Advertisement

Cultural Beliefs About a Patient’s Right Time to Die: An Exploratory Study

  • Henry S. PerkinsEmail author
  • Josie D. Cortez
  • Helen P. Hazuda
Populations at Risk

ABSTRACT

BACKGROUND

Generalist physicians must often counsel patients or their families about the right time to die, but feel ill-prepared to do so. Patient beliefs may help guide the discussions.

OBJECTIVE

Because little prior research addresses such beliefs, we investigated them in this exploratory, hypothesis-generating study.

DESIGN AND SUBJECTS

Anticipating culture as a key influence, we interviewed 26 Mexican Americans (MAs), 18 Euro-Americans (EAs), and 14 African Americans (AAs) and content-analyzed their responses.

MAIN RESULTS

Nearly all subjects regardless of ethnic group or gender said God determines (at least partially) a patient’s right time to die, and serious disease signals it. Yet subjects differed by ethnic group over other signals for that time. Patient suffering and dependence on “artificial” life support signaled it for the MAs; patient acceptance of death signaled it for the EAs; and patient suffering and family presence at or before the death signaled it for the AAs. Subjects also differed by gender over other beliefs. In all ethnic groups more men than women said the time of death is unpredictable; but more women than men said the time of death is preset, and family suffering signals it. Furthermore, most MA women—but few others—explicitly declared that family have an important say in determining a patient’s right time to die. No confounding occurred by religion.

CONCLUSIONS

Americans may share some beliefs about the right time to die but differ by ethnic group or gender over other beliefs about that time. Quality end-of-life care requires accommodating such differences whenever reasonable.

KEY WORDS

attitude toward death end-of-life cross-cultural comparison terminal care hospice 

Notes

Acknowledgments

Others besides the authors made important contributions to this manuscript. Sarah Piper McMahon, M.D.; Caroline McGee-Jones, M.D.; and Alisa Meny, M.D., helped analyze the data. Drs. Piper McMahon and McGee-Jones were students at The University of Texas Health Science Center at San Antonio, and Dr. Meny was a student at Harvard University when they participated in the study. Charles Cavazos from the Intercultural Development Research Association provided computer support. Susan Bagby made editorial suggestions about early drafts of the manuscript.

The John A. Hartford Foundation; the American Federation on Aging Research; and the Mexican-American Medical Treatment Effectiveness Research Center, the Aging Research and Education Center, and the Medical Dean’s Office at The University of Texas Health Science Center at San Antonio all contributed funds for this research. The authors thank all these people and funders for their help.

Authors’ Conflict of Interest Statement

Henry Perkins, Josie Cortez, and Helen Hazuda collaboratively conceived and designed this study, analyzed and interpreted its data, and prepared the manuscript reporting the results. The authors have no conflicts of interest to disclose.

