Table 3.

Ethnicity and cultural considerations at end of life

Ethnicity	Family structure/ Role of family	Communication considerations	Meaning of illness, suffering, and death	Healing practices and rituals	Considerations for palliative/end of life care
Chinese (Lipson et al., 1996; Mazanec & Tyler, 2003; Payne & Chapman, 2005; Campbell, 2006; Brolley et al., 2007)	Loyalty to family and devotion to traditions emphasized. When possible, engage the whole family in discussions that involve decisions and education about care.	May be reluctant to say “no” to a doctor or healthcare provider because it may be considered disrespectful or cause disharmony. Direct eye contact may be interpreted as hostile or rude, specifically with women. A slight bow demonstrates respect for authority figures. Patient and family may nod, say “yes” or offer other affirmative vocalizations, but this often conveys that they heard what the staff member is saying, not necessarily agreement, approval or understanding.	Illness and death often viewed as a natural part of life. Health is the result of balancing competing energies: hot and cold, light and dark.	May incorporate special cloths or amulets. May consume special foods and herbs that restore yin/yang balance. Patients may seek traditional Chinese therapies such as massage, acupuncture, and moxibuxtion (traditional Chinese medicine technique that involves the burning of mugwort, a small, spongy herb, to facilitate healing).	There is no one monolithic Chinese culture. Rituals will depend upon religion (Buddhism, Confucianism, Taoism, Christianity). Some believe that death in the home is a sign of bad luck. Some believe that if a person were to die in the hospital, his/her soul would get lost. Typically will not want organ donation or autopsy to be performed.
Japanese (Long, 2004; Pierce, 2007; Kongnetiman et al., 2008)	Family members collectively make the decision regarding medical treatment	Patient and family may use nonverbal, subtle, and indirect communication. Families prefer to be told the diagnosis directly first to decide whether or not to tell the patient.	Death is viewed as natural, inevitable and not the final aspect of life. Beliefs of reincarnation may be present. Families may not acknowledge that death is caused by cancer because cancer is stigmatized in Japanese culture.	May perform Reiki – a Japanese method of reducing stress and promoting relaxation as a healing mechanism. Other healing methods may include acupuncture and moxibuxtion. The prayer of “pillow sutra” may be recited before moving the body. May refer to die at home rather than in a hospital. Family members may gather around the bedside and have a minister perform special chants.	May prefer cremation instead of burial. Belief that the body should be whole to be properly reincarnated. May not want organ donation.
Korean (Murphy, 1995; Song & Ahn, 2007)	Mothers are exclusive caregivers, but the oldest male is typically the spokesperson	It is respectful to give a slight bow when you greet someone. Sustained eye contact is uncommon. Men and men may shake hands, but women and men and women and women do not. Self-control is often of high priority; patient may not express pain verbally.	If Buddhist or Confucian, illness and death are seen as a natural part of life. Symptoms may be result of bad karma Illness can result from conflict in family and peer relationships. Health is the result of balancing competing energies: hot and cold, light and dark.	May seek help from a hanui, or traditional healer, who often uses herbs. Ginseng is especially common.	The patient will often trust family to make medical decisions for him/her, and see no need for an advanced directive. May view Western medicine as too strong, and as a result may alter how much medicine is taken (only taking half, stopping medication before told).
Vietnamese (Lee et al., 2007; Phan & Tran, 2007)	The women in the family are the primary providers.	The family spokesperson may be the person with the best English. Family and patient may nod or say yes to demonstrate that they hear you, not as a sign of assent or understanding. Often seen as disrespectful to say no to a doctor as they are the expert. May avoid eye contact as sign of respect. May not request medicine for pain, even when needed.	Illness may be explained as imbalance between the body and nature, the result of germs, or the result of a behavioral cause.	May utilize coin rubbing (ao gio) or skin pinching (bat gio) to aid in removal of unwanted elements in the body.	Visit from a hospital chaplain may be viewed as signifying impending death. These visits should be explained thoroughly before occurring.
Filipino (Mazanec & Tyler, 2003; Kemp & Rasbridge, 2004; Lobar et al., 2006; Diversicare, 2009)	In the Philippines, family may be an extended multi-generational household. Philippine community persons should be contacted when family is not available.	Communication should be directed toward the head of the family, and should not take place while patient is present. On first encounter, use Mr. Mrs., Miss or professional title.	Sometimes discussing end-of-life preferences is avoided as it is thought it may hasten death	Most (90%) are Catholic; will often utilize “sacrament of the sick.” Use of rosary beads and frequent use of rosary beads and prayer at bedside.	Individuals will likely prefer to die at home. Family may prefer to clean body after death. Each family member may wish to personally say goodbye. Typically do not want organ donation, autopsy or cremation. Loud demonstrations involving crying and wailing show respect, importance, and love for the deceased.
