medicine.

The Farewell is a comedic drama, which deftly handles the heartbreak and humor that arise from experiences of illness. The tangible proximity of wedding celebration and funeral suspend the film in a delicate space between absurdity and deep suffering. Despite the artificiality of the arrangement itself, the film exudes familial tenderness. The protagonist, Billi, played by Awkwafina, asks her parents repeatedly whether secrecy is ethical in the face of a terminal disease. We follow Billi as she struggles to manage the mixed fear, anxiety and warmth she feels towards her grandmother, parents and extended family in China.

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Throughout the film, Billi is caught between the responsibilities of caring for her grandmother, the frustration of her own futility in saving her grandmother from imminent death, and the cultural differences in Chinese and American morals she stands between. The film successfully carries the thematic elements one would ask from a movie about cancer—the vexed and unexpected realities of illness; the realization of human insufficiency; the redundancy of that realization; and the convoluted path towards acceptance.

Striated in rich layers of pain and love, the film asks its viewers to question what it means to have responsibility over information, and the ethics of disclosing that information—or not doing so, as becomes important in the case of The Farewell . The film is, in many ways, inextricable from medicine because the questions it poses have and will always be important for empathic doctoring. The issues that emerge in the plotline around the delivery of medical information are present in today’s caregiving culture.

For instance, the balance of autonomy and beneficence in treating terminally ill patients remains fraught and unresolved in China . Cross-cultural case studies show that truth-telling is similarly opaque in other countries , including Taiwan, Japan, Turkey, Iran and more. But even in the United States, where truth-telling rings with virtue and moral clarity, sociocultural and individual differences make conversations between physician and patient, physician and family, complicated . While truth is a fundamental pillar for establishing trust in the clinical encounter, there is limited empirical information on the constituents of patient perspectives that physicians need to embrace for effective communication .

The film reaffirms the need for empirical research on how physicians can better accommodate the diversity of patient perspectives in regard to diagnosis, prognosis and family dynamics. Especially in a country like the U.S., where individual expression is valued, physicians must continue to rigorously investigate what their role is in truth-telling, and how those conversational nuances shift with each patient and family.

But beyond rekindling the urgency for such empirical knowledge, The Farewell allows us to grapple with a deeper, visceral and phenomenological understanding of truth. The film is successful on the surface because it is a meticulous reproduction of realities that persist between cancer and patient, patient and family, family and doctor, country to country. But it is perhaps even more successful when it acts as a moral exercise for its viewers.

The Farewell is emotionally challenging because it exists in morally gray terrain, and asks its characters, and audience, to linger in that discomfort. We become sympathetic to Billi because the insufficiency she feels about telling her grandmother the truth about her illness and, thus, saving her, is an active wrestling with control in her own coming of age story. If Billi could tell her grandmother, maybe she could save her. We, as viewers, hold onto this hope, even when we know the reality is unlikely. The film speaks as a larger metaphor: the desire of knowledge, and the fantasy of control; if the dissemination of information could be controlled, then maybe the disease could be too. Maybe death would be preventable .

But then, we are confronted with the consequences of control and deception—not just the thematic “deception” of withholding information from Billi’s grandmother, but the abstract idea of deception, which is that knowledge and control act in congruence with each other; they do not. The film ruptures these illusions of controlling knowledge as a way of controlling life, and by doing so, urges us to suspend our own desire for narrative control, and control more generally.

Stories like The Farewell are necessary in medicine because they provide us with safe spaces for exercising moral dilemmas that are essential for recognizing our own biases, and honoring the stories of others. Medicine, undoubtedly, requires precision for effective care. But medicine, undoubtedly, requires imagination too. And that’s what this film offers. It gives us the opportunity to take a step back and really ask ourselves: What is the patient’s narrative? What does the traditional narrative arc of recovery say about our own desires for narrative simplicity? And what are the consequences of such complacency? What are the areas of opacity, of unknowing, of discomfort in the stories we hear, and how do we respond with appropriate care? These questions will never be answered, not to completion at least, but perhaps we can get closer to their truths by seeking out stories that make us pause, ask, and listen.

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Lessons Learned from Cultural Conflicts in the Covid-19 Era

Cultural conflicts became more common during the height of the coronavirus pandemic. through a deeper understanding of how our cultural differences evolved, we can begin to deal with intercultural conflict..

By Katie Shonk — on January 29th, 2024 / Conflict Resolution

During the Covid-19 pandemic, new types of conflict arose. People would argue on Facebook or Twitter about whether stay-at-home orders had gone too far. Protestors—sometimes armed—showed up at state capitols, demanding the right to move about freely. In your own home, you might have been clashing with teens who trying to assert the same right.

Such conflicts reflect a fundamental intercultural conflict : a tension between personal liberties and societal constraint. Cultural conflicts between “loose” and “tight” cultures dates back many centuries, writes University of Maryland professor Michele Gelfand in her book Rule Makers, Rule Breakers: How Tight and Loose Cultures Wire Our World (Scribner, 2018).

By understanding the roots of the tight-loose cultural conflicts we witnessed, we can understand each other better and determine how to deal with cultural conflict more productively.

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The Tight-Loose Divide

All cultures have social norms—accepted standards of behavior, from whether jaywalking and tardiness are acceptable to whether citizens should wear protective masks in public. Cultures vary in the strength of their social norms along a tight-loose continuum, with profound effects on behavior.

The degree of threat that cultures face from the outside world greater determines whether they evolve to be relatively tight or loose (or somewhere in the middle), Gelfand and her colleagues have documented in their research. Countries such as China, Malaysia, Singapore, and Pakistan have survived severe threats—from earthquakes to wars to pandemics or scarcity—by “tightening up.” Coordination and strict adherence to social norms have been keys to their survival, though they risk becoming too homogenous or authoritarian.

By comparison, cultures that have faced fewer threats have the luxury of being loose. In loose cultures such as the United States, the Netherlands, Spain, and Brazil, citizens prize their freedom, and social norms are lax. Loose cultures run on creativity and innovation, but they can be chaotic and have difficulty responding to crises that require tight coordination.

Not surprisingly, countries that “lean tight,” such as Singapore and South Korea, were successful at slowing the spread of the coronavirus through their disciplined coordination and the ready compliance of their citizens. By comparison, the U.S. government’s disorganized response to the Covid-19 pandemic and the resistance of some citizens to restrictions on their freedom garnered predictably loose responses.

When Cultural Conflicts Arise

Beyond nations, all types of cultures—from states to companies to families—tend to vary from tight to loose. Moreover, a sudden threat can lead a culture to tighten up dramatically. New York City, for example, thrives on looseness, as seen in its reputation for openness, diversity, and creativity. But as the coronavirus threatened to overwhelm the city’s hospitals, New Yorkers quickly tightened up, largely accepting restrictions on their movement. Meanwhile, areas that have been less affected by the virus, such as Florida and Wisconsin, favored looser responses, such as allowing businesses and beaches to stay open.

Tight-loose cultural conflicts even showed up within families. Those most vulnerable to the virus, including the elderly and those with underlying health vulnerabilities, may have had the “tightest” responses, venturing outside rarely and wearing masks when they did. The young and the healthy may have been more inclined to resist such limitations, believing they’re at low risk of becoming seriously ill.

“When groups with fundamentally different cultural mind-sets meet, conflict abounds,” writes Gelfand in Rule Makers, Rule Breakers . Those who lean tight accuse those who lean loose of endangering their lives. And those on the loose end accuse those who favor tightening measures of devastating the economy and curbing fundamental American values.

Strategies to Prevent Cultural Misunderstandings

Given these cultural conflicts, how can we engage in effective intercultural conflict resolution in our homes, our communities, and society at large? “Creating space for empathy can prove invaluable for combating intergroup hostility,” Gelfand writes in Rule Makers, Rule Breakers .

When cultural conflicts about adherence arise in your home, think about whether tight-loose mindsets are clashing. Where do you fall on the tight-loose continuum? While all of us are capable of tightening (think libraries) or loosening (think parties) depending on the context, we tend to have a default preference for rule making and rule breaking. To find out yours, take the TL mindset quiz .

Next, think about where others fall on the continuum and why their own experiences may have affected their own mindsets. Listen to their perspective without judgment. Share your own experience and fears, then try to negotiate solutions.

Virtual interactions can reduce cultural conflicts for those located far apart. In their research, Gelfand her collaborator Joshua Jackson tried an intervention aimed at reducing hostility between Americans and Pakistanis—members of loose and tight cultures, respectively. Students from both cultures were asked to read diary entries written by other students about their daily lives. Those who read entries by students from the other culture came to view that culture as much more similar to their own than they had previously believed, and also more positively. By taking time to read and listen to people’s stories, we can better understand their behavior.

What types of cultural conflicts did you manage to resolve effectively during the Covid-19 pandemic?

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Cultural Differences and Their Impact Essay

One of the cultures to discuss as having exposure to is Korean culture, which is usually different in language, nationality, and perception of other things. Korean culture, like many other East Asian cultures, expose a high sense of hierarchy, attachment to ingroup members, and the necessity for formalities, rules, and standards for greeting and behaving in society. These differences can affect work and neighborhood life, creating misunderstandings or even nation-based conflicts.

One of the primary dimensions to review Korean culture is from the perspective of a high power distance society. Korean culture respects the elder and usually puts a strong hierarchy in all routine matters – such as eating, speaking, and greeting – to establish the relationship between senior and junior. Although it can be seen as irrational for other cultures, this superiority of age is explained by the responsibility the elders have in taking care of the family members and overall young people. The sense of respect for elders and their superior position over the youth can cause misunderstandings in daily life for other cultures that do not follow the hierarchy of age.

