10.7: Cultural Differences in End-of-Life Decisions

Cultural factors strongly influence how doctors, other health care providers, and family members communicate bad news to patients, the expectations regarding who makes the health care decisions, and attitudes about end-of-life care (Ganz, 2019; Searight & Gafford, 2005a). In Western medicine, doctors take the approach that patients should be told the truth about their health. Blank (2011) reports that 75% of the world's population do not conduct medicine by the same standards. Thus, outside Western nations, and even among certain racial and ethnic groups within those nations, doctors and family members may conceal the full nature of a terminal illness, as revealing such information is viewed as potentially harmful to the patient, or at the very least is seen as disrespectful and impolite. Chattopadhyay and Simon (2008) reported that in India doctors routinely abide by the family's wishes and withhold information from the patient, while in Germany doctors are legally required to inform the patient. In addition, many doctors in Japan and in numerous African nations used terms such as "mass," "growth," and "unclean tissue" rather than referring to cancer when discussing the illness to patients and their families (Holland et al., 1987). Family members also actively protect terminally ill patients from knowing about their illness in many Hispanic, Chinese, and Pakistani cultures (Kaufert & Putsch, 1997; Herndon & Joyce, 2004).

Figure \(\PageIndex{1}\). Image source.

In western medicine, we view the patient as autonomous in health care decisions (Chattopadhyay & Simon, 2008; Searight & Gafford, 2005a). However, in other nations the family or community plays the main role, or decisions are made primarily by medical professionals, or the doctors in concert with the family make the decisions for the patient. For instance, in comparison to European Americans and African Americans, Koreans and Mexican Americans are more likely to view family members as the decision-makers rather than just the patient (Berger, 1998; Searight & Gafford, 2005a). In many Asian cultures, illness is viewed as a "family event", not just something that impacts the individual patient (Blank, 2011; Candib, 2002; Chattopadhyay & Simon, 2008). Thus, there is an expectation that the family has a say in the health care decisions. As many cultures attribute high regard and respect for doctors, patients and families may defer some of the end-of-life decision making to the medical professionals (Searight & Gafford, 2005b).

The notion of advanced directives holds little or no relevance in many cultures outside of western society (Blank, 2011). For instance, in India advanced directives are virtually nonexistent, while in Germany they are regarded as a major part of health care (Chattopadhyay & Simon, 2008). Moreover, end-of-life decisions involve how much medical aid should be used. In the United States, Canada, and most European countries artificial feeding is more commonly used once a patient has stopped eating, while in many other nations lack of eating is seen as a sign, rather than a cause, of dying and using a feeding tube is not considered (Blank, 2011).

According to a Pew Research Center Survey (Lipka, 2014), while death may not be a comfortable topic to ponder, 37% of their survey respondents had given a great deal of thought about their end-of-life wishes, with 35% having put these in writing. Yet, over 25% had given no thought to this issue. Lipka (2014) also found that there were clear racial and ethnic differences in end-of-life wishes (see Figure \(\PageIndex{2}\)). Whites are more likely than Blacks and Hispanics to prefer to have treatment stopped if they have a terminal illness, while the majority of Blacks (61%) and Hispanics (55%) prefer that everything be done to keep them alive. Searight and Gafford (2005a) suggest that the low rate of completion of advanced directives among non-whites may reflect a distrust of the U.S. health care system as a result of the health care disparities non-whites have experienced. Among Hispanics, patients may also be reluctant to select a single family member to be responsible for end-of-life decisions out of a concern of isolating the person named and of offending other family members, as this is commonly seen as a "family responsibility" (Morrison et al., 1998).

Figure \(\PageIndex{2}\). Image source.