South Asian: India, Bangladesh, Nepal, Pakistan, Maldives, Sri Lanka (Laungani, 1996; Minarik, 1996; Moazam, 2000; Periyakoil et al., 2011)	While the decision maker is typically the family patriarch, the family is actively involved and death is viewed as a family and communal process. Rituals are very important.	Communication is enhanced when providers ask specific questions such as How do you think your child's sickness should be treated? What alternative therapies are you using currently? How do want us to help you? Who do you turn to for help? Who should be involved in decision making? Close knit family is common structure. Family members and physicians may share decision-making duties.	Cancer (and other chronic or terminal illnesses) is often attributed to sins committed in a past life. Because of this, there is often stigma associated with serious illness, and sometimes even social isolation of the family. May feel that the illness is washing away her/his sins and would resolve once the sins are washed away or by doing certain religious rituals. Illness should not be capitalized.	Many South Asians are Hindu, and may request such rituals as: Putting patient on the ground instead of in a bed Pouring holy water into the mouth or onto the bed of patient	Health professionals within the home should be cognizant of the spatial culture. Certain rooms are often delegated for specific activities, such as greeting or caring for the sick. Moslem death rituals may include ceremonial washing of the body with holy waters, directional positioning of the body toward the Holy Land of Mecca, and recitation of the Holy Koran by loved ones. May be different preferences for care of the remains of their child. Ask about preferred rites and rituals in a sensitive and gentle manner.
Latino (Mazanec & Tyler, 2003; Sandoval, 2003; Davidhizar & Giger, 2004; Cardenas et al., 2007; Tellez-Giron, 2007)	Mother determines when a person needs care, but the permission to seek/continue/ discontinue care comes from the father. Usually spokesperson is typically the father or oldest male. Although a male often speaks for the household, decisions are typically made as a family. Familismo is a term used to describe the power and strength of the family in Latino culture, and is characterized by interdependence, affiliation, and cooperation. The family is a source of emotional support and there is a high degree of intimacy between all family members. Patients will likely want to be near to and be able to see their family as much as possible.	Nodding often used to signify respect, and should not be taken as a sign of assent. Eye contact may be avoided by some Latino groups as a sign of respect, or because of the belief in evil eye. Personalismo: Having informal conversations with all family members, and not just addressing the patient and his or her parent can build trust. Mutual respect must be demonstrated. Respeto is highly valued in terms of familial hierarchy. Should address older individuals using Señor or Señora.	Pain often viewed as a form of punishment. The suffering of pain must be endured if the individual is to enter heaven. Illness may be seen as the result of an imbalance (between external and internal causes, hot and cold, natural and supernatural). May believe that the patient was specially selected for suffering. Belief in espiritismo: good and evil spirits affect health and well-being. Some believe that illness can be explained by mal ojo, or evil eye. For example, if people admire a child without touching them, child can become ill. Death viewed as a natural end to the life process, and something that is completely out of one's control (in hands of God).	Wailing at bedside of sick individual is common and seen as sign of respect. May seek care from curanderos (folk healers). Often use amulets or rosaries when praying for sick individual, and may display pictures of saints in hospital room. May ask to have candles lit at all times while the individual is in the hospital. May have concern that the spirit will get lost in the hospital room. After death, often offer daily masses and light candles in honor of the deceased.	Many Latinos will not want to stop life prolonging treatments, regardless of the severity of the illness of the child/individual. Jerarquimo may influence the family's belief that there is a medical cure for the patient. Do not typically utilize hospice services, perhaps due to unfamiliarity with system, language barriers, or distrust of healthcare system. Would greatly benefit from increased education regarding hospice. Prefer for individual to die at home (death in hospital could indicate loss of soul). Those who are Catholic (90%) will often want to have a priest or clergy member say the last rites when death is near. Often prefer to cleanse the body by themselves after death, as a sign of respect or life and death. Typically do not want organ donation or autopsy to be performed. Grieving is considered normal and natural, and wailing is common. May be hesitant to involve mental health as this connotes grieving is a sign of mental illness.
