Death and dying

Traditional families from Asian, Middle Eastern and African cultures do not like discussing taboo subjects such as death and dying. They believe that discussing death and dying may lead to something bad happening. An awareness of family expectations and views around death and dying beliefs and practices will help health professionals to approach such issues with distressed family members, in a culturally sensitive manner.

Chinese perspectives

The Chinese traditional view about “a good ending” is that, when facing death, the dying person feels comfortable, peaceful and surrounded by children/family.

Some families consider quantity of life more important than the quality of life and may insist that cardiopulmonary resuscitation (CPR) be provided until the last minute. This is because they want to do the best for their loved one (Con, 2007; Htut, 2007; Lip, 2009; Tse, 2003). They may not be aware that in New Zealand treatment that is not medically indicated will not be offered. Being aware of this will help health practitioners negotiate with the distressed families appropriately.

Religious views about death and dying include:

Korean perspectives

Beliefs about life after death differ according to a person’s age, religion, education and life experiences.

Korean people’s religious backgrounds affect their beliefs about the afterlife. The majority of Koreans in New Zealand are Christians. However, while Christians in general accept death because there is a positive outlook on death and the afterlife, there are other Korean Christians whose death and afterlife beliefs are deeply influenced by Confucian thought, particularly neo-Confucian (a term commonly applied to the revival of the various strands of Confucian philosophy and political culture). There are also Buddhist and Shamanistic influences in Korean traditional funeral rites.

South Asian perspectives

In South Asian families, the family plays a central role at the time of terminal illness or death. Many South Asian people prefer to die at home. From a traditional perspective it is very important for family members to be at the bedside of the terminally-ill client praying, chanting hymns and bringing in pictures of religious figures/gods/goddesses (Periyakoil & Dara, 2010).

Some families may be hesitant to allow health providers to give a dying person sedating medications (because it may be important to the family that they be as awake as possible during the dying process). These traditions reflect a belief that dying individuals should be thinking of God as they go through the dying process, because it is believed that the nature of one’s own thoughts at the time of death determines the destination of the departing soul.

However, if the clinician identifies that the client is suffering pain, dyspnoea or other symptoms, and the client is requesting relief of symptoms, sedation of the person and gentle education of the family members will likely result in consent to the needed palliative care measures.

Hindu families may request that the body be placed on the ground (as a mark of respect to mother earth). Hindu families may also request that health providers allow them to place a Tulsi leaf or drops of water from the Ganges River on a client’s lips. They may want to chant the Bhagavad Gita or other Vedic hymns at the time of death. This allows a client to focus on God as their soul leaves the body.

After death, it may be important for family members (of the same gender) to be allowed to perform ritual washing of the body and prepare it for burial (in the case of Muslim families) or cremation (in the case of Hindu families). This should ideally be done within 24 hours of the death. Christians may opt for burial or cremation. Most South Asian families will not request an autopsy but may not be opposed if there are clear reasons for it. This topic should be approached with great sensitivity.

The mourning family may prefer to have a priest perform a prayer and blessing. It is very important to provide privacy to the family after the death of a family member to allow religious rites to be performed. It is an accepted practice for family members and others to openly express grief. For Hindu families, after cremation, there is a mourning period that lasts for 10 to 40 days.

Religious views about death and dying include:

Sikhism arose from Hinduism and these religions share a culture and world view that includes ideas of karma and rebirth; collective versus individual identity; a strong emphasis on purity; and a lifestyle based on ‘Ayurvedic’ medicine (a system of traditional medicine native to the Indian subcontinent, a form of alternative medicine) (Con, 2007). These religions affect end-of-life decisions and care in a number of ways:

• There is a perception that talking about death may make it occur and therefore the family are often reluctant to let their loved one know about a terminal illness.
• There is a preference to die at home or in a hospital but not in a palliative care unit as the latter are seen as places for dying people and may be seen as tainted.
• Withdrawal of food and water at the end-of-life is not likely to occur because it is believed that both are needed for a good death.
• There may be a reluctance to use pain killers as pain must be endured (to help reach a higher state of mind).
• Withdrawal of treatment is acceptable if it is futile.

Muslim perspectives

Death is believed to have its set times for every human being and is expected to come at any time, therefore it is well accepted. Muslims believe in the afterlife and the Day of Judgment. They regard death as a transition from one phase of existence to the next. It is preferred that Muslim people die at home. Care of the dying is a regular and essential responsibility of the immediate and extended family and has historically been managed at home. With more young Muslims becoming professionals and moving away from their family homes, this is slowly eroding.

During illness, Muslims are expected to seek God's help with patience and prayer, increase the remembrance of God to obtain peace, ask for forgiveness, give more in charity, and read or listen to more of the Qur'an.

Muslim clients do not consider illness to be a punishment from God. They also believe that dying is a part of living and an entrance to the next life; a transformation from one life to another, a part of a journey, and a contract and part of their faith in God.

Muslim traditional practices believe that maintaining a terminal client on artificial life support for a prolonged period in a vegetative state is not encouraged. Although there is a belief that autopsy is not to be encouraged, it is permitted if required by law. Individual Muslim practices may vary.

NB: Information about end-of-life care for: Cambodian, Chinese, Indian, Japanese and Vietnamese cultures; and for Buddhist, Hindu, Sikh and Muslim faiths is available from Waitemata DHB eCALD® Services (2016) See “Death and Dying: Information from Different Asian Cultures and Religions”

Palliative care for Muslim clients

The aim of end-of-life care is to reduce anxiety. Optimism and hope are regarded as some of the fruits of faith in Islam. Illness and disease is a test from Allah and illness should be received with patience, meditation and prayer. Palliative care services are valued and effective but Muslim families need to be informed that such services exist.

Important aspects for consideration around palliative care for Muslims.

• In matters of terminal care, the attending physician should always consult the client and involve the family, before making a final decision.
• Health providers should comfort the terminally ill person, making sure they are pain-free and that their relatives and friends are able to be with them.
• The family should be given access to an Imam who can read the Qur'an and make special prayers.
• Muslim families may want to chant the Qur’an at the bedside.
• At the time of death, family members may request that the body be positioned in specific directions (for Muslims the dying person’s face is turned towards Mecca).
• It is important that funeral and burial arrangements be made in advance, in consultation with the family and according to the wishes of the dying or deceased person if possible.
• With minimum delay, the body is to be removed to the funeral home because Muslims prefer an expeditious burial. Provide routine post-mortem care. The body should be gowned and shrouded.
• Allow the family and Imam to follow Islamic guidelines for preparing the dead body for an Islamic funeral.