Spiritual and cultural influences on end-of-life care decision-making: a comparative analysis of the Arab Middle East and the United Kingdom

Abstract

Purpose of review

This review seeks to explain the impact of cultural and spiritual factors on end-of-life care decision-making from different countries to assist in the development of coherent responses for palliative care.

Recent findings

Spiritual and cultural factors shape end-of-life decision-making in the Arab Middle East and the United Kingdom. Arab cultures emphasize dignity through faith and family, leading to collective decisions, while the United Kingdom focuses on individual autonomy. Both allow withdrawal from futile treatment to alleviate suffering, but Arab approaches are more family centric. Additionally, spirituality in Arab cultures is often collective and religious, compared to the personal and secular practices common in the United Kingdom.

Summary

Western and Arab Middle East cultural beliefs influence our understanding of death, dying, and the acceptability of various care options. As people near the end of life, spiritual issues are likely to affect their values and preferences.

INTRODUCTION

Culturally and spiritually dictated values significantly influence end-of-life (EOL) care (EOLC) and the related decision-making processes. These frameworks shape how patients and families perceive concepts such as illness, suffering, and death, as well as their preferences regarding medical communication and interventions [1]. During terminal illness, individuals often seek spiritual support to cope with grief and uncertainty, while also seeking to infuse hope and meaning into their lives [2]

KEY POINTS

• Cultural and spiritual factors deeply influence end-of-life decision-making around the world; however, there are similarities between the Arab Middle East and the UK.

• In the UK, the healthcare system is strongly influenced by principles of personal autonomy and patient-centred care.

• In the Middle East, healthcare dynamics are shaped by cultural humility, diverse professional attitudes, and patient expectations influenced by collectivist values, religious beliefs, and cultural stigmas.

• In culturally diverse societies, it is crucial to exhibit cultural humility and recognise the different notions of authority and agency. This practice fosters understanding and prevents the majority from imposing their norms on minority groups.

Cultural considerations play a crucial role in determining the involvement of family members in decision-making processes, expectations regarding truth-telling, and guidelines for life-extending procedures [3]. For example, in many collectivist cultures, the emphasis on individual autonomy prevalent in Western medical ethics contrasts sharply with a patient-centred approach where family members or elders make EOLC decisions [4]. Different religious traditions also offer varying perspectives on concepts such as suffering, the experience of life during palliative sedation, and beliefs about the afterlife. For instance, Islamic, Hindu, Christian, and Buddhist traditions each present unique interpretations that can either support or challenge specific EOL practices [5].

In the context of globalisation, healthcare providers must develop culturally responsive and spiritually aware practices to respect the diverse healthcare needs of patients and families with varying beliefs. Failing to do so can lead to significant miscommunication, disputes, and moral distress, ultimately compromising the quality of EOLC [3]. This review aims to explore the impact of cultural and spiritual elements on EOL decision-making in 2 different cultural contexts, thereby assisting in the development of coherent and respectful responses for palliative care. By understanding the complexities of cultural and spiritual influences, healthcare providers can improve communication with patients and families, ensuring that care aligns with their values and beliefs.

METHODOLOGY

This literature review involved a comprehensive search of major databases, including MEDLINE, CINAHL, Embase, and PsycINFO, for original studies published in English over the past 2 years. The focus was on EOL decision-making, spiritual care, and cultural differences between the United Kingdom and the Arab Middle East countries (Table 1). In the initial search, a total of 1,935 articles were identified. After removing duplicates, 1,820 articles remained. Following the first round of review, 162 articles were selected for further consideration. A second round of review narrowed this down to 38 articles, which were ultimately included in this review. The selected studies specifically addressed the themes of interest, and studies conducted in non-Arab countries were excluded to ensure relevance to the cultural contexts under investigation. Data from the included studies were analysed and categorised according to cultural and spiritual factors influencing EOL decision-making. This approach facilitated a comprehensive understanding of spiritual care within these distinct contexts.

Table 1.

Geography of study contexts

Arab Middle Eastern contexts	The UK (Western) contexts
Country (N)a	Country (N)a
Jordan (9)	England (14)
Saudi Arabia (5)	North-West of England (1)
Palestine (2)	Southeast of England (1)
Lebanon (3)
Bahrain (1)
Sultanate of Oman (2)
Total studies = 22	Total studies = 16

^aN is the number of the studies by country.

FINDING

Spiritual and cultural factors significantly and intricately influence decision-making regarding EOLC in various countries. These influences are evident in religious beliefs, individual preferences, family dynamics, and societal norms. The following sections highlight key themes and variations, supported by evidence from diverse contexts, including the Arab Middle East and the United Kingdom (Table 2).

Table 2.