References

  1. 1.
    Callahan CM, Gramelspacher GP. Death and primary care. J Gen Intern Med. 2004;19:1066–7.CrossRefPubMedGoogle Scholar
  2. 2.
    Hardwig J. Going to meet death: the art of dying in the early part of the twenty-first century. Hast Cen Rep. 2009;39(4):37–45.CrossRefGoogle Scholar
  3. 3.
    McCormick TR. Patients’ perspectives on dying and on the care of dying patients. West J Med. 1995;163:236–43.PubMedGoogle Scholar
  4. 4.
    Billings JA, Block S. Palliative care in undergraduate medical education: status report and future directions. JAMA. 1997;278:733–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Emanuel EJ, Emanuel LL. The promise of a good death. Lancet. 1998;351(suppl 2): 21–9.Google Scholar
  6. 6.
    Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L, Tulsky JA. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000;284:2476–82.CrossRefPubMedGoogle Scholar
  7. 7.
    Crawley LVM, Marshall PA, Lo B, Koenig BA. Strategies for culturally effective end-of-life care. Ann Intern Med. 2002;136:673–9.PubMedGoogle Scholar
  8. 8.
    Baker LM. Information needs at the end of life: a content analysis of one person’s story. J Med Libr Assoc. 2004;92:78–82.PubMedGoogle Scholar
  9. 9.
    Kaldjian LC, Curtis AE, Shinkunas LA, Cannon KT. Goals of care toward the end of life: a structured literature review. Am J Hosp Palliat Med. 2009;25:501–11.CrossRefGoogle Scholar
  10. 10.
    Orr RD, Marshall PA, Osborn J. Cross-cultural considerations in clinical ethics consultations. Arch Fam Med. 1995;4:159–64.CrossRefPubMedGoogle Scholar
  11. 11.
    Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Ann Intern Med. 1999;130:829–34.PubMedGoogle Scholar
  12. 12.
    Kagawa-Singer M, Blackhall LJ. Negotiating cross-cultural issues at the end of life: “You got to go where he lives.” JAMA. 2001;286:2993–3001.CrossRefPubMedGoogle Scholar
  13. 13.
    Perkins HS. Culture as a useful conceptual tool in clinical ethics consultation. Camb Q Healthc Ethics. 2008;17:164–72.Google Scholar
  14. 14.
    Koenig BA, Gates-Williams J. Understanding cultural difference in caring for dying patients. West J Med. 1995;163:244–9.Google Scholar
  15. 15.
    Hallenbeck JL. Intercultural differences and communication at the end of life. Prim Care. 2001;28:401–13.CrossRefPubMedGoogle Scholar
  16. 16.
    Krakauer EL, Crenner C, Fox K. Barriers to optimum end-of-life care for minority patients. J Am Geriatr Soc. 2002;50:182–90.CrossRefPubMedGoogle Scholar
  17. 17.
    True G, Phipps EJ, Braitman LE, Harralson T, Harris D, Tester W. Treatment preferences and advance care planning at end of life: the role of ethnicity and spiritual coping in cancer patients. Ann Behav Med. 2005;30:174–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Barclay JS, Blackhall LJ, Tulsky JA. Communication strategies and cultural issues in the delivery of bad news. J Palliat Med. 2007;10:958–77.CrossRefPubMedGoogle Scholar
  19. 19.
    O’Connell LJ. Religious dimensions of dying and death. West J Med. 1995;163:231–5.PubMedGoogle Scholar
  20. 20.
    Hallenbeck J, Goldstein MK, Mebane EW. Cultural considerations of death and dying in the United States. Clin Geriatr Med. 1996;12:393–406.PubMedGoogle Scholar
  21. 21.
    Daaleman TP, VandeCreek L. Placing religion and spirituality in end-of-life care. JAMA. 2000;284:2514–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Johnson KS, Elbert-Avila KI, Tulsky JA. The influence of spiritual beliefs and practices on the treatment preferences of African Americans: a review of the literature. J Am Geriatr Soc. 2005;53:711–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Phelps AC, Maciejewski PK, Nilsson M, et al. Religious coping and use of intensive life-prolonging care near death in patients with advanced cancer. JAMA. 2009;301:1140–7.CrossRefPubMedGoogle Scholar
  24. 24.
