Spiritual & Cultural Considerations at End of Life (2023-2024 Handouts) PDF

2023-12-21 Facilitating and meeting the Spiritual and Cultural needs of patients at End of Life 2023 Jackie Santiago – ( some slides used with permission from Al McBurney Palliative care Chaplin, RHC). CRNM –Jurisprudence module Cultural safety, 2023 1 Presentation Objectives • Explore Spiritual...

2023-12-21 Facilitating and meeting the Spiritual and Cultural needs of patients at End of Life 2023 Jackie Santiago – ( some slides used with permission from Al McBurney Palliative care Chaplin, RHC). CRNM –Jurisprudence module Cultural safety, 2023 1 Presentation Objectives • Explore Spiritual and Cultural Dimensions in palliative and end-of-life care: • Examine the nurse’s role in addressing the spiritual care needs • Differentiate spirituality from religion • Strategies/tools to assess for spiritual needs • Health care professional’s approaches to assess and respect cultural practices at end-of-life -Disclosure and truth-telling -Use of life sustaining treatment -Traditional therapies -Care of the body, honouring rituals -Expressions of loss and grief -Organ donation and autopsy 2 Text Spirituality, Culture and Palliative care nursing spiritual assessmentet, when goal of care doesnt line with family • Palliative nursing strives to meet the physical, emotional, social, and spiritual needs of the patient and family across the disease trajectory • The Clinical Practice Guidelines for Quality Palliative care recommends attention to cultural considerations for patients and families living with life-limiting illness and facing the transition to end of life (Ferrell and Paice, 2019) 3 1 2023-12-21 Total Suffering/Pain Several domains merging Pain Spiritual & existential Other symptoms Total Suffering Psychological Cultural 4 Social & financial 4 World Health Organization • WHO states that in end-of-life care, “the control of pain, of other symptoms, and of psychological, social, and spiritual problems" is paramount. (Bernat, 2008, Aspects/Domains of Holistic Care p.155) Physical Psychological Social/Cultural Spiritual Adapted from: “Domains of Issues Associated with Illness and Bereavement” in A Model to Guide Hospice Palliative Care: Based on National Principles and Norms of Practice. CHPCA, March 2002, page 15. 5 Religion and Spirituality • Religion- An organization that has a set of rites, rules, practices, values, and beliefs that prescribe how individuals should live their lives and respond to God (Ferrell & Paice, 2019) • Spirituality- Our relationship with ourselves, others, and the transcendent-it gives our life meaning and purpose • Religion is a means of expressing spirituality. 6 2 2023-12-21 7 What is Spiritual Care? • Spiritual care is simply meeting the other person, human to human, providing compassionate presence, and being available for whatever comes up. • Good spiritual care requires that we put aside our own expectations and agenda, and instead focus on the patient- doing whatever is needed, at the time, for the person receiving the care. • Equal relationship when we serve rather than “help” our patients • Examples of spiritual caring: sitting with a patient, bringing food to friends, listening to a patient's life story 8 Compassionate Presence and Deep Listening • We can't guarantee that our patients will never experience pain or suffering or to guarantee a calm and peaceful death. • We can however assure the patient that we will do everything possible to alleviate pain and suffering and that the patient and family will not be abandoned. • Compassionate presence- being with the patient – body, mind, and spirit. It is about exhibiting empathy and focused attention. 9 3 2023-12-21 How to provide good quality spiritual care? • Good spiritual care does not require superhuman acts. It does require human kindness, compassion and caring. • Nurses recognized that conversations of a spiritual nature cannot be forced would share and that patients would often choose when and with whom they their spiritual concerns. 10 Spiritual Care Assessment • Engaging a patient and family in the discussion of their spiritual /beliefs can help to establish trust and understanding of the patient’s approach to their illness. • Health Care professionals must consider Spiritual assessment to be as important as a thorough medical history and physical examination. • Several spiritual assessment tools exist and one of the best known, the FICA spiritual assessment tool , in an effective way for clinicians to integrate open –ended spiritual questions into the medical history. (Jennifer Gentry, Accommodating Religiosity and Spirituality in Medical Decision-Making, 2012) • WHEN TO ASSESS? • Non-Verbal /Environmental Assessment? 