Another important perspective to take is from high uncertainty avoidance society. In this sense, it is necessary to follow formalities, rules, and proceedings that are known to society and seem appropriate. If they behaved differently from expected, people from Korean culture can find it disruptive or even see it as rude or ill-intention towards them. From this point, misunderstanding can occur simply from different greetings.

The information gained from cultural conflicts and differences can help to enable better and more efficient communication with other cultures, such as Korean culture. There would not be misunderstandings, like the threat of rude behavior, that can disrupt communication daily. It can be the interaction with colleagues at work that will require respect from the older workers or the proper greetings for neighbors to avoid ill intentions.

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IvyPanda. (2024, February 19). Cultural Differences and Their Impact. https://ivypanda.com/essays/cultural-differences-and-their-impact/

"Cultural Differences and Their Impact." IvyPanda , 19 Feb. 2024, ivypanda.com/essays/cultural-differences-and-their-impact/.

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1. IvyPanda . "Cultural Differences and Their Impact." February 19, 2024. https://ivypanda.com/essays/cultural-differences-and-their-impact/.

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Chapter 10: Death and Dying

Cultural differences in end-of-life decisions.

According to Searight and Gafford (2005a), cultural factors strongly influence how doctors, other health care providers, and family members communicate bad news to patients, the expectations regarding who makes the health care decisions, and attitudes about end-of-life care. In the United States, doctors take the approach that patients should be told the truth about their health. Outside the United States and among certain racial and ethnic groups within the United States, doctors and family members may conceal the full nature of a terminal illness as revealing such information is viewed as potentially harmful to the patient, or at the very least, is seen as disrespectful and impolite. Holland, Geary, Marchini and Tross (1987) found that many doctors in Japan and in numerous African nations used terms such as “mass,” “growth,” and “unclean tissue” rather than referring to cancer when discussing the illness to patients and their families. Family members actively protect terminally ill patients from knowing about their illness in many Hispanic, Chinese, and Pakistani cultures (Kaufert & Putsch, 1997; Herndon & Joyce, 2004).

Figure 10.10

In the United States, we view the patient as autonomous in health care decisions (Searight & Gafford, 2005a), while in other nations the family or community plays the main role, or decisions are made primarily by medical professionals, or the doctors in concert with the family make the decisions for the patient. For instance, in comparison to European Americans and African Americans, Koreans and Mexican-Americans are more likely to view family members as the decision makers rather than just the patient (Berger, 1998; Searight & Gafford, 2005a). In many Asian cultures, illness is viewed as a “family event”, not just something that impacts the individual patient (Candib, 2002). Thus, there is an expectation that the family has a say in the health care decisions. As many cultures attribute high regard and respect for doctors, patients and families may defer some of the end-of-life decision making to the medical professionals (Searight & Gafford, 2005b).

According to a Pew Research Center Survey (Lipka, 2014), while death may not be a comfortable topic to ponder, 37% of their survey respondents had given a great deal of thought about their end-of-life wishes, with 35% having put these in writing. Yet, over 25% had given no thought to this issue. Lipka (2014) also found that there were clear racial and ethnic differences in end-of-life wishes (see Figure 10.10). Whites are more likely than Blacks and Hispanics to prefer to have treatment stopped if they have a terminal illness. While the majority of Blacks (61%) and Hispanics (55%) prefer that everything be done to keep them alive. Searight and Gafford (2005a) suggest that the low rate of completion of advanced directives among non-whites may reflect a distrust of the U.S. health care system as a result of the health care disparities non-whites have experienced. Among Hispanics, patients may also be reluctant to select a single family member to be responsible for end-of- life decisions out of a concern of isolating the person named and of offending other family members, as this is commonly seen as a “family responsibility” (Morrison, Zayas, Mulvihill, Baskin, & Meier, 1998).

• Authored by : Martha Lally and Suzanne Valentine-French. Provided by : College of Lake County Foundation. Located at : http://dept.clcillinois.edu/psy/LifespanDevelopment.pdf . License : CC BY-NC-SA: Attribution-NonCommercial-ShareAlike

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Cultural Relevance in End-of-Life Care

Author(s): Phyllis R. Coolen, DNP, MN, RN

Reviewer(s): Lorin Boynton, MD; Daniel Lam, MD; Darrell Owens, DNP, MSN

Date Authored: May 1, 2012

The author performed a literature review and incorporated published literature, interviewed health care providers experienced in end-of-life care, and drew from her own clinical experience.  The author, a community health and hospice clinician, has over 30 years’ experience with hospice care.

Introduction

The discussion a health care provider, including physicians, advanced nurse practitioners, nurses, and social workers, has with a patient about end-of-life care is often a challenge.  The challenges can be influenced by a number of variables, such as the provider’s training and experience is this area, the provider’s comfort level in discussing the subject, and the availability of adequate time for having the discussion (Kamaka, 2010; Tait & Hodges, 2009).  A provider may be challenged further when the patient’s cultural norms differ from the health care provider’s, particularly around end-of-life care, which can impact the provision of quality end-of-life care.  American core values emphasize autonomy and individual rights to make life choices, especially health care choices. 

The Patient Self Determination Act (PSDA) of 1990 was developed to ensure those rights were protected, including the fundamental rights to treatment choices, informed consent, truth-telling and open communication with health care providers, and control over the individual’s own life and death (Electronic Code of Federal Regulations, 2011).  These American core values may often be in conflict with the values of many ethnic and culturally diverse groups in the United States.  These conflicts can lead to health disparities resulting in fragmented care, inadequate or inappropriate symptom management, miscommunication with the patient and family, and a difficult and poor death for the patient.  There are numerous studies that support these conclusions (Campinha-Bacote, 2011; Doorenbos et al., 2010; Eues, 2007; Giger, Davidhizar, & Fordham, 2006; Huff & Kline, 2007b; Searight & Gafford, 2005a). 

Enhanced cultural competency with regard to improving end-of-life care continues to be an identified need for hospice nurses, social workers, family practice physicians, psychiatrists and other health care providers (Braun, Ford, Beyth, & McCullough, 2010; Rushton, Scanlon, & Ferrell 1999; Schim & Doorenbos, 2010; Schim, Doorenbos, & Borse, 2006).  The focus of this article will be on cross-cultural issues at the end of life for ethnically and culturally diverse groups in the United States.

The health care provider must have a clear understanding and recognition of the unique and specific influences culture has on a patient’s behavior, attitudes, preferences, and decisions around end-of-life care.  It is important to remember that simply because a person is identified as a member of a particular ethnic group or practices a particular religion it does not necessarily mean that the person or person’s family maintains beliefs that may be associated with the ethnicity or religion.  Additionally, an assessment should be made of how acculturated a person and their family are, their language skills, and whether an interpreter is needed.  Be aware of some of the overall cultural values of the community and then explore the pertinent themes as they relate to providing health care for individual patients.  Remember there is great diversity within a community.  Experiences will vary greatly depending, for example, on whether people lived in rural or urban communities in their countries of origin, how long they have been in the United States, their immigration experiences, former occupations, and levels of education.  Keep in mind that patients are individuals.  The examples included are to illustrate concepts and are not meant to be all inclusive or representative of everyone within a particular community or of all ethnic groups.

This resource will address three major areas of cultural relevance in end-of-life care:

• cultural competency in clinical practice;
• advance directives; and
• pain management

Cultural Competency in Clinical Practice

Diversity in our society.

The United States is rapidly moving towards becoming a more ethnically and culturally diverse country, with whites expected to account for less than fifty percent of the population by 2040 (Frey, 2012).  The national trends continue to see ethnic minorities dominating national growth, with continuing immigration (largely from Latin America and Asia) resulting in an increase in the “minority majority” population (Frey, 2012).  Four states and an increasing number of metropolitan areas and their suburbs have a minority majority population composed of over fifty percent non-whites and Hispanics (Frey, 2012).  When immigrants relocate, they don’t leave their culture behind, but bring those values, beliefs, and norms to their new home.  And depending on how acculturated a person is, aspects of his or her culture may have a strong influence on the person’s response to illness and health care.

As America evolves into a multiethnic society, how health care providers manage that shift is critical in establishing culturally appropriate and effective care.  Through cultural competency in clinical practice, health care providers can provide care that ensures the individual receives high quality of care regardless of culture or ethnicity. 

Cultural Competency

Cultural competency can be viewed as an ongoing journey of commitment and active engagement through the process of cultural awareness, cultural knowledge, cultural skills, cultural collaboration, and cultural encounter (Kachingwe & Huff, 2007; Leininger, 2002a).  Cultural competency allows for the delivery of individualized health care services within the cultural context of the patient and the avoidance of stereotyping (Kagawa-Singer & Backhall, 2001).  Trust is the underlying purpose behind cultural competency in the development of the health care provider and patient relationship.  Without trust there cannot be an effective relationship, which increases health disparities (Campinha-Bacote, 2011; Huff & Kline, 2007b; Kachingwe & Huff, 2007; Leininger, 1999; Schim & Doorenbos, 2010; Tervalon & Murray-Garcia, 1998).

Key Elements of Cultural Competency

The following are the key process elements that require a health care provider to commit to lifelong learning in order to enhance health care services (Campinha-Bacote, 2009, 2011; Kachingwe & Huff, 2007; Leininger, 2002b).

Cultural Desire   is the process of wanting to become culturally competent.  It is the motivation that is behind the health care provider’s desire to actively engage and commit to becoming culturally competent.  Humility is the key factor in this process.   Humble health care providers have a genuine desire to discover what the patient is thinking and feeling.  Also of critical importance is seeing each individual as a unique and worthy person to be treated with dignity, fairness, and deserving of quality of care.

