Cultural perspectives

The following section outlines the cultural influences on CALD patients’ willingness to participate in ACP and AD. While aspects of culture are described, it is important to avoid stereotyping patients as having the same worldviews. The patient’s degree of acculturation and the strength of their ties with traditional beliefs will be important factors in patient and family responses to ACP and AD.

This section also provides culturally appropriate approaches to addressing ACP and AD with CALD clients, including additional guidelines on how to communicate and engage with clients and their families. Knowing how to assess the need for an interpreter and how to work with interpreters effectively is essential for working with patients with low or no English language ability.

Chinese

Some families may not be familiar with the concept of ACP and AD. Some may value length of life more than quality of life and may make every attempt to prevent someone from dying and may even ask for cardiopulmonary resuscitation (CPR) to be attempted at the last minute or in the ACP or AD plan. This is usually because they do not want to feel guilty at not doing enough for the loved one during the end-of-life period (Con, 2007; Htut, 2007; Lip, 2009; Tse, 2003). It is important to be aware that some families are not aware that in New Zealand treatment that is considered not effective for ameliorating or correcting serious or life-threatening conditions, will not be offered. This needs to be explained in a culturally appropriate manner.

Families’ protection of elders may result in not informing their family member of a serious diagnosis, and there may be a reluctance to place the older person in long-term care. For the same reasons, families are unlikely to want to discuss ACP with their older family member. Traditional Chinese families do not like discussing taboo subjects such as death, dying and cancer. They believe that discussing death and dying may lead to something bad happening. Health professionals need to be sensitive and aware of these possible beliefs when approaching such issues when discussing ACP.

Decision making is traditionally expected of the husband or the eldest son. Caring for the sick and dying is the duty of the family. It is also important to ask about whether there is an accepted family decision-maker (Yeo, 1995). Physician and family-based decision making is preferred over patient autonomy.

There may be resistance towards organ donation. This may result from a wish to keep the body whole for the afterlife, and out of respect for the deceased person. However, attitudes can change in families depending on their level of acculturation.

Korean

Traditional Korean families consider family-based medical decisions as a function of filial piety. Illness is considered a family event, rather than an individual occurrence (Searight, 2005). It is also expected that family leaders be the decision makers, e.g. husband or oldest son.

In Korean families, it is expected that a parent will make decisions in the best interests of their children, and children will make decisions in the best interests of their parents to meet filial piety obligations. This may conflict with practical decisions. Parents and children may assume that they know what is best and may not discuss issues with each other. It is important for health professionals to understand why Koreans may not make clear decisions about ACP or end of life care, and why they often change their minds.

South Asian

Traditional South Asian families value physician and family-based decision making over patient autonomy. Caring for the sick and dying is the duty of the family. There are social taboos against using words such as cancer, and death and dying when talking to a family member with a serious diagnosis. The avoidance of contemplating serious ill-health and death presents a barrier to the discussion of ACP in Asian families (Lip, 2009).

It is important to note that due to religious beliefs and practices post mortems or organ donation is generally unacceptable to people from South Asian backgrounds, unless it is necessary.

Muslim

Family support is seen as integral to the process of recovery. If a family member is sick the whole family may feel a responsibility to look after the one in need (Con, 2007; Shah, 2012). Seeking any form of treatment is allowed whether traditional or Western, as long as it is a recommended and legal form of treatment.

Some families could urge that “everything needs to be done” for the dying patient because they want to prolong life for as long as possible. Sometimes there is family disagreement about what is best for the dying patient. It is important to be aware of this and explain that treatment cannot be offered to the patient if it is not medically indicated.

Many Muslim families may not be familiar with advance directives or advance planning. Some think that if they give an AD they will not be treated and that by appointing a health-care representative they are giving up control of their health-care decisions. There should be a discussion on AD with members of the family and expressed wishes should be recorded. There are also misconception amongst Muslims (a) that an advance directive is a permanent document and that it cannot be changed; (b) verbal wishes are not legal; (c) that physicians do not have to follow one’s wishes because they are “gods;” they will do whatever they want (Athar, 2011).