11 FICA only spiritual assessment!!!!!!!!!!!!!!!!! F: Faith, Meaning, Belief “Do you consider yourself spiritual or religious?” “What gives your life meaning?” I: Importance and Influence- importance of faith or belief “How would you rate the importance of faith or belief in your life(0-5 point scale)?” “Do your beliefs help in handling stress?” “How do your beliefs affect making health care decisions?” C: Community “Are you part of a religious or spiritual community?” “How does this community offer support to you?” “Is there a group of people that are very important in your life?” A: Address in Care “How can your health care team best support your spirituality?” “How would you like your health care team to use the information we have talked about in your care?” (Jennifer Gentry, 2012) F: religious/spiritual. what gives your life meaning? I: more important , more open ended qs do they have belief system, get more information, is for pt to tell you how they can support you, 12 4 2023-12-21 Definition of Culture *Culture*patterns of learned behaviours and values shared among members of a group that are transmitted over time. Included: Race, ethnicity, language, religious and spiritual beliefs, gender, socio-economic class, age, sexual orientation, geographical origin, group history, education and upbringing and life experiences. (Feser, 2003) (Ferrell & Paice, 2019) is how you identify Text 13 Questions we should ask? 1) How does culture shape one’s understanding of the meaning of illness, suffering and dying? 2) What impact does culture have on choices that patients make about caregivers, access to services, and symptom management? 3) What impact does system culture have on quality of care? 14 Text Impact of Culture • Culture is a strong determinant of people's views of the very nature and meaning of illness and death, of how end-of-life decisions can or should be controlled, how bad news should be communicated and how decisions – including end-of-life decisions –should be made. • Culture impacts all aspects of palliative care. 15 5 2023-12-21 Culture and End of Life care 1) Micro culture the culture of palliative patients and family caregivers, and the beliefs and practices about health and illness that they bring to their health care experience. family, pt+caregiver Examples: – Attitudes toward truth telling – Life prolongation technology – Decision‐making styles 16 Text Culture and End of Life care • 2) Meso culture -cultural values and practices of the health professionals providing palliative/end of life care our cultural values, of healthcare professional • 3) Macro culture – refers to system organization and capacity for cultural competency in health care. (Provide example of the WRHA Indigenous Health-Patient services team). Elders, languages services, traditional medicines and ceremonies.**** • “ Ongoing training is needed to give both clinical and non-clinical staff the knowledge, tools, and skills to successfully engage in the process of cultural proficiency. ” (WRHA-Framework For Action Cultural Proficiency & Diversity, July 2012) where are you working? 17 Culturally Competent care • The goal of providing culturally competent care to diverse cultural groups at end of life is to be aware that a variety of beliefs, values, traditions, and practices exist and to honour these when providing care. * CNA- believes that cultural competence is the application of knowledge, skills, attitudes or personal attributes required by nurses to maximize respectful relationships with diverse populations of clients and coworkers. CNA position statement –October 2010 18 6 2023-12-21 Client-centered model of care evolution: • Cultural awareness: The knowledge, awareness, and acceptance of other cultures and others' cultural identities. • Culture sensitivity: Being aware that cultural differences and similarities between people exist without assigning them a value. • The client-centred model has continued to evolve. Health professionals can further improve health outcomes by expanding their awareness of their own unconscious biases, power imbalances, structural barriers, and systemic obstacles faced by many of their clients. This modified approach to care delivery is sometimes called “equity-oriented care.” CRNM, 2023 Text 19 Cultural Safety should be the goal of health care professionals. CRNM 2023 • The term “cultural safety” originated with New Zealand nurses working with Maori clients. The concept is multifaceted and refers to a state wherein a person feels accepted in psychological, physical, mental, socioeconomic, sexual, and spiritual terms. It is subject to each client’s determination and, in practice, it likely cannot be achieved fully; “culturally safer” spaces, care, and interactions should be the goal. cultural humility impacts relationships 20 Cultural safety and cultural humility CRNM, 2023 • British Columbia’s First Nations Health Authority defines “cultural safety” this way: Cultural safety is an outcome based on respectful engagement that recognizes and strives to address power imbalances inherent in the healthcare system. It results in an environment free of racism and discrimination, where people feel safe when receiving healthcare. • To help reduce health inequity for clients, health professionals can develop a more nuanced understanding of what makes a practice setting safe or unsafe for people impacted by health inequity. This is where cultural humility comes in. According to the First Nations Health Authority, cultural humility is a process of self-reflection to understand personal and systemic biases and to develop and maintain respectful processes and relationships based on mutual trust. Cultural humility involves humbly acknowledging oneself as a learner when it comes to understanding another’s experience. 