Cultural awareness  is the process of becoming more sensitive, respectful, and attentive to the patient’s cultural beliefs and practices.  Through this process the health care provider becomes cognizant and reflective of his or her own cultural identity, attitudes, biases, and prejudices and how they shape his or her behavior, specifically in the provision of health care services.

Cultural knowledge  is the process of developing an understanding of the differences and similarities between and within cultural groups.  This includes learning about various cultural groups’ values, beliefs, lifestyle practices, and perspectives on life.  Culture is a powerful determinant of behavior towards illness.

Cultural skill  is the process of cultural assessment, which obtains relevant information about the patient’s beliefs, values, and practices.  A critical component of cultural skill is the development of interpersonal communication skills that convey respect, appreciation, and sensitivity to other cultures.

Cultural collaboration  is the process that requires a partnership approach between the health care provider, the patient, and the family.  An important part of the collaboration is the development of mutually agreeable goals between the health care provider, patient, and family.

Cultural encounter  is the process of obtaining cultural experience through active engagement and, if possible, immersion in another culture.  Meaningful encounters require being open to learning, understanding, and appreciating the other person’s viewpoint.

The Relevance of Cultural Competency in End-of-Life Care

Working within the cultural context of the patient and family is an essential underpinning of end-of-life care.  Cultural influences can significantly impact the patient’s reaction to the dying process and the decisions the patient and family make (Giger, et al., 2006; Kagawa-Singer & Backhall, 2001; Koenig & Gates-Williams, 1995; Searight & Gafford, 2005a).

Fostering trust is vital to the care of the patient and family during this difficult time.  End-of-life care means more than treating physical symptoms, but extends to the psychosocial, existential, and spiritual aspects of the patient’s needs.

Numerous studies devoted to understanding culture’s relevance to death and dying found that communication was the greatest barrier between the health care provider and the patient and family during end-of-life care (Eues, 2007; Jovanovic, 2011; Klessig, 1992).  

A provider needs to consider the following (Lopez, 2007):

• the patient and family’s perspective on death and dying
• the patient and family’s perspective on health and suffering
• the patient and family’s perspective on hospice and palliative care services
• the patient and family’s acceptance of Western health care practices and their use of alternative traditional practices
• the role of spiritual and religious beliefs and practice
• the role of the family, including who is considered part of the family
• how the patient and family communicate (such as the need for interpreter services or that only certain words are acceptable when discussing illness and dying)
• the patient’s own role in problem-solving and in the process of decision-making

Cultural Factors to Consider in End-of-Life Care

Death as a taboo subject.

In some cultures, talking openly about death and dying is not acceptable because it is considered disrespectful, bad luck, or causes loss of hope (Giger, et al., 2006; Kagawa-Singer & Backhall, 2001; Searight & Gafford, 2005a, 2005b).  Many cultures actively protect dying family members from knowing their prognosis (Carteret, 2012; Giger, et al., 2006; Searight & Gafford, 2005a, 2005b).  For example, some Filipinos may request the family member not be told he or she is dying because of concern for the person’s loss of hope and the belief that only God can decide a person’s fate.  For many Southeast Asian families, the dying family member is not to be told about a terminal diagnosis because talking about death would bring it on sooner or doing so is disrespectful to the soon-to-be ancestor.  Some Somalis consider it uncaring for the health care provider to tell the terminally ill family member he or she is dying (Stratis Health, 2010). And for some Muslims, talking about death is taboo and a religious leader may be needed to facilitate the conversation with the male family leader and the health care provider about end-of-life care.

Collective Decision-making

Collective decision-making is the norm in many cultures, but it often clashes with the American  value of autonomy and an individual’s right to make one’s own decisions about health and dying (Giger, et al., 2006).

Collectivism’s core values can cause a treatment dilemma for the health care provider whose focus is on getting the patient involved in the treatment plan.  In collective decision making, the family decisions will be family oriented.  In these circumstances, it is important to understand and respect that the power of collectivism is more important than an individual (Huff & Kline, 2007b; Logan, Fukuda, & Baldwin, 2006).

A family may expect information to be given to them first, so they can make the health care decisions (Countries and Their Cultures, 2012; Giger, et al., 2006; Klessig, 1992; Koenig & Gates-Williams, 1995).  For example, Koreans and Mexican Americans are more likely to consider the family as the decision-maker regarding withholding of aggressive treatment, rather than the patient alone (Maly, Umezawa, Raliff, & Leake, 2006).  For many Asians and Pacific Islanders, filial piety, as supported by Buddhism, Confucianism, and Christianity, requires family members to take over the decision-making role for the seriously ill elderly patient (Giger & Davidhizar, 2002). 

Family and extended family ties are extremely important to the Filipino and Hawaiian communities, with the extended family participating in the discussions and decision-making for the seriously ill family member.  Some Somalis believe that health care decisions involve the whole family, with a male family member being the spokesperson for the family and the father being the bearer of bad news to the patient (Carteret, 2012).  When death is imminent, the Asian Indian male head of the household is responsible for deciding when the patient is to be told and when to inform the rest of the family members (Stratis Health, 2010).

Perception of the Physician’s Status and Health Care Experience in Country of Origin

Immigrant patients may come from countries where the physician makes all health care decisions and patients are unaccustomed to being asked to choose among treatment options (Kingsley, 2010).  The patient and family may have the expectation that it is the physician’s role to decide on end-of-life care (Searight & Gafford, 2005b).  For many Filipinos, physicians are held in high esteem and are given extensive authority, so questioning the physician’s treatment decision or being asked to make a decision about one’s own health care is not expected.  They would expect the physician to make all decisions about their health care. Additionally, some immigrant patients may not be accustomed to or comfortable asking questions of the physician, even if aspects of the illness or treatment plan are not understood because of concern that they will be perceived as challenging the physician (Shavers, Bakos, & Sheppard, 2010).  For example, Southeast Asian cultures value politeness and respect for authority, so questions or voicing concerns about the family member’s terminal illness or treatment may not occur. 

Perception of Pain and Request for Pain Relief

Culture can affect a person’s response to pain, both in the meaning and expression of pain.  Pain may be seen as something positive, that it a sign that the body is fighting towards recovery or as a test of one’s faith through suffering or even as a punishment (Giger, et al., 2006; Shavers, et al., 2010).  Therefore for some individuals, asking for pain medication may be considered a sign of weakness.

Culture can influence the initiative a patient takes in asking for pain medication.  For example, Cambodian culture values an indirect communication style, avoiding public display of emotion and confrontation, so rather than asking directly for pain medication, the patient may wait to be asked if medication is needed (Mahloch et al., 1999).  For many Somalis, the concept of autonomy is foreign and they may wait for the health care provider to ask if the patient is experiencing pain (Countries and Their Cultures, 2012).  For more information about pain, see the  Pain Management section below.

Role of Religion and Faith

For many ethnically diverse cultures, the approach to health and illness is through the interconnection of mind, body, spirit with nature or the environment.  Faith and spirituality can play a significant role in the perception and response to the dying process (Countries and Their Cultures, 2012; Huff & Kline, 2007b; Kachingwe & Huff, 2007; Koenig & Gates-Williams, 1995; Mark & Lyons, 2010; Yee, 2007).

For example, in the Vietnamese culture, health and religion are connected and therefore, suffering and illness are part of life.  Death cannot be avoided or ignored as it is part of life.  Vietnamese Buddhists believe that a person’s life is predetermined and prolonging life is futile.  The family may want a monk to pray at the bedside to assist the person for a peaceful journey to the next life (Braun, Beyth, Ford, & McCullough, 2008).                                              

Maori spiritual healers strongly believe in reconnecting with their culture, their land, and their genealogy to restore the sense of identity and sense of belonging during serious illness.  So, in order to heal the person’s spirit, the person must relearn the culture as part of a ritual health passage (Mark & Lyons, 2010).

For Filipino Catholics, a priest would be requested to give the sacrament of the sick, so that the person may ask forgiveness for their sins in order to gain strength and peace as they go through the dying passage.  In addition, some families will hold evening prayers with family and friends gathering together for support as they all go through the journey with the patient.

Traditionally, Hmong believe that the soul is lost due to an evil spirit or that a curse is the cause of the illness.  Spiritual ceremonies by a shaman are crucial to bringing back the lost soul.  However, the Hmong also believe in reincarnation; when the person is dying, religious ceremonies by the shaman are conducted for the purpose of helping the person have a good journey to the next life (Carteret, 2012).

As in other Asian and Southeast Asian cultures, such as in the Cambodian and Vietnamese cultures, there is a belief in the importance of harmony in and between the body, mind, and soul with the universe.  Imbalance in these elements can cause a mild to life-threatening “wind illness.”  Wind illness is associated with fever, dizziness, and sickness; however the more severe manifestation might be likened to a stroke or heart attack.  Traditional healing practices are often used to treat wind illness.  For more on wind illness, see EthnoMed article  Ethnographic Study among Seattle Cambodians: Wind Illness .

For many African Americans there is a strong belief that prayer and the power of God will heal the patient. In comparison with non-Hispanic whites, African Americans are more likely to consider religion as a coping strategy in dealing with end-of-life issues and advanced planning.  It is important that the health care provider consider the role of spirituality and partner with spiritual leaders in end-of-life care discussions (Shrank et al., 2005).

Native Hawaiians have a strong belief in a higher spiritual God and that prayer, chanting, and music will restore the balance of mind, spirit, and body (Logan, et al., 2006).  To show respect to a dying elder, Hawaiian families – including extended family and community members – will gather, even in the hospital, to tell stories, pray, and play music.