Comparison and key differences of cultures

UK (Western) cultures	Arab Middle Eastern cultures	Dimensions
Independence, self-worth	Faith, family, social role	Element of dignity
Individual-centred more autonomy in individual decisions	Collective, family based; strongly family-centric, sometimes protective	EOL decision-making
Withholding/withdrawing is allowed in many contexts	Allowed to withdraw if futile and suffering is prolonged	Life-prolonging treatment
Personal, often secular	Collective, religious rituals	Spirituality

RELIGION AND SPIRITUALITY

When examining the religion and spiritual factors influencing EOLC decisions, clear differences emerge between Islamic and traditionally Christian or secular cultures. In predominantly Muslim societies, such as those in the Middle East, spirituality is deeply connected to Islamic beliefs, emphasising a direct relationship with Allah. Practices like continuous prayer, reading the Holy Quran, and facing Mecca are essential, with families and healthcare providers actively supporting these spiritual activities at the bedside [6]. Faith provides comfort and hope play a vital role in helping individuals cope with the certainty of death [7^▪]. Many patients and their families strongly believe that Allah has the power to heal, fuelling hope for miraculous recoveries even in severe situations. This faith can cause reluctance to accept death’s finality, leading to a desire to pursue all possible medical treatments [8–13]. Islamic teachings highlight virtues such as patience (sabr), reliance on God (taqwah), and acceptance of divine will, which influence both individual coping and family decision-making. While these virtues inspire hope for recovery, they also promote acceptance of impending death [14,15,16^▪▪]. Additionally, Islamic principles emphasise the sanctity of life, creating tension around euthanasia and the withdrawal of futile treatments. Although euthanasia is generally considered ‘haram’ (forbidden), there are recognised exceptions where medical consensus and religious ‘Fatwa’ (formal ruling or interpretation on a point of Islamic law by a qualified person) may permit withholding treatments that provide no benefit [10^▪].

Conversely, in majority regions with traditionally Christian or secular cultures such as the UK, spirituality in EOLC tends to be more personal and less focussed on specific rituals. In these settings, spirituality covers broader themes such as finding meaning, leaving a legacy, and feeling connected, which may not always match organised religious practices. For example, in palliative care in the UK and Ireland, healthcare providers often aim to create an environment where patients can reflect on their lives and relationships rather than following strict religious rituals [17–19]. In Christian Middle Eastern countries like parts of Lebanon and Jordan, beliefs in the inherent value of suffering and accepting God’s will may shape views on treatment futility and dignity during illness or approaching death. Practices like prayer and religious rituals serve as main coping mechanisms, and spiritual distress may occur if these needs are unmet or misunderstood by healthcare teams. While many Christian traditions emphasise prayer and sacraments at the EOL, there is often more flexibility with EOL decisions, including discussions about assisted dying in some denominations [20,21]. However, training healthcare staff on spirituality remains an ongoing challenge, particularly in multicultural settings where providers may lack understanding of patients’ diverse religious needs [11,22,23^▪▪]. Overall, although both Islamic and traditionally Christian or secular cultural frameworks value spirituality during EOL, their expressions and interpretations vary greatly, reflecting the complexity of religious beliefs.

CULTURAL NORMS AND END-OF-LIFE DECISION-MAKING

Most research on the cultural aspect of EOL decision-making comes from the Arab Middle East and focuses on cultural values and attitudes toward death in practice. Attitudes toward death are often assessed through validated scales, such as the Frommelt Attitude Toward Care of the Dying (FATCOD) scale [8,15,24,25]. Healthcare providers from Arab Middle Eastern cultural backgrounds were seen to have a significant impact on EOL decisions. Their approaches to caring for the dying were viewed both positively and negatively [8,15,24]. For instance, a study by Alaswami and colleagues explored perceptions and attitudes toward analgesic use for dying patients. The authors found that concerns about the potential negative effects related to tolerance and addiction to pain medication received the highest average score of 2.84 ± 1.37 [25]. Research examining attitudes (particularly among nurses, medical professionals, and students) found that fostering a positive, accepting attitude through education and support is essential for delivering compassionate and effective EOLC [9,15,26,27]. Cultural norms have a strong influence on attitudes towards death; however, there are some differences. Hamadeh and colleagues [26] provide a comparative study of attitudes of medical students toward death between Arab and Western contexts. In Arab and Muslim contexts, for instance, death is generally accepted, and there is an emphasis on coping through faith, prayer, and charity. In contrast, Western contexts more commonly encourage grief counselling and support groups, reflecting different cultural norms [26,28].

Patient and family centred (involvement and autonomy)

Family-centric cultures across the Arab Middle East families play a central role in EOL decisions. Rather than prioritising individual autonomy (which is more common in Western countries), collective family preferences and shared discussions are the norm [20,29]. The family role emphasises the responsibility of withholding diagnoses or prognostic information to protect their loved one from emotional distress [10^▪,30]. Patients are frequently expected to defer to family or clinician authority, a norm reinforced by cultural and health system structures. Decision-making may shift from patients to next-of-kin, with the goal of minimising harm and maintaining family honour [10^▪].