21 7 2023-12-21 Lack of cultural safety can result in patients afraid to seek health care 22 exam!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Culture may influence: • Expression and meaning of pain and suffering • Attitude towards disclosure and awareness (of illness) • Beliefs about the cause and meaning of illness • Choice of healer and treatment regimen*explain -use of alternative medicine. • Attitude toward death and dying 23 Culture may influence: • Beliefs about the afterlife, the value of human ex: organ donation life, and the body • Expressions of loss and grief • Death rituals including preparation for burial, funeral practices or memorial services, customs for disposing of the body and mourning rites. (From the Alberta Palliative Care Resource, 1999) - Advance care directives, prolongation of life, Euthanasia - Post mortem and organ donation 24 8 2023-12-21 Statistics to be aware of: • Manitoba is culturally diverse with an increasing visible minority population. • Immigration is from Asian, Middle Eastern, Caribbean, and African Countries, who have different cultural and religious values, beliefs and traditions compared to those of North Americans. • If the patient and family carry a cultural perspective that differs from that of the health professional care providers, the process of assessment can be complex. • The challenge is intensified when providing palliative care and grief support to these new comers. (Hall, Stone & Fiset, 1998; Alberta Health Services, 2008) 25 Multiculturalism in Canada • Canadian Charter of Rights and Freedoms recognizes multiculturalism as constitutional (1982) • Canadian Multiculturalism Act commits the Government of Canada to helping communities in bringing about equal access and participation for all Canadians (irrespective of their origins) in the economic, social, cultural, and political life of the nation. (1988) • Canada is a cultural mosaic and not a Melting pot-The act gives the right to individuals to practice the religion, belief, and customs of their ethno cultural heritage and denies the notion that everyone must fit into some set mold. (Kanth, Dalhousie University, 2006) 26 Recent Immigrants 2 7 StatsCan 2016 Survey 27 9 2023-12-21 Recent Immigrants 2 8 StatsCan 2016 Survey 28 Classical Bioethical Principle Autonomy recognizes a person’s right or ability to decide for himself or herself according to beliefs, values and a life plan. It exists when people act intentionally with understanding and without controlling influences. Information must be shared honestly, completely, and gently and must be determined to have been understood. 29 Implications for practice-Autonomy vs. Family wishes? • Western health care teams believe that the person experiencing the illness is the best person to make health care decisions. • However, many non-western cultures vest in the family or community the right to receive and disclose information, and to make decisions about and organize patient care. (Ian Anderson End of life program, University of Toronto) 30 10 2023-12-21 Cultural backgrounds of Manitobans *Census2011 : Immigrant influx boosts Manitobanpopulation( Winnipeg Free Press 08/8/12) • While palliative care health professionals cannot be expected to have extensive knowledge of all immigrant groups and all diverse populations, it is prudent to have some idea of the values and beliefs of the groups that clinicians will come into contact with on a regular basis. (Feser, 2003) • Note: It is important that any cultural knowledge be reviewed and validated with individual and family to determine its relevance for them. 31 Medicine wheel and holistic health 32 "There was a level of profiling and stereotyping that had to happen in order for a physically disabled man to languish and die in full public view and surrounded by health professionals," said Vanessa Ambtman-Smith, Aboriginal health lead for Ontario's Southwest Local Health Integration Network (LHIN). • The case of Brian Sinclair, an Aboriginal man who died in a Winnipeg emergency room after waiting 34 hours in a wheelchair, has spurred discussion about cultural safety. • Lauren Vogel, CMAJ, November 27, 2014 33 11 2023-12-21 ‘It was unnecessary’: Death of Indigenous mother sparks bias concerns in Ontario healthcare (Global News Winnipeg, Dec. 18, 2023 • The death of an Ojibway mother a year ago in Winnipeg is raising concerns over health-care bias in Ontario. • “She was this beautiful, beautiful, bright, articulate young woman. And her death is a tragedy. There’s no other way to put it. We believe it was unnecessary,” said Chief Jeff Copenace of Onigaming First Nation, three hours east of Winnipeg near Lake of the Woods. • November Kelly, 25, from Onigaming, survived a serious crash in October 2022 when she was a passenger in a car that skidded off a highway. Her mother Carrie Kelly says she was rushed to the hospital in Thunder Bay for internal bleeding. • Six days later she was sent home and for the next four months, her mother says the pain got worse. 