For some Thai Buddhists, when a person is dying, an effort is made to have the person focus upon Buddhist scriptures or repeat one of the names of the Buddha, such as  Phra Arahant .  If the person is too weak, then the name is whispered in his ear.  Sometimes four syllables ( ci, ce, ru, and ni ) which represent the heart of the Buddhist teachings (Abhidharma) are written on a piece of paper and put in the mouth of the dying person.  It is thought that if the person’s last thoughts are the teachings of the Buddha, the person will have a good next life (Buddhist Studies, 2012).

Among many Somali Muslims, prayers assume a pivotal role at the end of life.  Reciting from the Quran at the patient’s bedside is done to ensure that the last words the person hears before death are the words from the Quran, as the prayers allow the person’s soul to enter paradise after death.  Also Muslims pray towards Mecca, so asking the family if the patient would like his or her bed positioned to face towards Mecca, if possible, would be an important part of the patient’s care (Klessig, 1992; Schim & Doorenbos, 2010).

Use of Traditional Healing

The use of Western medicine is generally acceptable by ethnically diverse patients in the care of terminal illness, although the level of acceptance depends on a number of factors, including how assimilated the individual is to American culture (Le & Le, 2005).  Alternative practices may be used simultaneously with Western medicine because of the perceived or real effectiveness of the treatments as experienced by the patient.  Symptoms often experienced as a result of the disease and dying process include pain, nausea and vomiting, breathing difficulties, skin wounds, bowel and bladder problems, anxiety and depression, and sleep disturbances.  To address these symptoms, patients may seek the care of spiritual healers and the use of alternative practices, such as coining, cupping, moxibustion, palm reading, use of astrological computations for life guidance, and herbal and folk remedies.

Some Filipinos may seek medicinal healing through the use of  halaman  (herbs) and an  herbolaryo  (witch doctor), if they believe that evil spirits entering the body caused the illness.  For more information on traditional medicine, see our Pharmacy clinical topic page .

Hospice and Palliative Care

Although the hospice and palliative care movements have been instrumental in increasing awareness in end-of-life issues, many people are still not familiar with these services.  For some cultures, hospice and palliative care’s focus on comfort, harmony, family and support fits nicely with the culture’s values and beliefs.  For cultures where dying at home is a valued norm, those values are congruent with hospice care.  Providing services in the home is a hallmark of hospice care.

Palliative care, which is generally provided on an inpatient basis, is designated for patients regardless of their life expectancy, who have a progressive, debilitating and/or life-limiting illness that adversely affects their daily functioning or will predictably reduce life expectancy (National Guideline Clearinghouse, 2011).  The palliative care team works in conjunction with the primary care physician and can offer assistance with end-of-life care.  This includes the treatment of pain and other symptoms, emotional and spiritual support, assistance with communication of bad news, support for patients and families in medical decision-making, and navigating the complex medical system (National Guideline Clearinghouse, 2011).

Hospice also provides palliative care.  However, hospice services are for patients who are no longer seeking curative therapy and have a prognosis of less than six months.  Hospice care is provided in any setting that is considered the patient’s home, which includes the patient’s home, skilled nursing facilities, assisted living facilities, retirement homes, and even the hospital.

Cultural Assessment

There are numerous cultural issues germane to end-of-life care.  A critical step in understanding cultural relevance in end-of-life care is performing a cultural assessment.  A cultural assessment provides a systematic way of gathering and documenting information about the patient’s cultural beliefs, meanings, values, patterns, and expressions as they relate to the patient’s perception and response to an illness (Leininger & McFarland, 2002).  Gathering of information is conducted through asking the patient and family specific questions and also through observations of the patient, including family behavior patterns.  A cultural assessment can be performed by any health care provider, with modifications of the assessment tool based on the health care provider’s particular discipline, interests and therapeutic goals (Leininger, 2002a).  It is critical that the assessment by each discipline and the documentation of the assessment be coordinated and incorporated into the patient’s treatment plan to ensure continuity of care.  It is also important to remember to communicate the cultural assessment findings to all members of the patient’s health care team, including specialists to whom the patient is referred.  Sharing the patient’s cultural assessment with the other health care team members lays the foundation for care and can provide a smooth transition for the patient as he or she moves through the health care system.

There are a number of assessment tools available.  Regardless of which is utilized, the focus must be on the uniqueness of the individual patient and how culture shapes his or her response to dying and end-of-life care.  An approach to beginning an assessment might be to say, “I would like to learn more about you and your culture, so that I can be sure and meet your needs and provide the best care for you.”

Kleinman and Campbell’s Patient Explanatory Assessment Model

Kleinman’s (Kleinman, Eisenberg, & Good, 1978)  patient’s explanatory assessment model devised eight simple questions that clarify cultural generalizations and provide insight into the patient’s personal meaning of the illness.  Campbell et al. (Campbell, McDaniel, & Cole-Kelly, 2003) added family-focused questions to be included along with Kleinman’s questions. The questions may be varied and individualized depending on the patient’s problem or if the questions are being asked of the family members.  The term “illness” can be substituted with a specific symptom or a term that may be commonly used by the patient, such as “sickness,” “pain,” or “fluid in your stomach area” to help the health care provider understand the patient’s perception of the effects of the illness. The questions are:

• What do you think has caused your illness?
• Why do you think your illness started when it did?
• What do you think your illness does to you? How does it work?
• How severe (serious, terrible) is your illness?  Will it have a short or long course?
• What kind of treatment do you think you should receive?
• What are the most important results you hope to receive from this treatment?
• What are the main (biggest) problems your illness has caused you?
• What do you fear most about your illness?
• What do your family members believe caused the illness?
• What do your family members believe could treat the illness?
• Who in your family is most concerned about your illness?
• How can your family be helpful to you in dealing with your illness?

Giger-Davidhizar and Huff Cultural Assessment Models

Geiger-Davidhizar’s Cultural Assessment Model considered six components relevant to end-of-life care: communication, space, time, environment control, social organization, and biological variation (Giger, et al., 2006).  The author added additional assessment from her own practice as well as  from Huff’s assessment model to the table in the sidebar in order to enhance information gathering (Huff & Kline, 2007a). 

Kagawa-Singer & Blackhall’s ABCD Cultural Assessment Model

Kagawa-Singer and Blackhall developed a cultural assessment mnemonic approach to assess the degree of cultural adherence to help avoid stereotyping and decrease the risk of miscommunication (Kagawa-Singer & Backhall, 2001).  The ABCD cultural assessment is outlined in the accompanying table (in sidebar). 

Advance Directives

The Patient Self-Determination Act (PSDA) of 1990 (Electronic Code of Federal Regulations, 2011) requires health care facilities to ask patients if they have an advance directive and if not, requires them to provide patients with information about advance directives.  The intent of the advance directive is to improve end-of-life care.

There are two types of advance directives: a document called an advance directive which is also known as a living will, personal directive or advance decision, and a durable power of attorney for health care (WSMA, 2012).

Key Points to Know About an Advance Directive

• An advance directive is a document expressing a person’s wishes concerning certain life sustaining medical treatment when the person is seriously ill or at the end of life, should the person not be able to communicate his or her wishes.
• Although the advance directive is legally valid throughout the United States, each state may have different laws governing advance directives.
• In Washington State, the advance directive is used only when life-sustaining treatment would artificially prolong the process of dying in a terminal condition or if the individual is in an irreversible coma and there is no reasonable expectation of recovery.
• The advance directive becomes a legal document once the individual signs it and it is signed in front of the two required witnesses.  The witness must not be the attending physician, an employee of the physician or the health care facility in which the individual is a patient, or any person who has a claim against any portion of the patient’s estate upon the death of the patient.
• The completed advance directive form does not need to be notarized, but it is advisable.
• The advance directive form does not need to be filled out by a lawyer.
• The advance directive does not have an expiration date.
• The individual can change or use his or her own words on an advance directive form or even create their own form; however, individual and witness signatures are still required.
• Five Wishes   is considered a legal advance directive document in Washington State ( Five Wishes , 2012).  It is translated into 26 languages.  There is a cost associated with obtaining the document in an online or booklet format.  The health care provider could utilize the online version of the  Five Wishes  as a discussion tool with the patient and family, and take the opportunity for the patient and family to fill out the form and have it printed and signed during the office visit.
• The Physician’s Orders for Life Sustaining Treatment (POLST) is not the same as an advance directive.  The POLST are specific  orders by the physician  that indicate what type of life-sustaining treatment the individual wants, or does not want at the end of life.

Key Points to Know About a Durable Power of Attorney for Health Care

• A durable power of attorney for health care is a legal document in which an individual designates a person to make medical decisions when the individual is incapacitated.
• The designee can be a family member and more than one person can be designated, including a back-up person if the designee is not able to fulfill the role.
• In Washington State, the document does not need to be notarized or witnessed.  However, it is advisable to have a lawyer prepare the document and notarize it.
• The Washington State Medical Association provides information on advance planning, including forms available for download for advance directive, POLST, and for durable power of attorney for health care:  Advance Directives

Cultural Issues around Advance Directives

Studies indicate that ethnic minorities in comparison to whites continue to have lower rates of completing advance directives (Kwak & Haley, 2005).  These lower rates are due to a lack of knowledge and understanding by the patient and family about the advance directive; a distrust in the American health care system and concern that the person’s wishes won’t be carried out; fear of death; and cultural differences regarding the need for an advance directive, which relate back to “death is a taboo subject” (Campinha-Bacote, 2009; Giger, et al., 2006; Searight & Gafford, 2005a).  The key in discussing advance directives is in the planning process.  Fostering a trusting relationship between the health care provider and the patient and family is a critical component in the planning process which requires discussing the patient’s values, preferences, and options with the health care provider (Braun, et al., 2010).

