The Hospice e-News
What the Media Said about End-of-Life Care This Week
Week of August 15, 2006
…a service of
APPLYING
TRANSCULTURAL NURSING PRINCIPLES TO HOSPICE
An article in the Journal of Hospice &
Palliative Nursing examines transcultural nursing principles and explores their
application to hospice nurses.
Transcultural nursing is defined as “the blending of anthropology and
nursing in both theory and practice.”
Anthropology, the authors say, “refers to the study of humans: their origins, behavior, customs, social relationships,
and development over time. The use of
transcultural nursing principles provides a venue to examine many aspects of
the delivery of care.”
Authors Mimi Jenko, of Lifepath Hospice &
Palliative Care, and Susan Raye Moffitt, of Good Shepherd Hospice, say,
“Providing end-of-life care that honors an appreciation for the sanctity of
human life requires nurses to develop cultural competence.” Their article surveys transcultural nursing
literature to provide a framework for developing that competence.
Jenko and Moffitt refer to several studies that
emphasize the importance of understanding one’s own self and culture in order
to understand the culture of others.
They cite J. Bigby, author of Beyond Culture, as saying, “The beginning
of cultural competence is the desire to better one’s relations with other
groups of people.” In examining one’s
own culture, the article suggests, one must look at potential sources of bias,
values that one holds in common with others, awareness of one’s heritage,
ethnicity (which may mean a “common geographic origin” or shared traditions in
addition to, or instead of, race) and religion.
Jenko and Moffitt offer the Giger and Davidhizar
Transcultural Assessment Model as “an orderly method of acquiring
knowledge.” The model contains six
domains.
* The first domain is communication. In addition to different languages,
expressions may easily be misunderstood.
When one nurse reported that a patient was getting “cold feet” over an
upcoming procedure, the foreign-born doctor immediately checked for circulatory
problems. Silence may signify respect,
agreement or the need for privacy.
Gestures often have entirely different meanings in different
cultures. Touch is very important in
some cultures, but not in others.
Patting a young person on the head in
* The second domain is space. Cultures view space differently, and the
practice of nursing requires “interaction in the intimate or personal distance
zones” (closer than three feet).
“Effective and culturally competent nurses respond to patient cues, thus
maximizing comfort,” the article says.
* The third domain consists of biological
variations. Culturally competent nurses
must be aware of growth, development and other biological factors that affect
nursing assessments. Many cultures have
“hot-cold” theories, with diseases, foods, medicines, herbs and other items
classed as one or the other. These
cultures see the body as being healthy when hot and cold are balanced and a
treatment of the opposite class is applied to restore body balance. Complicating the matter is the fact that
different cultures have different lists of what is considered hot or cold.
* The fourth domain is time. Appointments should be scheduled by clock
time, as cultural differences may affect a person’s understanding. One Hispanic
family arrived for a “lunchtime” appointment after 1 PM, only to find an
irritated nurse and pharmacist who had been waiting for more than an hour. Orientation of time into past, present and
future can affect health care.
Future-oriented individuals usually take active roles in their care and
have no difficulty planning ahead.
Present-oriented ones take little account of the future, focusing
instead on the present, as some American Indians do. Those oriented to the past “display respect
for tradition, a reverence for ancestors, and strong family ties.”
* The fifth domain is environmental
control. Western medicine “focuses on
health prevention and curative medicine.”
On the other hand, folk medicine systems may focus on “the body and
natural phenomena, such as phases of the moon, position of the planets, and
changing of the seasons.”
* The sixth domain consists of social
organizations. Families, religious and
social organizations are very important to most people, and much has been
written about differing cultural beliefs in these groups. Nurses should be
attentive to ethnic origins since, in some cultures, to plan ahead for
healthcare needs is to defy the will of God.
Applying this knowledge to hospice nursing is
fraught with difficulties. Ethical
conflicts may arise in three areas:
* Communicating bad news. The American views of informed consent and
individual autonomy are not universal.
Telling someone that they have a serious illness is considered to be
disrespectful and impolite in Asian cultures, while in some parts of
* Decision making. Gypsy grandparents make decisions for family
members because their culture sees wisdom as part of old age. Some societies are patriarchal and others are
matriarchal. In the
* Advance directives. Some cultures are expected to vigorously
preserve life. In others, the whole
family is expected to be involved and families are often reluctant to designate
one family member as the spokesman.
Suffering may be seen as an opportunity to atone for sin.
Various religious groups oppose the removal of
life support.
Because of the many cultural differences that
exist, the authors offer the following guidelines for practitioners.
* If a translator is needed, be careful in
choosing one. “It is generally not
advisable to utilize housekeeping staff or a family member, because of age or
gender differences, lack of medical knowledge, and possible hidden agenda.”
* If it fits the patient’s preferences, be
prepared to plan with the extended family instead of just the patient.
* Disease processes “must not override the
‘essence of what makes up one’s human experience.’”