34 Cultural safety? • Until recently, most Indigenous health initiatives targeting health workers have focused more on raising cultural awareness. Often that boils down to learning about differences in the beliefs, practices and needs of Indigenous groups, as well as the historic roots of health disparities. • Cultural safety is what you do with that knowledge — whether that means examining your own biases or challenging those of a health institution or system. More importantly, "it's an outcome that's defined and experienced by those who receive the service," explained Ambtman-Smith. In other words, if an environment doesn't feel safe, it's not. (CMAJ, Nov.27, 2014) 35 WRHA –Indigenous Health Together we can learn how to enhance levels of communication so as to gain a deeper level of understanding of Indigenous patients and their families. We want to ensure that all patients are able to receive care that meets the needs and expectations of their given situation. • WRHA Indigenous Health works with Regional programs and facilities in helping identify, develop and implement culturally safe environments, practices and services. WRHA Indigenous Health also provides a range of services for staff, community members, patients and patients' families through its Patient Services, Workforce Development and Cultural Initiatives programs. 36 12 2023-12-21 37 you need to contact indigineous patient services 38 Text 39 13 2023-12-21 40 Required Readings: • Dr. C. Bourassa’s article was removed from required readings provide an explanation. • Kaufert, J.M. (1999). End-of-Life Decision Making Among Aboriginal Canadians: Interpretation, Mediation, and Discord in the Communication of “Bad News”. Journal of Palliative Care, 15(1), 31-38. • Kaufert, J.M. (2012). Seeking Physical, Cultural, Ethical, and Spiritual “Safe Space” for a “Good Death”; The Experience of Indigenous Peoples in Accessing Hospice Care. In Religious Understanding of a Good Death in Hospice Palliative Care (pp. 231-255). New York: SUNY Press. 41 • A woman whose final conscious hours were spent curled up in pain on the floor of the Seven Oaks General Hospital — while her family says they tried in vain to convince staff to treat her — deserved a more honourable way to die, her son said. • "Maybe nothing could have been done," he said. "But this wasn’t dignified. She didn’t have to die lying on the floor." 42 14 2023-12-21 Filipino Canadian Perspective * The family is the basic social and economic unit of Filipino kinship. Although family is important in many cultures, the central role that the family plays in the lives of its members in the Philippines is unusually significant, with family being rated the most important source of happiness (Virola, 2010). *Important values that might affect interactions between providers and patients and families in the context of terminal illness include a strong respect for elders, a strong reliance on family as decision makers in case of illness, and strong expectations of care by the family. (Wright et al, 2008) 43 Filipino Canadian Perspectives at End of Life • Four of the top 20 most important interventions were spiritual comfort interventions: ‘encourage patient to express spiritual concerns’, ‘protect religious beliefs’, ‘provide spiritual support’, and ‘provide privacy for spiritual behaviour’. • These interventions to promote dignified dying are consistent with Periyakoil et al’s 2010 study of Filipino Americans, which reported that finding meaning in one’s existence and death was one of the factors influential in preserving dignity at the end of life. 44 Filipino End of life cultural practices • When someone from a Filipino culture is dying in a hospital, it is important that family members be allowed to visit when they wish in order to ensure that their loved one does not die alone (Braun & Nichols, 1997) • In Philippine hospitals, the bantay (watcher) system is in place. i.e. if the dying person is the child the full time “ bantay” is the mother. (Atuel, Williams, & Camar, 1988) 45 15 2023-12-21 Filipino Spiritual beliefs • Many Filipinos follow the Catholic faith, which postulates that those who follow the doctrine go to heaven. • Some Filipinos have beliefs that co-exist with catholic faith i.e. beliefs in animism, a faith in the existence of spirits and their power to influence the world of living (Shimabukuro et al., 1999) • Traditional Filipino spiritual beliefs include those related to ancestral spirit visitations. Souls may linger on earth for a time afer death to watch over loved ones. (Shimabukuro et al., 1999) • Traditionally, Filipinos consider organ donation as undesirable because of the importance of having the body remain intact for burial. 46 Chinese Canadian Perspective • Kerry Bowman, a bioethicist at Mount Sinai Hospital in Toronto, the “good death” from a Chinese viewpoint generally places less emphasis on autonomy. • “There’s a strong current in Western culture and in health care in which overt direct communication about death is valued because ultimately the “truth shall set you free.” But in Chinese culture, forceful discussions of an approaching death is often unacceptable, and in fact, can be seen as destructive and harmful, said Bowman. 