Conversely, in UK societies, there is a strong emphasis on patient autonomy and informed consent [12]. Patients are typically encouraged and enabled to make their own EOL decisions, ideally documented in advance directives or anticipatory care plans [3]. However, in UK societies, ethnic and cultural minority groups may still adhere to family-centred models, revealing the persistent impact of culture within multicultural societies [31^▪▪,32–34]. Certain cultures, for example, families of forced migrants, continue to make decisions collectively, and healthcare systems may implicitly assume a preference for direct patient participation, which can lead to institutional conflict and moral distress for both professionals and families [19,31^▪▪,32].

Dignity is not just cultural or spiritual; it is a complex idea that relies on the connection between culture and spirituality. In Arab Middle Eastern cultures, spirituality offers inner strength and acceptance [21]. Culture, on the other hand, anchors dignity in family, social belonging, and access to compassionate care [16^▪▪,21]. The importance of each aspect can vary among societies and individuals. However, dignity is most stable when both cultural and spiritual needs are met and acknowledged [16^▪▪,21]. In UK and Western cultures, dignity is mainly about the individual’s rights and agency. It centres on autonomy, personal preference, and independence. The healthcare system, ethical guidelines, and cultural values stress the importance of respecting patients as individuals who make their own choices [18].

Grief and bereavement (care afterlife)

In the Arab Middle East and Muslim world, people mainly process grief within religious and family settings. This approach focusses on acceptance, restraint, and ongoing spiritual care for those who have died [35^▪▪]. There is limited formal professional support or bereavement services. Believing that the deceased move on to an afterlife, either Heaven or Hell, with a continued connection through religious acts is common. Taking care of the soul after death, such as making donations or saying special prayers, is viewed as essential [35^▪▪,36,37]. Alshammari and colleagues [38] studied nurses’ beliefs about EOLC, and the result showed that professionals from various cultural or religious backgrounds may struggle to understand or connect with the bereavement needs and practices of patients and their families. This can affect the quality of care provided after a death. In the UK, the context is more varied, mixing religious, cultural, and non-religious approaches. While formal bereavement services are easier to access (bereavement counsellors, group therapy, ‘Tell Us Once’ administrative services, etc.) [36], cultural gaps still exist, especially for Muslim patients and families [14,17,39]. This shows the need for care that is tailored, sensitive, and inclusive [14,40].

COMMUNICATION AND INFORMATION DISCLOSURE

Communication regarding EOLC decision-making exhibits significant differences between the Arab Middle East and the UK, shaped by cultural values and social norms. In Arab societies, discussing death is often considered taboo, fostering discomfort and avoidance of open dialogue about EOL issues [41]. This cultural reluctance is compounded by spiritual beliefs and social stigma surrounding illness, where discussing death may evoke fear or be perceived as inviting misfortune [10,20,21]. Consequently, indirect communication and euphemisms are frequently employed to shield patients from distressing truths, as many believe that revealing bad news could diminish hope or hasten decline. Families often play a central role in decision-making, and there is a strong emphasis on maintaining familial dignity and social status during the dying process [20,26].

In contrast, the UK adopts a more transparent approach to communication about EOLC. Here, open and honest conversations regarding prognosis and treatment options are seen as essential parts of patient-centred care. Euphemisms and indirect methods of discussing death are actively discouraged (particularly among healthcare providers), although many members of the public still rely on euphemisms such as ‘passed away’ or ‘gone to a better place’ [42]. Patients are usually encouraged to take an active role in their treatment choices, reflecting a cultural norm that values individual autonomy and informed consent [17,18,31^▪▪,36,43]. Healthcare professionals are generally trained to deliver bad news with sensitivity and clarity, enabling patients to fully understand their options and engage in meaningful discussions about their wishes [19,44].

Additionally, while patients in the Middle East may express a desire to know the truth about their prognosis, their decisions are often influenced by familial roles and the collective nature of decision-making, which may lead to a preference for withholding certain information to protect loved ones from distress [12]. In contrast, in the UK, the emphasis on personal autonomy often means that patients expect to be fully informed, even if the news is difficult [12,19]. These cultural differences highlight the complexities of communication, truth-telling, and information sharing in EOL decision-making [23,45], emphasising the need for culturally sensitive approaches that respect the diverse values and beliefs of patients and families in both contexts.

CONCLUSION

In conclusion, despite the differing practices of EOLC in the Arab Middle East and the UK, both approaches prioritise compassion, dignity, and care. While they may vary in other aspects, there is a common belief that dying individuals and their families should be supported in achieving a ‘good death’ as defined within their cultural context. Recognising this shared objective fosters a more empathetic understanding of diverse death and dying practices globally.

Financial support and sponsorship

This work was supported by Princess Nourah bint Abdulrahman University Researchers Supporting Project (Number PNURSP2025R718), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.

Conflicts of interest

There are no conflicts of interest.