The following are specific areas of concern:

• Lack of knowledge and understanding about advance directives.  Major misconceptions about the advance directive are that it is related to a will or treatment consent, that it requires an attorney, and it pertains to funeral and burial arrangements (Perkins, Geppert, Gonzales, Cortez, & Hazuda, 2002).  Surrogate decision-makers may lack knowledge of the patient’s preference.  Studies of African Americans, Hispanics, and Asian surrogate decision-makers revealed their concerns about the lack of knowledge of the patient’s preference on advance directive; the tremendous burden they felt in trying to make a decision without knowing the patient’s preference; feeling under pressure to make a decision in a short period of time; feeling guilty about losing the patient; and preference for the physician to make end-of-life decisions (Perkins, et al., 2002; Washington, Bickel-Swenson, & Stephens, 2008).  From the author’s experience, some of her patients thought signing a legal document like an advance directive meant they were also signing over their house to the health care facility.
• Distrust of the health care system.  In the U.S. health care system, there is a long history of mistreatment of African American patients and evidence of health disparities.  As a result, some people distrust the health care system and may view it as having control over all treatment and worry that their wishes will be ignored (Koenig & Gates-Williams, 1995).  For some minorities and the poor, stopping treatment or referring to hospice services may raise a patient’s suspicions of receiving poorer quality of care and neglect (Washington, et al., 2008).  Trust issues between the patient and provider can cause discord, leading to non-compliance with treatment suggestions and unwillingness to complete an advance directive.
• Acculturation.  Acculturation refers to the process of adopting the cultural norms of the dominant culture, which in this case is how acculturated the individual is regarding American core values and beliefs relevant to end-of-life issues.  A study of English-speaking Japanese Americans found that despite acculturation, many of the subjects retained some of their Japanese cultural values and beliefs influencing end-of-life care and decision-making process, such as a strong preference for the group surrogate decision-making model (Matsumura et al., 2002).  Some Filipino Americans, although they may have lived in the U.S. for over forty years, as they have gotten older may rely more on traditional health care beliefs and practices as a means of comfort and enhancing their ties to the Filipino culture, which may include an unwillingness to talk about death and dying.
• Collectivism. When the family is the decision-maker on health care issues, this may include the discussion and decision around an advance directive.  For example, many older Koreans believe that their children will decide about their end-of-life care and therefore there is no reason for an advance directive (Kwak & Haley, 2005).  However, for some Filipinos the thought of burdening one’s children with end-of-life decisions is stressful. Having advance directive planning discussions with the patient, before a serious illness, can eliminate this stress at end of life.
• Preference for physician to make health care decisions.  Some cultures may feel that initiating discussions about advance directive planning may be a sign of disrespect.  Therefore, family members may prefer the health care provider initiate the discussion and make decisions about life-sustaining treatment (Kwak & Haley, 2005).
• Taboo.  Talking about death and dying is taboo in many cultures.  This taboo may contribute to resistance and lack of acceptance of advance directives.
• Influence of faith and spirituality.  Among many African Americans the strong belief that an illness is a test of their faith requires that there not be any barriers put up, such as discontinuation of life support or aggressive treatment (Koenig & Gates-Williams, 1995).  Likewise, some Hispanics view life as a gift from God and therefore life must be protected (Klessig, 1992).

Many Southeast Asians are Buddhist and believe in the cycle of life, karma, reincarnation, and that death is part of life.  Aggressive treatment may be viewed as disturbing the natural ebb of life and a sign of a bad death (Jagaro, 2004).  The palliative and hospice focus of comfort care with peaceful and family support aspects may be more acceptable and in line with Buddhist beliefs and values.  Patients and families may be more open to the discussion about and acceptance of advance directive planning.

In some cultures, such as the Samoan, Vietnamese, and Asian Indian cultures, there is belief that dying away from home can lead to disturbances of the spirits.  Some people may also believe that there are too many disturbing spirits in the hospital, so dying in the hospital should be avoided (Countries and Their Cultures, 2012:  Yee, 2007).  For Koreans, dying at home is a norm encouraged in the culture (Kwak & Salmon, 2007).  Patients and families from these cultures may consequently be more open to discussion about advance directives and hospice services.  On the other hand, many Chinese avoid dying at home, because of the belief that ghosts will linger in the home (Koenig & Gates-Williams, 1995).

Approaches to Consider When Discussing Advance Directives

The following are approaches to consider when discussing advance directives in order to provide an open and supportive environment:

• Ideally, discussions on advance directive planning should be performed in advance of an impending health care crisis.  For example, it should be part of the patient’s routine care.  It should also be a continuing discussion as patient’s views change, they grow older, or their health status declines and their perspective on advance directives may change.  Incorporating an advance directive discussion on a yearly basis is advisable.
• When the family is the designated decision-maker on health care issues, the discussion about advance directive planning must be done with the family.  It is also important to determine the patient’s preference for being present at the discussion.
• Sufficient time must be allocated for the discussion.  Setting up a separate time for the discussion allows for a more thorough discussion and question and answer session.  Also the patient may need to make arrangements for family members to attend the discussion.
• The discussion should be done in private.  The health care provider should encourage the patient and family to ask questions.  The health care provider should reassure the patient and family that the advance directive will only be shared with those who are on the patient’s health care team.
• Determine if the patient and family understand the purpose of an advance directive.  Common misconceptions are that it is a will, that if the person signs the document he or she will lose their home, that it requires an attorney, and that it addresses funeral and burial arrangements.
• Provide detailed information including the natural course of the disease, the prognosis, and chance of survival.  Many family members will pursue less aggressive treatment if the chance of survival is poor.  Help the patient and family understand that “doing everything” may also bring about additional pain and suffering.  However, recognize that for some people, even in the face of a low survival rate, aggressive treatment is expected and supporting those decisions is important.  When the patient or family wants “everything possible done,” an exploration of what that means can provide a greater understanding of what’s behind the request.  Consideration may be: denial of the illness or the progression of the illness, unrealistic goals, fear of dying, and loss of self-control, false hope, or a sense of familial duty (Braun, et al., 2008).
• Patients and family members need to be assured that an advance directive that excludes curative treatment does not mean the patient will be abandoned by the health care system.  The health care provider must provide reassurance that stopping curative or life-supporting treatment does not mean no treatment, but that the focus of the patient’s treatment will be aggressive management of any pain and symptoms the person may experience.
• For some cultures, the concept of present orientation is to “take each day as it comes.” The health care provider may suggest having a trial intervention to help with the decision-making process.  A trial intervention is time limited and takes the approach of  “Let’s see what happens to your mom’s condition in the next few days and we can then revisit the discussion on life-sustaining treatment.  Meanwhile if you have any questions for me, please feel free to ask them.”
• A religious leader can play an important role in facilitating the discussion and decision-making process in advance directive planning through clarification of how certain aspects of a religion’s principles or beliefs may influence the decision on providing life support measures.  The religious leader can also act as a crucial intermediary in helping the patient connect with his or her faith or spiritual life.
• When the discussion of death and dying is a taboo subject, the health care provider might initiate having the patient do a life review.  Xiao et al.’s study on Chinese patients with advanced cancer found that encouraging patients to do a life review prepared them for death (Xiao, Kwong, Pang, & Mok, 2011).  Encouraging the patient to review and value his or her life experiences and complete unfinished business may enable the patient to work on advance directive planning.
• More subtle, indirect and implicit non-verbal communication may be preferred when discussing advance directive planning (Matsumura, et al., 2002).  Non-verbal communication includes active listening with pauses between sentences, silence, and holding the patient’s hands.
• Development of educational tools in collaboration with a targeted culture community can increase awareness of the value and usefulness of advance directive planning and end-of-life choices.

The following are examples of scripts for the discussion on advance directives.  Adjust the script if the discussion is with the family.  Remember, asking permission to have the discussion shows respect.

• “I would like to talk to you about what kind of care you (your mother) would like if you (she) got really sick.  Is that ok?”
• “If you get really sick, I would be afraid of not knowing what you want or how you would like to be cared for.  Could we talk about it now?  I would feel better if we had this talk.”
• “What kind of medical care would you want if you were too ill or hurt to let someone know your wishes?”
• “There is a way to let your family, friends, and health care providers know what your wishes are and to avoid any confusion later.  This is called an advance directive.  It is a legal document that helps make it clear what you want and do not want if you are very seriously ill.”
• If the patient is terminally ill and does not have an advance directive:   “I realize these are hard questions for you to think about, but because you are so seriously ill, if your heart stopped or you stopped breathing what would you like to have done?”
• Instead of saying to the patient  “Nothing more can be done”  say  “The focus of your care will be aggressively managing your symptoms, so that you can be more comfortable and have the best care possible.”
• Some patients avoid discussing or completing an advance directive because of a belief around “hope or a miracle for a cure.”  One way to support the patient is being open and honest, and refocuses on the possibility of different types of hope and miracles:   “I believe in hope and miracles, but sometimes a cure doesn’t happen.  However, there may be other types of hopes and miracles to consider, such as a good death, a peaceful death with having all your family around you, or for the relief from pain and suffering.  What do you think?”   This can lead to further discussions with the patient on advance directive planning.

Pain Management

Health disparities in pain management.

There is strong evidence that health disparities continue to exist among ethnically diverse groups. In comparison to their white counterparts, ethnic minorities experience higher rates of mortality, shorter life expectancy, greater difficulty with access to health care services, higher rates of chronic disease, lower rates of cancer screening, and higher rates of having a more advanced stage of cancer at the time of diagnosis (Ho, Muraoka, Cuaresma, Guerrero, & Agbayani, 2010; Kline & Huff, 2007; Minority Health Initiatives, 2006; Politzer, Yoon, Hughes, Regan, & Gaston, 2001; Shavers, et al., 2010).  The 2010 National Healthcare Disparities Report indicates that disparities in quality of care and access to care are common, and that ethnically diverse groups such as African-Americans, Hispanics, American Indians/Alaska Natives, Asians/Pacific Islanders, and the poor receive worse care than whites and people with higher incomes (Agency for Healthcare Research and Quality, 2011). 