47 End of life decision making For example, when it comes to end-of-life decision making — an important element of the “good death” in terms of being prepared — it’s not a question of “what would your mother want if she could speak for herself” but “how do you think your mother would want a decision like this to be made?” said Bowman. • The difference is fairly nuanced, he said, but essentially family members, more so then the dying person, become an integral part of the “good death” process. 48 16 2023-12-21 Chinese Canadian Perspective • Chinese families prefer that health professionals not reveal a prognosis to dying patients as their last days should be worry free and painless. (Turner, 2002) • They also believe that sharing a prognosis of terminal illness can be harmful to the patient and it may even” hasten their death” (Payne, Chapman, Holloway, Seymouor & Chau, 2005) • Woo (1999) described that it is the family’s wish and responsibility to share prognosis news in a sensitive way that helps to protect their loved one from emotional turmoil. 49 Canadian Indian perspective (Hindu) • When a Hindu person dies in a Canadian Hospital, the family prefers to wash and dress the body before it is removed from the hospital (Irish et al., 1993) • Hard to make generalizations about beliefs and practices because much is dependent on class, education, and religion. (give examples) • Hindu’s view death as rebirth, transition to another phase of the life cycle (Firth, 2005) • There will be multiple cycles until the soul’s final karmic passage into “Nirvana”. Good karma leads to a good rebirth and bad karma leads to a bad rebirth (Firth, 2005) • Cremating the deceased less than 24 hrs after the death is a crucial consideration. If this does not happen, it can cause great distress for the family. (Laungani, 1996) 50 End of Life decision making process • The family’s need to be part of the decision making is also crucially important as death is seen as a family and communal process (Laungani, 1996) • Many Indian Muslim families do not wish their dying relative to be told about the prognosis; rather, this information should be communicated to an immediate relative who may or may not disclose it to the patient. • Within the Muslim Culture, death is viewed as an act of God, which is not to be questioned by humans (Long & Elghanemi, 1987) 51 17 2023-12-21 Buddhist perspectives of End of life care and dying • Buddhism focuses on personal spiritual development. • There is no one Buddhist religion. • To Buddhists, death is an important reminder to live life well. • Buddhists want to ensure that a person dies with an un-deluded peaceful mind, but also to use the act of dying to link this life to a transition point to the next life. (Chan et al.,) 52 Buddhist perspectives of End of life care and dying • Certain pain management and palliative sedation regimes may impede the dying person`s spiritual preference for full awareness. • Buddhists may decline pain medication or limit their uses, as they feel if a person experiences pain and suffering calmly and peacefully, without becoming emotionally distressed they can attain higher realms of rebirth. • Nurses can balance the level of pain relief needed against the need for alertness in the dying Buddhist. • At time of death the body needs to be undisturbed with minimal direct contact for 8 hrs. 53 End of Life Customs Eritrean Immigrants • A lot of Refugees from the war between Ethiopia and Eritrea. • In Eritrea and Ethiopia Culture and Religion are closely intertwined. • Some illnesses may be understood to have their origin in a problem with spirits. • Traditional healers are important –give example ( Source-Holt, 2001) 54 18 2023-12-21 End of Life Customs Eritrean Immigrants • Impact on pain management practices; Eritreans tend to have a good deal of respect for injections, but not much for pills, and very little for medications that must be taken over an extended period of time. -In Eritrea, a single injection had been known to produce rapid and dramatic improvement (Holt, 2001) Impact for palliative pain management principles? 55 Impact on disclosure and information giving • Family do not want to disclose the diagnosis of terminal illness to the patient, and strongly disagree with providing a time estimate for a terminal illness to the family. • Any communication with the patient should be positive in order to preserve the patient`s hope for healing. • This arises out of the belief that it is out of place for one human being to tell another human being that the time to die has come. • Special prayers are offered at the bedside and at church. • Life preserving technology was not seen as useful because if a person’s time to die has come then that should be accepted because it is God’s will. (Holt, 2001) 56 African Canadian perspectives on End-of-Life Care • In African Canadian families when family members get sick, it is the expectation that family care for themnursing homes, hospitals are not desirable even at huge financial burdens for families. • The role of the caregiver is complex-women who perceive themselves as care givers serve in the role of care giver up to the point of (and sometimes during) their own terminal illness. (maddalena et al., 2010 ) • Spirituality was highlighted as being an important dimension of end-of-life care for patients and family and integral to a sense of well-being during the terminal illness. 