Death and Dying - Cultural Diversity
There is not just one attitude or approach toward dying and death among Americans. Studies in the social science and health literatures on how cultural diversity influences patient, family, and provider responses to end-of-life treatments and decision-making have been appearing slowly but steadily since the mid-1980s. Two themes emerge from this research. First, health workers are trained in particular professional cultures and bring their own experiences to bear on the dying process. Physicians, nurses, social workers, chaplains, and other health care professionals hold different assumptions from one another about how death should be approached as a result of their different types of training, and those sets of assumptions differ from the experiences of patients and families (Koenig). Second, the relationships among ethnic identification, religious practices, ways of dying, and beliefs and priorities about care, autonomy, and communication are complex and cannot be neatly organized along ethnic, class, or professional lines. In assessing cultural variation in patient populations, for example, cultural background is only meaningful when it is interpreted in the context of a particular patient's unique history, family constellation, and socioeconomic status. It cannot be assumed that patients' ethnic origins or religious background will lead them to approach decisions about their death in a culturally specified manner (Koenig and Gates-Williams).
In an increasingly pluralistic society, there is growing diversity among health care workers as well as among patient populations. Especially in urban areas, the cultural background of a health professional is often different from that of a dying patient to whom care is being given. It is impossible and inappropriate to use racial or ethnic background as straightforward predictors of behavior among health professionals or patients. In their study of ethnic difference, dying, and bereavement, Kalish and Reynolds found that although ethnic variation is an important factor in attitudes and expectations about death, "individual differences within ethnic groups are at least as great as, and often much greater than, differences between ethnic groups" (p. 49). The impact of cultural difference on attitudes and practices surrounding death in the United States cannot be denied. The challenge for society is to respect cultural pluralism in the context of an actively interventionist medical system.
SHARON R. KAUFMAN
CALLAHAN, D. The Troubled Dream of Life: Living with Mortality. New York: Simon and Schuster, 1993.
GILLICK, M.; HESSE, K.; and MAZZAPICA, N. "Medical Technology at the End of Life: What Would Physicians and Nurses Want for Themselves?" Archives of Internal Medicine 153 (1993): 2542–2547.
Institute of Medicine. Approaching Death: Improving Care at the End of Life. Washington, D.C.: National Academy Press, 1997.
KALISH, R. A., and REYNOLDS, D. K. Death and Ethnicity: A Psychocultural Study. New York: Baywood, 1976.
KOENIG, B. "Cultural Diversity in Decision Making about Care at the End of Life." In Approaching Death: Improving Care at the End of Life. Institute of Medicine. Edited by M. Field and C. K. Cassel. Washington, D.C.: National Academy Press, 1997. Appendix E. Pages 363–382.
KOENIG, B., and GATES-WILLIAMS, J. "Understanding Cultural Difference in Caring for Dying Patients." Western Journal of Medicine 163 (1995): 244–249.
MCCUE, J. D. "The Naturalness of Dying." Journal of the American Medical Association 273 (1995): 1039–1043.
MULLER, J., and KOENIG, B. "On the Boundary of Life and Death: The Definition of Dying by Medical Residents." In Biomedicine Examined. Edited by M. Lock and D. Gordon. Boston: Kluwer, 1988. Pages 351–374.
QUADAGNO, J. Aging and the Life Course: An Introduction to Social Gerontology. Boston: McGraw-Hill, 1999.
SCITOVSKY, A. A., and CAPRON, A. "Medical Care at the End of Life." An American Review of Public Health 7 (1986): 59–75.
SLOMKA, J. "The Negotiation of Death: Clinical Decision Making at the End of Life." Social Science & Medicine 35 (1992): 251–259.
SOLOMON, M., et al. "Decisions Near the End of Life: Professional Views on Life-Sustaining Treatments." Journal of Public Health 83 (1993): 14–23.
SUPPORT Principal Investigators. "A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients." Journal of the American Medical Association 274 (1995): 1591–1634.