With regard to palliative and end-of-life care, the 2010 National Healthcare Disparities Report (Agency for Healthcare Research and Quality, 2011) found when comparing African-Americans, Asians/Pacific Islanders, American Indians/Alaska Natives, and Hispanics to whites:

• The ethnically diverse hospice patients were less likely to receive the right amount of emotional support.
• The ethnically diverse hospice patients were less likely to receive end-of-life care consistent with their wishes.
• The ethnically diverse hospice patients were more likely to report poorer communication with their physicians and nurses.

Health disparities in quality of care and access to care have also lead to disparities in the treatment and management of pain during end-of-life care.  Shaver et al.’s review of the literature found disparities in pain management for ethnically diverse patients (Shavers, et al., 2010).  These disparities are likely due to a lack of access to care, lack of appropriate access to analgesics and opioids, lack of access to pain specialists, and language barriers.  The patient’s fear of addiction and the provider’s lack of knowledge about effective pain management during end-of-life are other contributing factors.  Examining the cancer pain experience among non-Hispanic whites, African American, and Asian participants, miscommunication between the provider and patient regarding the patient’s perception and expression of cancer pain was a common theme found across all ethnic groups (Im et al., 2010).  Chung et al. (2009) found that Chinese- and Japanese-American cancer patients’ pain intensity was significantly underestimated by both physicians and nurses, while Anderson et al. (2000) found that physicians significantly underestimated the pain severity of African American and Hispanic patients with recurrent and advanced cancer.  Other studies found that minorities were more likely not to receive pain medication or would receive a lower dose of an analgesic even if the patient had advanced cancer or was receiving end-of-life care (Green, Montague, & Hart-Johnson, 2009; Mossey, 2011; Payne, Medina, & Hampton, 2000; To, Ong, Rawlings, Greene, & Currow, 2012).  Additionally, underreporting of pain intensity by minority patients was a significant barrier to effective pain management (Dhingra, 2008; Mossey, 2011; Shavers, et al., 2010).

Cultural Influence on Pain Response

Pain is more than a response to a physical/biological injury.  It is a complex event that encompasses psychosocial, emotional, and social components, which any treatment of pain must take into consideration (Fortier, Anderson, & Kain, 2009).  A key element of palliative and hospice services is to assess and relieve suffering from not only physical pain, but also from psychological, social, and spiritual distress (National Guideline Clearinghouse, 2011).  In order to provide culturally sensitive pain management, a patient’s pain must be considered within the context of the individual’s beliefs and values, as culture may influence the individual’s perception and response to pain, whether or not the patient will ask for pain medication, or whether the use of traditional healing practices take precedence over Western medical treatment (Dhingra, 2008; Im, et al., 2010; Mossey, 2011; Narayan, 2010; Shavers, et al., 2010).  It is important to remember there are variations among individuals within a cultural group with regard to their perception and expression of pain.  However, understanding the broader aspects of cultural influence affecting response to pain can provide the health care provider with the necessary foundation for assessing specific and individual cultural influences and providing effective pain treatment.

The use of certified medical interpreters for limited English proficient (LEP) patients can facilitate effective communication between the health care provider and the patient about end-of-life care, including the difficult issues around pain management (Norris et al., 2005).  Supporting the use of the interpreter as a cultural broker can also enhance the communication between the health care provider and patient through greater understanding of the cultural aspects and perspectives of the patient (Norris, et al., 2005). 

The following examples of miscommunication are based on several of the author’s clinical observations and experiences and are intended to illustrate the issue.  

When a Cambodian hospice patient was asked if he had pain, he pointed to his heart.  The clinician assumed that the patient was having cardiac pain and further assessment and treatment focused on eliminating the cardiac pain, without effective results.  Upon further discussions with the family it was revealed that the patient’s “heart pain” was referring to his health and how painful it was to him and his family to see him so ill, as well as worrying about his family and the burden his illness placed on them.  For Cambodians, the heart symbolizes love, kindness, willingness to help others, and health (National Head Lung and Blood Institute, 2010). 

Another example of miscommunication is that of an elderly Chinese woman, who when asked if she had any pain, she pointed to her head.  The hospice clinician’s treatment was then focused on treating the patient’s “headache.”  Much time was spent on treating the patient’s headache without effective elimination of the pain.  It was finally realized through persistent assessment and working with the family that the patient’s reference to the pain in her head was not due to a headache, but that the patient had been referring to her anxiety and stress about her illness. 

In these two examples the patient and family were frustrated by not being able to effectively communicate their concerns, and the health care providers were frustrated by not being able to effectively manage the patient’s pain.  The use of a medical interpreter as a cultural broker would have improved communication between the health care providers, the patients and their families, with greater likelihood of positive results in more timely, effective, and appropriate treatment and support.

In addition to language barriers, the way a person expresses pain due to cultural influences can make it difficult for the health care provider to effectively assess the patient’s pain. For some elderly Chinese patients, stoicism and fatalism can create barriers to effective pain management (Carteret, 2011; Dhingra, 2008).  Fatalism as influenced by Buddhist and Confucian beliefs proposes that pain should be endured, as it could lead to spiritual growth (Carteret, 2011).  Stoic patients may be less likely to openly express their pain verbally and non-verbally, and may prefer to be left alone in order to bear their pain and suffering.  Being stoic and hiding one’s pain may influence requests for pain medication or result in the underreporting of pain.  Studies have found stoic pain behavior is more often found among Mexican Americans, American Indians, and Asian Americans (Carteret, 2011; Narayan, 2010; Shavers, et al., 2010).  Health care providers may assume that if the patient is not expressing pain, that pain does not exist, resulting in under treatment.  On the other hand, patients from Middle Eastern or Mediterranean cultures may be more expressive in their communication and more likely to openly express their concerns about their pain.  Being openly expressive does not necessarily mean their pain is intense, but may indicate the need to validate their suffering (Carteret, 2011; Im, et al., 2010; Shavers, et al., 2010).  

According to a study by Im et al. (2010), some Asians and Hispanics felt that since cancer was related to death, increasing pain meant their cancer was getting worse and since death was a taboo subject, talking about pain was not appropriate or they minimized the amount of pain they were having (Im, et al., 2010).  Not acknowledging pain or the intensity of the pain also results in barriers to effective pain management.

In many cultures, religious or spiritual belief in fate and karma (“God’s will”) explain why an individual has developed a life threatening illness and that pain is seen as a test of one’s fate, spiritual beliefs, as a means of achieving higher religious status, or even as a punishment for a sin (Carteret, 2011; Shavers, et al., 2010; Yee, 2007).  If these beliefs are held, patients may not ask for pain medication or expect pain relief.  On the other hand, the role of religion and spirituality can be considered a positive pain coping strategy, as seen in some studies of African-Americans, with the result of lowering pain scores, more positive pain and symptom attitudes, and greater acceptance of pain medication (Shavers, et al., 2010).  

In some cultures, not wanting to be a burden to the family by not complaining may lead to increasing pain intensity.  Pain that is out of control may be more difficult to effectively manage.  The following is an example taken from the author’s experiences:  A Hawaiian woman with stomach cancer was experiencing abdominal pain but did not inform the family about her increasing pain because she did not want to be to a burden.  Only when the pain became so severe that it was affecting her ability to eat and sleep did she finally tell her daughter.  The daughter, who was her caregiver, was very frustrated with her mother for not sharing that she was in pain and that it took a long time before her mother’s pain was brought under control.

Some patients may not want to take opioid pain medication for a variety of reasons, including preference for traditional healing practices, fear of addiction, fear of being overly sedated, a lack of access to insurance coverage, and a lack of access to opioids at their local pharmacies (Narayan, 2010).  In the author’s experience, sometimes even hospice clinicians have difficulty obtaining opioids for their patients as the local pharmacies either stock a very limited supply or do not stock them at all due to an increased risk of robberies. In addition, studies have found that some health care providers associate some minority groups and low income people with drug-seeking and drug addiction behavior, with the result of under treatment of legitimate pain (Coolen, Best, Lima, Sabel, & Paulozzi 2009; Narayan, 2010).

Pain Assessment

Obtaining a comprehensive, culturally sensitive pain assessment will allow the health care provider to have a better understanding of the patient’s pain and to effectively manage it.  The nurse or physician can perform the pain assessment, which should then be documented in the patient’s treatment plan.  The pain assessment results should be shared with the patient’s health care team in order to ensure continuity of care and eliminate pain management disparities.

Utilizing Kleinman’s assessment questions can provide cultural insight into the meaning of the patient’s pain (Kleinman, 1980):

• What do you think caused the pain?
• Why do you think your pain started when it did?
• What do you think your pain does do you?
• How severe is your pain?
• What are the main problems your pain has caused you?
• What do you fear most about your pain?
• What kind of treatment do you think you should get?

The Explanatory Model Interview for Pain Assessment is another tool that provides cultural  insight into the patient’s perception and response to pain (Lasch, 2000; Narayan, 2010):

• What do you call your pain?  What name do you give it?
• Why do you think you have this pain?
• What does your pain mean to your body?
• How severe is it?  Will it last a long or short time?
• Do you have any fears about your pain?
• If so, what do you fear most about your pain?
• What are the chief problems that your pain causes you?
• What kind of treatment do you think you should receive? What are the most important results you hope to receive from the treatment?
• What cultural remedies have you tried to help you with your pain?
• Have you seen a traditional healer for your pain?  Do you want one?
• Who, if anyone, in your family do you talk to about your pain?  What do they know? What do you want them to know?
• Do you have family and friends that help you because of your pain?  Who helps you?