57 19 2023-12-21 • There has been little or no change in hospice utilization rates for African Americans or Hispanic/Latinos over the last five years (Bullock, 2011). • These populations are family centered and prefer to avoid disclosure of illness to patients, keep ill loved ones at home.(Mazanec, Daly & Townsend, 2010), avoid advanced directives (Carr, 2011), • seek aggressive treatment (Mack, Paulk, Viswanath & Prigerson, 2010), and distrust the health care system (Johnstone & Kanitsaki, 2009). 58 Hutterites in Western Canada • The Hutterites are a Christian group who strictly follow the Ten Commandments and the teachings of Jesus Christ. According to the 2006 census, about 30,000 Hutterites live in Canada, with about half living in colonies in Alberta and the remainder in colonies across western Canada. • Hutterites are the followers of Jacob Hutter and are named after him. • Hutterites immigrated to North America in the early 1900s. Hutterites live in communities known as colonies. They do not have privately owned property; all the property is owned by the colony. • Hutterites believe that all death results from the will of God, whether the death is natural or due to disease. • Hutterites believe that the ability to keep faith even in pain is the hallmark of a true Christian martyr. 59 • "He Died too Quick!" The Process of Dying in a Hutterian Colony Peter H. Stephenson -Journal of Death and Dying 01/1983; 60 20 2023-12-21 What to do in Practice? 1) 2) 3) 4) Approach with a spirit of Inquiry- ( when uncertain about how a patient or family perceives a situation, it is best to simply ask) Listen carefully Ask the right questions ( Assessment) Negotiate a treatment plan (Ian Anderson, U of Toronto) 61 get 4 questions that give info Cross-Cultural Assessment Questions (Adapted from Ferrell & Paice2019, and Dawn ChaitramBSW) to develop good plan of what culture is important to you? • How do you describe your culture? • What aspect of your culture is important to you? • Is there a specific ethnic group that you relate to? Is there more than one group that you identify with? • What language would you prefer to speak? • I want to be sure I’m giving you all the information you need. What do you want to know about your condition? To whom should I speak about your care? • How are decisions about healthcare made in your family? Should I speak directly with you, or is there someone else with whom I should be discussing decisions? 62 Cross-Cultural Assessment Questions (Adapted from Ferrell & Paice2019, and Dawn ChaitramBSW) • (address to patient or designated decision maker) Tell me about your understanding of what has been happening up to this point? What does the illness mean to you? • How are illness and pain regarded in your belief system? • We want to work with you to be sure you are getting the best care possible and that we are meeting all your needs. Is there anything we should know about any customs or practices that are important to include in your care? • Do you adhere to any food restrictions or practices that are culturally dictated? 63 21 2023-12-21 Cross-Cultural Assessment Questions (Adapted from Ferrell & Paice2019, and Dawn ChaitramBSW) • When you are ill, do you consult a medical doctor or another type of practitioner or healer? • Many people have shared that it is very important to include spirituality or religion in their care. Is there something that is important for you? Our chaplain can help contact anyone that you would like to be involved with your care. Text • What do you and your family expect from thoseti develop good cultural nursing plan 4 questions providing care? 64 Cross-Cultural Assessment Questions (Adapted from Ferrell & Paice2019, and Dawn ChaitramBSW) • Are there any concerns that you would like to share with me, or anything else that you would like to tell me that would help me in developing a plan of care for you? • In an ideal world, what would you want us to do related to your health? Negotiate with patient and family if wishes are unrealistic. Always be sensitive regarding health care directives. 65 Cross-Cultural Assessment Questions (Adapted from Ferrell & Paice2019, and Dawn Chaitram BSW)) • Death rituals and practices: -Is there a way for us to plan for anything you might need both at the time of death and afterward? -Is there anything we should know about care of the body, rituals, practices, or ceremonies that should be performed? -Should the family be involved in the care of the body? -Is there anything we should know about whether a man or woman should be caring for the body after death? 66 22 2023-12-21 Something to think about. • “We need to trust that our patients are the experts on their lives, culture, and experiences, and if we ask with respect and genuine desire to learn from them, they will tell us how to care for them. 67 23