Native American (Campbell, 2006; Olsen et al., 2007)	Family unit includes not just immediate and extended family, but also community leaders.	Direct eye contact may be interpreted as hostile, rude or dangerous to the soul. Pain will either not be expressed or may be expressed through storytelling rituals. Storytelling is also used as a way to build trust and relationships with people. Silence is highly valued.	Often view health and illness as holistic in nature. People, community, nature and spirituality are all connected, as are physical, spiritual, emotional and mental health. People become sick when there is a disruption in the balance of these forces.	May want to seek traditional healers for help in restoring harmony of sources of life. Herbal remedies may be used in conjunction with healing ceremonies. May use sweat lodges	May be hesitant to sign advance directives or other end of life documents because of general mistrust of signed documents (history of misuse of written treaties and documents with Native Americans by the U.S. government and other majority entities).
African- American (Mazanec & Tyler, 2003; Sandoval, 2003; Campbell, 2006; Mitchem, 2007)	Place large importance on family.	Conversation should be initiated with the eldest member of the family. Likely to see public displays of emotion from the family. Direct eye contact may be interpreted as hostile or rude.	In African-American folk healing, human life is understood relationally. Illness is derived from germs and from situations that break connections with others. Death is not a formal break with life because the spirit/soul continues and may be able to interact from the next plane of existence.	Story and action are intertwined in healing. The healer or “rootworker” is important as this person can orchestrate the natural, spiritual, and relational aspects of life.	Rely on healthcare team for help with cleaning and preparation of body. May refuse to stop life prolonging treatments because of a belief in divine rescue. This signifies that an all-powerful God can bring about miraculous interventions and is derived from the Old Testament. Do not typically complete advance directives, in part because of belief that this limits access to appropriate medical care. Often will prefer a life-prolonging treatment to a pain-reducing one. May see palliative care as an effort on the part of medical providers to deny them the best treatment possible.
Caribbean-American (Lipson et al., 1997; Fernandez Olmos & Paravisini-Gebert, 2003)	Men hold a position of authority whereas women are seen as the nurturers and tend to the family. Children are to be respectful of elders.	Families may be more expressive or demonstrative than the average family.	Healing practices often originated in spiritual practices. Sickness and death are not always attributable to natural causes – a curse can cut lives short. Afro-Cuban therapies are often plant based and herbs are used for spiritual cleansing.	Those who require balance due to illness may seek out the help of a priest of Ocha. Prayer and hymn-singing at the patient's bedside may occur. Some Caribbean-Americans may use voodoo practices in addition to following Catholic traditions. Those who practice Voodoo will have rituals that evolve around spirits that represent a fusion of African and Creole gods, the spirits of deified ancestors, and Catholic saints.	Close relatives will likely want to be present at the time of the patient's death and efforts to bring the family together are important. Patient and family may desire that, if the patient is of age, he or she have holy communion before his or her death. Older generations may believe that the body needs to be intact for it to pass into the afterlife, thus may object to either autopsy or organ donation. Burial is most common, and funerals are very important. Home is usually kept open for a week to welcome mourners.
Russian- American (Milshteyn & Petrov, 2007; University of Washington Medical Center, 2007).	The parent or the eldest child typically makes decisions.	The patient is often not told of prognosis as there is a belief that this will only worsen his or her condition. Often prefer that the doctor, rather than a nurse or other staff member, communicate diagnosis and treatment considerations. Family members often want to have long conversations with the doctor regarding the patient, and prefer these conversations be held in a private room. Family members may appear cheerful with patient to avoid causing further distress to patient.	Illness may be attributed to environmental causes, including familial stress and conflict. For many Russians, and specifically Russian Jews, nutrition is extremely important to health. If a patient can eat it is seen as a very positive sign.	Family is very important, and usually at least one family member will always be at the bedside of the patient. Laying of the hands often used. Religious icons may be brought to the hospital room. The earth is considered sacred, and therefore soil might be brought into the room in jars or pots.	Often will not grieve in front of the dying individual; however it is acceptable for the patient to express their pain and grief openly. Providing a patient with morphine may be interpreted to mean that the patient's case is hopeless/terminal. Autopsy is acceptable, but organ donation often is not. Typically will not want to sign an advance directive or durable power of attorney document. All relatives and friends are expected to visit the patient if death is judged to be close. Often prefer a priest, rabbi, or other religious figure to be present at the death. Family may either close the eyes and mouth of patient after death or place coins on their eyes. If the child dies in the hospital, may request the body to be brought by the home for a final visit. Wailing and other public expressions of mourning common in the home, not in public. Often have specific rituals for washing the deceased's body.