There are a number of scales available for assessing pain among culturally diverse populations, such as the Wong-Baker FACES™ Pain Rating Scale, the 0-10 Numeric Rating Scale, the Visual Analogue Scale (VAS), and the Memorial Pain Assessment Card (MPS), which have been validated for appropriate use with ethnically diverse populations, including African-Americans, Hispanics, Asian Americans, and Native Alaskans (Badr (Zahr), Puzantian, Abboud, Abdallah, & Shahine, 2006; Hunter & Cassey, 2000; Kim & Buschmann, 2006; Luffy & S., 2003; Newman et al., 2005; Ramer et al., 1999; Shavers, et al., 2010; Shin, Kim, Kim, Chee, & Im, 2008; Tomlinson, von Baeyer, Stinson, & Sung, 2010).  Patients usually indicate on the various scales by pointing to the area that best depicts their level of pain.

The Wong-Baker FACES™ Pain Rating Scale  has a series of 6 gender-neutral face circles that range from depicting a neutral facial expression of “no pain/no hurt’ to the “worst possible pain/hurt worst” depicting a crying face.  The Wong-Baker FACES™ Pain Rating Scales is available in 13 different languages, including Spanish, French, Vietnamese, Chinese and Romanian (see Figure 1).  Free access to download the scale can be obtained at FACES Download - Wong-Baker FACES Foundation .  The Wong-Baker FACES ™ scale has been validated with African American, Thai, Asian, Hispanic, and older Korean American populations.  A modified Wong-Baker FACES™ scale used on fabric dolls with Lebanese children also validated the effectiveness of the scale. Curtin and Goldstein (Curtin & Goldstein, 2010), who work with the Native Alaskan Yup’ik culture, effectively utilized the modified Wong-Baker FACES™ scale, known as the Northern Pain Scale, which depict Native Alaskan faces to improve  communication about pain with patients (Curtin & Goldstein, 2010; Ellis et al., 2011).

The Visual Analog Scale (VAS)  consists of a 10-centimeter horizontal line with “no pain” anchored on the left side and “worse possible pain” anchoring the right side.  The patient marks the area on the line that indicates the intensity of his/her pain and the mark is then measured from the left side of the anchor (Kim & Buschmann, 2006).  A VAS color-coded slide ruler can also be used, which the patient moves to indicate the intensity of his/her pain.  The far left side of the ruler is color coded blue, indicating “no pain,” and the far right side is color coded red, indicating “pain as bad as it could possibly be.”  The back of the ruler has a 100 millimeter scale that quantifies the pain intensity (Ramer, et al., 1999).  The VAS scale was considered reliable and validated for measuring pain in older African-Americans, older Koreans, non-Hispanic whites, and Asians with cancer pain (Kim & Buschmann, 2006; Shavers, et al., 2010).

Case Studies

The following three case studies have been developed to address the complex issues surrounding cultural relevance in end-of-life care. These case studies are a compilation of a number of clinical situations and the purpose of the case studies is to examine real-life situations and provide the reader with guidance for reflective practice in the clinical setting.  After reviewing the case studies, the reader may want to reflect on the following questions:

• How does this relate to my previous experiences?
• Would I handle this differently in a similar situation?
• What are my own emotions, values, and biases that may affect the way I would handle a similar situation?
• What have I learned from these case studies?

Case Study 1:  Mr. S

Mr. S is a 53-year-old Cambodian immigrant with incurable metastatic colon cancer diagnosed three months ago. Mr. S has been in the United States for 25 years and has limited English proficiency. His wife is Cambodian, 35 years old, and has been in the U.S. for 10 years. English is her second language. They have three young children. Mr. S worked as a day laborer. His wife has never worked outside the home. They follow Theravada Buddhism.  Mr. S has been referred to hospice services.

Mr. S has been admitted to inpatient services for placement of a peritoneal drainage catheter for malignant ascites.  Nurses’ notes indicated that since admission “Mr. S has been stable with no complaints of pain or discomfort.  His wife accompanied him on admission and stayed until evening. Mr. S was given one Vicodan tablet before bedtime.  Neither the patient nor the wife appears to understand English well.  Interpreter services will be needed when his wife is taught how to manage the peritoneal catheter.” The only medication the physician has ordered is Vicodan, 1-2 tablets every 6 hours as needed for pain.

Upon entering his room, the hospice health care provider, who is not Cambodian, greets Mr. S and his wife with the traditional Cambodian Sampheah greeting of bowing with the hands together at chest level and says in English, “Good Morning.  How are you this morning?”  Mr. and Mrs. S return the greeting with a smile, although it is clear that the effort of putting his hands together and bowing is very taxing for Mr. S.  Mrs. S immediately expresses her concerns about her husband’s pain. She is obviously distressed and explains that Mr. S has been suffering with severe pain in his stomach, did not sleep last night, and has been sick to his stomach.  She states that he threw up this morning, but that she cleaned him up and had not told the nurse.  She wonders if something can be done to make him more comfortable.  She also revealed that she does not want to bring their children to visit because they are too young to understand and she does not want them to see their father in so much pain.  Mr. S. has not participated in the conversation but lies quietly in bed.  However with any slight movement he grimaces, moans, and opens and closes his fist.

The health care provider asks Mr. S the following questions and verifies with Mr. S’s wife that he understands the questions: 

HCP:   “Mr. S, you seem to hurt.  Can you tell me if you are in pain and where is your pain?”

Mr. S:   “Pain here” (pointing to his stomach and back).

HCP:  “What does your pain do to you?  How does it work?”

Mr. S:   “It make me very sick.  I cannot do anything.  I cannot walk. Too weak. I cannot sleep.”

HCP:   “What do you think caused your pain?”

Mr. S:   (He does not answer, but moans and grimaces.)

Mrs. S:   “He wants to go home.  He suffers, but it is too much for him.  Doctor told him he has a tumor.  Can he have a stronger pill to take the pain away?”

HCP:   “Mr. S, how bad is your pain?  Is it there all the time or does it go away sometimes?”

Mr. S:   “Pain very bad.  No sleep, no eat, no move.  I suffer much.”

HCP:   “Do you take anything for your pain that helps?”

Mrs. S:   (She explains he uses Tylenol and  koah kshal  (coining) but that they do not seem to help.  She said the pill the nurse gave him last night also did not help his pain.)  (For more information on coining and other traditional Cambodian healing practices, see the Traditional Medical Practices section of the Cambodian Cultural Profile .

HCP:   “Mr. S, when you are having pain, will you ask the nurse for a pill?”

Mrs. S.  “He will not ask for anything.  He will wait for the nurse to bring him something.”

Reflective Questions and Discussion

What are your impressions regarding this scenario?

A limited cultural awareness and sensitivity on the part of some of the health care providers added to the inadequate management of Mr. S’s pain and symptoms.  Interpreters should be used for initial and ongoing assessment, not only for teaching at discharge.

How could an understanding of the cultural beliefs assist the hospital staff in providing effective end-of-life care?

If the staff performed a cultural assessment on Mr. S they would gain valuable information and insight into his behavior, reactions and decisions.  The assessment would guide the staff in the development of appropriate interventions within the cultural context of Mr. S and his family.  For example, an assessment would ascertain how well Mr. and Mrs. S understood English and if interpreter services were needed to prevent misunderstandings with his treatment. For many Cambodians, pain and other symptoms are often endured with stoicism.  Questions must be asked directly and specially about each symptom the patient may be experiencing. General questions or fleeting questions are meaningless. An assessment, such as using Kleinman’s Eight Questions (see Cultural Assessment in this unit) would help providers understand Mr. S’s behavior, his response to his pain, and his expectations about treatment. This would result in pain and symptom management, including providing pain medication on a routine basis, rather than waiting for him to ask for medication.

What are some key elements that should be included in Mr. S’ treatment plan in anticipation of potential problems or concerns?

• Identify who is the health care decision maker: Mr. S or Mrs. S, both, or other family members.
• Although the nursing notes indicated that Mr. S did not complain of any discomfort, based on his diagnosis, symptoms, and prognosis, comfort measures should be in place. Adequate treatment orders should be written to ensure effective pain and symptom management, including: adequate pain medication on a routine basis to provide a constant level of analgesic and to avoid the roller coaster effect of worsening pain; medication for breakthrough pain; medication for anxiety, nausea and vomiting, pruritus, and bowel management. Frequent assessment and monitoring of his pain and symptoms must be included in the treatment plan.
• In addition, the health care provider should have assessed Mr. S’ perception of and expectations about pain and its management, as negotiations may need to be made regarding the treatment plan.  For example, Mr. S may want a lower dose of pain medication in order to maintain alertness or he may want to avoid medication in order to experience that pain and suffering as an important part of his spiritual beliefs.
• Determine Mr. S’s preference for continued use of traditional practices, such as coin rubbing or herbal remedies. It is important to know about Mr. S’s expectations from traditional remedies.  The provider needs to determine if there are contraindications to their use with Western medicines.
• Determine what role Mr. S’s religious beliefs play in his life and if he would like arrangements to be made to ensure access to his religious community.

A variety of resources including information on specific cultures and cultural practices, end of life care, and guidelines on cultural assessments should be made available to staff. This may include having access to consultation services with palliative care or hospice providers or access to resources on the internet such as The National Cancer Institute . 

What assessment and strategies are needed to improve communication between the health care providers and Mr. and Mrs. S?

An assumption was made that Mr. and Mrs. S did not speak or understand English well.  Consider how that information was determined and passed on to other staff, as well as the impact it had on his care. An initial assessment should include determining how well the patient and family speak and understand English and if there is a need for a certified medical interpreter. If the family does not want interpreter services, check with the organization’s policy on the use of interpreter services. Having a family member translate is not ideal and can result in significant misunderstandings.

