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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Site Index
    Back to Module 13: Cultural Issues
    Tools for Diagnosing and Mediating Cultural Misunderstandings

    Touch and Gender
    Medical Subculture
    Traditional Medicine
    Body Language
    Bad News
    Meaning of Illness
    Alternative Medicine
    Imminent Death

    Imminent Death

    Expectations and Preparations around the Time of Death

    Star Trekkers are familiar with Klingon death rituals. For a Klingon warrior, death in battle is desirable. Otherwise the warrior death is ritualized at the deathbed. At the moment of death, a comrade (Lt. Worf) holds open the eyes of the dying warrior so he may enter the afterworld courageously, eyes open. A chorus of war-like howling accompanies the moment of death. We don’t see many Klingons, but cultures have different practices and beliefs about the last hours of life, the moment of death and the time period immediately following.

    • When death is expected within a few weeks or days it is appropriate and considerate to ask the patient and/or family what they expect to happen and what is needed to prepare
    • The Victorians clearly had etiquette if not a ritual for the good death. These practices are intended to reassure the patient and insure that they do not die alone. How many relatives constitute not alone is variable. It can mean immediate family (spouse and children) or the whole family (out to second cousins)
    • Preparations may take awhile, so it is important to know how soon the family needs to be notified of imminent death
    • Sometimes the patient, if conscious, needs to be informed of imminent death in order to say certain prayers, make bequests and give instructions to heirs


    What to Do when Cultural Practices Conflict with Hospital Routine

    • Sometimes practices conflict with hospital routine
        For Example
        Some Hindus believe that death must occur in contact with the mother earth. The patient will need to be on the floor or have earth in the bed. There may be burning of candles, incense or fragrant herbs. Such practices may be in conflict with institutional routine
    • If there is no actual danger, such as lighting fires around oxygen tanks, bending the rules is preferable to stressing the family
    • If death is imminent, reconsider the necessity for oxygen or move the patient to a safer area
    • If hospital rules cannot accommodate the patient it may be better to arrange for death at home
    • Bedside purification rituals are common. It may be necessary to wash or anoint the body. Obviously a few hours can be accommodated. If the length of time needed exceeds institutional regulations it is best to have home transfer worked out in advance of the death. Few public health authorities will permit transport of a cadaver to a private home


    Definitions of Death

    • Medical professionals define death different ways. Cessation of brain cortical activity OR cardiac asystole. Others may define it as cessation of breathing, which is difficult to demonstrate for a patient on a ventilator
    • Establish early with the family how you will define death of the body
    • Medical professionals view death as instantaneous. Alive one minute, your heart stops and you are dead
    • Death occurs in stages to other people
        For Example
        In some cultures, death has not occurred until the soul leaves not just the body, but the building. The soul may stay around for several hours or days after the death of the body and must be assisted on its journey or it will stick around to harass the survivors
        Some belief systems allot several souls per person, each with it’s particular travel requirements
    • You need not have detailed knowledge of these beliefs, but be aware that even though you may believe the patient has died, the family may believe the patient is not alive, but not quite dead either. You have heard inklings of this when autopsies are requested and the family refuses because s/he “has suffered enough.” (Also see the section on surgery)
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