    McKinley ED, Garrett JM, Evans AT, Danis M. Differences in end-of-life decision making among black and white ambulatory cancer patients. J Gen Intern Med. 1996;11:651–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Hanchate A, Kronman AC, Young-Xu Y, Ash AS, Emanuel E. Racial and ethnic differences in end-of-life costs: why do minorities cost more than whites? Arch Intern Med. 2009;169:493–501.CrossRefPubMedGoogle Scholar
  26. 26.
    Barnato AE, Anthony DL, Skinner J, Gallagher PM, Fisher ES. Racial and ethnic differences in preferences for end-of-life treatment. J Gen Intern Med. 2009;24:695–701.CrossRefPubMedGoogle Scholar
  27. 27.
    Perkins HS, Geppert MA, Gonzales A, Cortez JD, Hazuda HP. Cross-cultural similarities and differences in attitudes about advance care planning. J Gen Intern Med. 2002;17:48–57.CrossRefPubMedGoogle Scholar
  28. 28.
    Perkins HS, Cortez JD, Hazuda HP. Advance care planning: does patient gender make a difference? Am J Med Sci. 2004;327:25–32.CrossRefPubMedGoogle Scholar
  29. 29.
    Perkins HS, Shepherd KJ, Cortez JD, Hazuda HP. Exploring chronically ill seniors’ attitudes about discussing death and postmortem medical procedures. J Am Geriatr Soc. 2005;53:895–900.CrossRefPubMedGoogle Scholar
  30. 30.
    Arber S, Vandrevala T, Daly T, Hampson S. Understanding gender differences in older people’s attitudes towards life-prolonging medical technologies. J Aging Stud. 2008;22:366–75.CrossRefGoogle Scholar
  31. 31.
    Babbie ER. Survey research methods. Belmont, California: Wadsworth Publishing, Company, Inc. 1973:106–7.Google Scholar
  32. 32.
    Lincoln YS, Guba EG. Naturalistic inquiry. Newbury Park, California: SAGE Publications, Inc. 1985:199–202.Google Scholar
  33. 33.
    Wittink MN, Joo JH, Lewis LM, Barg FK. Losing faith and using faith: older African Americans discuss spirituality, religious activities, and depression. J Gen Intern Med. 2009;24:402–7.CrossRefPubMedGoogle Scholar
  34. 34.
    Hazuda HP, Comeaux PJ, Stern MP, Haffner SM, Rosenthal M. A comparison of three indicators for identifying Mexican Americans in epidemiologic research: methodologic findings in the San Antonio Heart Study. Am J Epidemiol. 1986;123:96–112.PubMedGoogle Scholar
  35. 35.
    Lo B, Quill T, Tulsky J. Discussing palliative care with patients. Ann Intern Med. 1999;130:744–9.PubMedGoogle Scholar
  36. 36.
    Puchalski CM. Spirituality and end-of-life care: a time for listening and caring. J Palliat Med. 2002;5:289–94.CrossRefPubMedGoogle Scholar
  37. 37.
    Bullock K. Promoting advance directives among African Americans: a faith-based model. J Palliat Med. 2006;9:183–95.CrossRefPubMedGoogle Scholar
  38. 38.
    Branch WT, Torke A, Brown-Haithco RC. The importance of spirituality in African Americans’ end-of-life experience. J Gen Intern Med. 2006;21:1203–5.CrossRefPubMedGoogle Scholar
  39. 39.
    Copp G. A review of current theories of death and dying. J Adv Nurs. 1998;28:382–90.CrossRefPubMedGoogle Scholar
  40. 40.
    Ganzini L, Goy ER, Dobscha SK. Oregonians’ reasons for requesting physician aid in dying. Arch Intern Med. 2009;169:489–92.CrossRefPubMedGoogle Scholar
  41. 41.
    Heeren O, Menon AS, Raskin A, Ruskin P. Religion and end of life treatment preferences among geriatric patients. Int J Geriatr Psychiatry. 2001;16:203–8.CrossRefPubMedGoogle Scholar
  42. 42.
    Carrese JA, Perkins HS. Ethics consultation in a culturally diverse society. Public Affairs Q. 2003;17:97–120.Google Scholar
  43. 43.
    Silvestri GA, Knittig S, Zoller JS, Nietert PJ. Importance of faith on medical decisions regarding cancer care. J Clin Oncol. 2003;21:1379–82.CrossRefPubMedGoogle Scholar
  44. 44.
    Fins JJ, Miller FG, Acres CA, Bacchetta MD, Huzzard LL, Rapkin BD. End-of-life decision-making in the hospital: current practice and future prospects. J Pain Symptom Manage. 1999;17:6–15.CrossRefPubMedGoogle Scholar
  45. 45.
    Teno JM, Fisher E, Hamel MB, et al. Decision-making and outcomes of prolonged ICU stays in seriously ill patients. J Am Geriatr Soc. 2000;48:S70–4.PubMedGoogle Scholar
  46. 46.
    Teno J, Clarridge BR, Casey V, et al. Family perspectives on end-of-life care at the last place of care. JAMA. 2004;291:88–93.CrossRefPubMedGoogle Scholar