Listening with empathy and patience to Mr. and Mrs. S’s perceptions of pain and other symptoms is an important part of effective communication. Clarifying and acknowledging the differences and similarities in the practitioner’s perception of Mr. S’s pain and other symptoms can provide an understanding of Mr. S’ behavior and response to his pain and vomiting. The information can then be incorporated in the development of an effective treatment plan, such as routinely monitoring and asking Mr. S about any pain or symptoms he may be having, rather than waiting for him to tell the nurse.

Respect is central to Cambodian culture.  Greeting the patient and family with the traditional Cambodian greeting shows great respect and can open the door towards a trusting relationship.  The health care provider in this scenario knew that the initial greeting of respect would be helpful to establishing good rapport. Though it may not be practical for health care providers to learn phrases of greeting for all their LEP patients, demonstrating an interest in the patient’s culture or language in other ways can go a long way towards building rapport. 

Case Study 2:  Mrs. V

Mrs. V is a 68-year-old Filipino Hawaiian widow with end-stage chronic obstructive pulmonary disease (COPD).  She is also an insulin dependent diabetic. Last year she moved in with her son, daughter-in-law, and four grandchildren because she was no longer able to live independently.  Mrs. V is by herself all day. She is very short of breath with minimal activity and uses oxygen.  She uses a wheeled walker to get around the house. In the past couple months she has gotten weaker and has fallen a couple times, tripping over rugs and “stuff” on the floor. In addition, her diabetes is not well controlled as she continues to eat peanut butter and jelly sandwiches, juice, and cookies for both breakfast and lunch, as “that is the only thing I like to eat.” Mrs. V is Catholic and her faith is very important to her. English is her primary language. 

The health care provider asked Mrs. V a series of questions to assess Mrs. V’s condition. Mrs. V did not answer the questions directly.

HCP:   “How is your breathing today?”

Mrs. V:   “You know, when I lived in Hawaii, I loved to watch and smell the burning sugar cane fields. I felt so free and relaxed. I moved to the mainland to be near my son and daughter. I used to have my own house, but my son, he wants to take care of me, and so I moved in with him. I don’t like being a burden to him. I miss Hawaii. I wish I could go back there to die. I think the air is much cleaner in Hawaii. Some days I have a very hard time breathing. It can be scary.”

HCP:   “How is your strength? Have you fallen lately?”

Mrs. V:   “I took care of my mother when she was very sick and we never left her alone. That is expected in our culture—to take care of our parents. My son takes good care of me, but his wife is not a good housekeeper. The house is cluttered, but this is not my home. I am here by myself until the family comes home from school or work. I usually stay in my room and watch TV and only get up to eat or go to the bathroom. I still manage. I don’t want to be a burden.   God watches over me and gives me strength and protection. He gives me the strength not to be afraid of dying.”  

HCP : “It is noted that for breakfast and lunch, you only like to eat peanut butter and jelly sandwiches with juice and a cookie. Why is that? You know that is not a good choice because of your diabetes.”

Mrs. V:   Laughing she says ,  “I was a great cook. I loved cooking Filipino and Hawaiian dishes. It is important in our culture to welcome guests into our home and to share our food. The kitchen belongs to my daughter-in-law and I do not feel comfortable cooking in her kitchen. It is hard to get around and I don’t have the strength to do a lot of cooking.  I don’t want to be a burden and make waves with my daughter-in-law. My youngest grandson, he likes to do things for me. He likes to make my breakfast and lunch. He is only in the third grade. Peanut butter and jelly sandwiches are easy for him to make. I don’t like to make a fuss and complain.”

What would be helpful in understanding the cultural aspects of communication by Filipinos/Hawaiians?

For many Filipinos and Hawaiians, “talk story” is a common means of communicating. Instead of answering a question directly, “talk story” is a sharing of personal experiences and opinions, which may initially appear unrelated. It is a powerful communication tool, if the provider takes the time to listen and participate in the conversation, because often it reveals in-depth insight into the thinking and concerns of the individual. However, allowing the patient to “talk story” requires the willingness to take the extra time to listen, and to follow up by asking open-ended questions to encourage the individual to talk, and share some of one’s own personal insights. 

What are some key points Mrs. V revealed during her “talk story”?

The key points Mrs. V revealed were:

• She was having increased difficulty in breathing, which is scary to her;
• She was afraid of being alone;
• She did not want to be a burden and did not feel it was her place to express  her concerns to her son;
• Custom dictates that the house belongs to the son and his wife; therefore, Mrs. V felt she could not request changes to be made even for her health and safety;
• Her faith is important in helping her cope with her terminal illness;
• She felt like a guest in her son’s home, which made her feel uncomfortable.

What cultural issues may be influencing Mrs. V’s response to her health care issues?

• Family comes first, before the individual. In the Hawaiian language, this value is called  ‘Ohana  (family, including extended family and the community) and is the foundation of all Hawaiian and Filipino values.  Maintaining harmony is essential so as not to be a burden to the family.
• The son is the head of the family and deference is made to the wife.
• Taking care of an elder or sick parent is an expectation of the family, with the son usually having the biggest responsibility.
• Communicating though the common form of “talk story” is a way of expressing a person’s concerns.
• Custom dictates that the house belongs to the son and the elder parent has no say in making household changes.

C ase Study 3:  Mr. W

Mr. W is a 70-year-old Chinese American man who lives with his wife of 40 years.  Mr. W was diagnosed with lung cancer two years ago, but is now failing rapidly.  He is very weak.  He can no longer eat due to increased difficulty swallowing and breathing. He does not complain of pain, but his wife says that his back hurts. His two sons live nearby. His daughter moved in recently to help her mother care for him.

Mr. W’s primary care physician wants to make a referral to hospice services. Mr. W says the doctor must talk with his sons first. In a telephone conversation with the sons, the sons agree to hospice services. However, the older son does not want his father to know he is dying and does not want the word “death” to be used when talking with his father. The son tells the doctor, “We do not tell our father that he is dying.  Telling him is harmful, causing undue emotional burden for him.  We are responsible for protecting him from harm.” Mr. W does not take part in the conversation nor does he make his wishes known.  Mr. W does not have an advance directive.

A week later, Mr. W is admitted to the hospital with aspiration pneumonia. He is barely conscious, febrile, and his breathing is slow and irregular. The family continues to encourage Mr. W. to eat. The older son is considering aggressive treatment and the use of a feeding tube and antibiotics. The wife and older son refuse to discuss or participate in the conversation regarding end-of-life care with the nurse or physician. However, the younger son acknowledges that his father is dying. After much discussion and tension within the family, the family agrees to allow Mr. W to die peacefully with comfort measures only and without aggressive treatment. Mr. W dies within 24 hours of admission.

For this case, describe ways in which the issues of self-determination and informed consent can be approached with the family that respect their cultural values/wishes.

• When discussing medical issues with the family, it is important to confirm their understanding of the situation.  Ask the family to explain what they understand about Mr. W’s condition and treatment.
• While Mr. W is cognizant and able to participate in a discussion, the health care provider should assess Mr. W’s preference for wanting to know everything about his medical condition and if he prefers that the discussions occur with the family and in his presence.  It is also very important to ask Mr. W if he prefers making his own decisions about his medical treatment or if he would prefer that someone else (who specifically) make those decisions for him.
• Ask the family if there are preferred terms to use when talking about terminal cancer, whether in front of Mr. W or even with the family. 
• Ask the family if Mr. W has any religious or spiritual beliefs that he might rely on in helping him deal with a serious situation, such as his illness. Let the family know assistance can be provided in meeting his religious or spiritual needs, such as arranging a visit by a religious leader (i.e., monk, minister, priest).
• The health care provider might describe elements of informed consent and offer to provide information about advance directives and durable power of attorney to the family.
• If the patient does not have an advance directive, the health care provider should have an initial discussion with the family about life-sustaining treatment, such cardiopulmonary resuscitation (CPR) or artificially administered nutrition and allow the family time to discuss these issues among themselves before making a decision.  If the patient did have an advance directive, the health care provider should discuss and support the patient’s desires with the family.
• In this situation where there are strong cultural influences in the perception and response to a serious illness, it might be good to assess the comfort level of the family in working with a health care provider from a different background (if that is the case).  An approach might be for the provider to acknowledge that he/she is from a different cultural background and ask if they are uncomfortable discussing these issues with someone who is from a different race or cultural background and asking them, “Will you please let me know if there is anything about your background that would be helpful for me to know in working with you or your (mother, father, sister, brother).”

What Essential Components of a Cultural Assessment should be Performed Relevant to End-of Life Care? 

Please see the table listing essential components of a cultural assessment in the sidebar (Geiger, et al., 2006; Huff & Kline, 2007a).

What could an interdisciplinary team do to improve end-of-life care for Mr. W and his family?

• Ask the family what they would like to see happen to make Mr. W more comfortable, such as helping to ease his breathing or ease his pain.
• Offer ways the family can participate in his care to make him more comfortable.
• Minimize the use of medical jargon to explain what is happening with Mr. W’s condition.  For example, although they would like to see him eat, ask them what their greatest concern is if Mr. W does not eat.  Assure the family that not eating is a natural process as Mr. W no longer needs food for energy as his body slows down.
• To help the family make an informed decision regarding aggressive treatment, such as artificial tube feeding, provide them with information, such as the pros and cons of the treatment.  Explain that as the body begins to shut down, it is difficult for the body to absorb and use the antibiotics or the extra fluids.  The extra fluids can accumulate in the body making Mr. W more uncomfortable. 

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