The article is online at www.medscape.com/viewarticle/534031.(Journal
of Hospice & Palliative Nursing, 2006;8(3):172-180)
ARTICLE
EXPLORES DREAMS THAT INCLUDE “VISITS” FROM LOVED ONES
Every night, The Wall Street Journal says,
“millions of people are visited by deceased loved ones. In dreams, the living and the dead embrace,
converse and reach understandings. What
are we to make of these encounters?
Are they merely emotional responses to dreamers’
grief? Or, as research suggests, are
there patterns to these dreams that could explain the inexplicable?”
At the recent Compassionate Friends annual
conference, the sessions on after death communication, or ADC, were filled to
capacity. Conference speakers delineated
two types of dreams: 1) “Basic grief”
dreams are “fragmented and filled with symbolism.” Travel may be involved, with the deceased
persons getting off the train and the survivors going on without them. 2) “Visitation” dreams need less
interpretation and are usually more vivid.
The deceased person is often healthy.
Researchers say that women are more open to
receiving messages from the dreams and that men may underreport their grief
dreams. Bill Guggenheim, co-founder of
the ADC project, thinks that men may be afraid of “being perceived as weird or
too grief-stricken.”
The article says that research in brain imaging
has shown that the part of the brain that engages in rational thinking – the
prefrontal cortex – “basically goes offline” when a person goes to sleep. The parts of the brain that involve imagination
and emotion then become active.
Kelly Bulkeley, former president of the
International Association for the Study of Dreams, says that researchers can’t
determine whether dreams are “visitations” or “expressions of deepest
wishes.” “It’s an unanswerable debate,”
he says. But one speaker, telling of
losing her five-year-old son, said that dreams about late loved ones are often
gifts.
“Don’t overanalyze it,” she said. “Accept it with gratitude.” (The Wall Street Journal, 8/3)
RESEARCH
& RESOURCE NOTES
* The Journal of Pain & Symptom Management
reports on a study of experienced caregivers and their perspectives on
existential and spiritual distress in palliative care. Interviews with focus groups identified eight
themes: “conceptualization of
spirituality; creating openings; issues of transference and
countertransference; cumulative grief; healing connections; the wounded healer;
sustaining a healing environment for the caregiver; and challenges and
strengths for the spiritual and existential domains of palliative care.” “Transference and countertransference issues
and the ‘wounded healer’ concept were considered fundamental to effective
care.”
(Journal of Pain
& Symptom Management, 2006;32(1):13-26)
* NHPCO is partnering with the National
Alliance for Hispanic Health to create a new help line, Cuidando con Cariño,
Compassionate Care.
The Spanish-language service, which began in
early August, will offer bilingual specialists who answer questions about
hospice, palliative care, grief and loss, caregiving and advance care
planning. Written information will also
be available. The help line’s number is
(toll-free) 877-658-8896.
(NHPCO News Release, 8/8)
END-OF-LIFE NOTES
* An editorial in The
* Florida lawyer David Gibbs III, who
represented Terri Schiavo’s parents, has written Fighting for Dear Life: The Untold Story of Terri Schiavo. Gibbs says, “The public missed how alive
Terri was. They had in mind the thought
of a vegetative state. But I watched her
kiss her mother and cry when she left the room.
Here was a disabled person who was alive. If the public had seen that,
we could not have let her die the death we allowed her to die.” (
*
* Yahoo! News reports that in 2004, 1.06
million people asked for hospice care, an increase of 110,000 over the year
before. In 1974, there was one hospice
in the
OTHER
NOTES
* The RWJF program, Promoting Excellence, is
closing its program office and the organization is partnering with NHPCO to
make sure that its materials remain available at www.promotingexcellence.org. In its nine years of existence, Promoting
Excellence supported demonstration projects, funded grants and sponsored
workgroups, all aimed at promoting excellence in end-of-life care. (PR Newswire, 8/10)
* Nanotechnology has been around for a while
and the wave of the future is “nana technology,” which will provide the things
your grandmother needs. Companies and
universities are teaming up to devise all sorts of living aids for the
elderly. Balance boosters are insoles
for shoes that send vibrations to the bottom of a person’s foot, making them
more sensitive to signals that they’re off balance. Walkers that can avoid obstacles and come
when called are in the works. Smart pill
dispensers will signal an elderly person that it’s time for their medications. Robots that will help caregivers lift persons
who can’t walk are in the works. Intel
is working on an intelligent telephone that displays a picture of the caller,
the person’s relationship to the caller and notes about the last conversation.
(
* On All Things Considered, hosts Michelle
Norris and Melissa Block examined the work of the palliative care team at
Children’s
Glatfelter Insurance Group is the national
sponsor of Hospice News Network for 2006.
Glatfelter Insurance Group provides property and liability insurance for
hospices and home healthcare agencies through their Hospice and Community Care
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* There will be no publication of The Hospice e-News on the week of September 12, 2006. *