  47. 47.
    Lorenz KA, Lynn J, Dy SM, et al. Evidence for improving palliative care at the end of life: a systematic review. Ann Intern Med. 2008;148:147–59.PubMedGoogle Scholar
  48. 48.
    Pearlman RA, Cain KC, Patrick DL, et al. Insights pertaining to patient assessments of states worse than death. J Clin Ethics. 1993;4:33–41.PubMedGoogle Scholar
  49. 49.
    Singer PA, Martin DK, Kelner M. Quality end-of-life care: patients’ perspectives. JAMA. 1999;281:163–8.CrossRefPubMedGoogle Scholar
  50. 50.
    Steinhauser KE, Clipp EC, McNeilly M, Christakis NA, McIntyre LM, Tulsky JA. In search of a good death: observations of patients, families, and providers. Ann Intern Med. 2000;132:825–32.PubMedGoogle Scholar
  51. 51.
    Ganzini L, Goy ER, Dobscha SK. Why Oregon patients request assisted death: family members’ views. J Gen Intern Med. 2007;23:154–7.CrossRefPubMedGoogle Scholar
  52. 52.
    Carrese JA, Rhodes LA. Bridging cultural differences in medical practice: the case of discussing negative information with Navajo patients. J Gen Intern Med. 2000;15:92–6.CrossRefPubMedGoogle Scholar
  53. 53.
    Morrison R. Patients’ sense of completion. BMJ. 1994;308:1722.PubMedGoogle Scholar
  54. 54.
    Larson DG, Tobin DR. End-of-life conversations: evolving practice and theory. JAMA. 2000;284:1573–8.CrossRefPubMedGoogle Scholar
  55. 55.
    Curtis JR, Patrick DL. Barriers to communication about end-of-life care in AIDS patients. J Gen Intern Med. 1997;12:736–41.CrossRefPubMedGoogle Scholar
  56. 56.
    Quill TE. Initiating end-of-life discussions with seriously ill patients: addressing the “elephant in the room.” JAMA. 2000;284:2502–7.CrossRefPubMedGoogle Scholar
  57. 57.
    Ressler AB. Aesthetic expression: an existential examination of healthcare ethics. Int J Human Caring. 2006;10:61–7.Google Scholar
  58. 58.
    Back AL, Young JP, McCown E, et al. Abandonment at the end of life from patient, caregiver, nurse, and physician perspectives: loss of continuity and lack of closure. Arch Intern Med. 2009;169:474–9.CrossRefPubMedGoogle Scholar
  59. 59.
    Perkins HS. Controlling death: the false promise of advance directives. Ann Intern Med. 2007;147:51–7.PubMedGoogle Scholar
  60. 60.
    Pantilat SZ. Communicating with seriously ill patients: better words to say. JAMA. 2009;301:1279–81.CrossRefPubMedGoogle Scholar
  61. 61.
    Zier LS, Burack JH, Micco G, et al. Doubt and belief in physicians’ ability to prognosticate during critical illness: the perspective of surrogate decision makers. Crit Care Med. 2008;36:2341–7.CrossRefPubMedGoogle Scholar
  62. 62.
    Carr D. A “good death” for whom? Quality of a spouse’s death and psychological distress among older widowed persons. J Health Soc Behav. 2003;44:215–32.CrossRefPubMedGoogle Scholar
  63. 63.
    Seymour JE. Negotiating natural death in intensive care. Soc Sci Med. 2000;51:1241–52.CrossRefPubMedGoogle Scholar
  64. 64.
    Maciejewski PK, Zhang B, Block SD, Prigerson HG. An empirical examination of the stage theory of grief. JAMA. 2007;297:716–23.CrossRefPubMedGoogle Scholar
  65. 65.
    Hauser JM, Kleefield SF, Brennan TA, Fischbach RL. Minority populations and advance directives: insights from a focus group methodology. Camb Q Healthc Ethics. 1997;6:58–71.Google Scholar
  66. 66.
    Block SD. Psychological considerations, growth, and transcendence at the end of life: the art of the possible. JAMA. 2001;285:2898–2905.CrossRefPubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2009

Authors and Affiliations

  • Henry S. Perkins
    • 1
    Email author
  • Josie D. Cortez
    • 2
  • Helen P. Hazuda
    • 3
  1. 1.Division of General Medicine, Department of MedicineThe University of Texas Health Science CenterSan AntonioUSA
  2. 2.Intercultural Development Research AssociationSan AntonioUSA
  3. 3.Division of Clinical Epidemiology, Department of MedicineThe University of Texas Health Science CenterSan AntonioUSA

Personalised recommendations