Pain and Palliative care

Pain and Palliative care

The influence of culture on pain and palliative care.

Introduction

Palliative care provides support for people with a life-limiting illness. Pain is a common symptom at the end of life and for many people it is a source of distress. When providing care at the end of life there may be cultural influences that need to be considered, and these may differ between people and within families. Here we explore some of the different cultural views of pain, serious illness and palliative care among people from across the world.

The aim is not to remember everything, but to acknowledge the diversity. Speaking with people about any cultural preferences or beliefs that are important to them is the best approach. This includes with the person and their family as appropriate and with health professionals who may have their own cultural influences.

Unless indicated otherwise, this work is based on:

• Givler et al 2021, The Importance of Cultural Competence in Pain and Palliative care. 2020 Dec 1. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–.
• Palliative Care Victoria. Cultural perspectives and values from ten culturally and linguistically diverse communities in Victoria November 2016, https://www.pallcarevic.asn.au/
• Pain booklet. South East Melbourne Medicare Local, 2015, Pain Australia, www.apsoc.org.au
  
  

Pain - Europe

People from European cultures vary in their views on pain and palliative care. Here we provide some examples to show this variation. Click on a country to find out more.

Croatian Culture

Pain and illness:

In Croatian Culture, there is a preference for family to deliver the diagnosis of a serious illness to a person.

Attitudes to pain control vary, and morphine is often seen as a signal that death is near. However, people may be more accepting of the use of morphine if the reason for use is clearly explained.

Counselling is associated with mental illness and may be rejected despite the need for psychological support.

Palliative Care:

Palliative care is an unfamiliar practice to older people in Croatian culture. People will usually accept support to stay at home for as long as possible. In Croatian culture, there is a strong preference for female workers and for non-family to carry out personal care tasks. Family may wish to bathe and dress the deceased person. Many Croatian people observe Catholic rituals and rites which is particularly relevant towards the end of life.

Greek culture

Pain and illness:

In Greek culture, there are no taboos around pain control when it is needed. However, the use of opioids for pain should be clearly explained and an interpreter used if required.

Cupping is a common remedial therapy in Greek culture which leaves small bruises. This should not be confused with signs of abuse.

Palliative Care:

There is acceptance of palliative care in Greek culture. Interpreters are important to enhance understanding of the disease and treatments or approaches to care. Traditionally the family would be made aware of prognosis and the patient would not be told. This is changing over time.

People of Greek culture are often guided by the Greek Orthodox religion for end-of-life rituals and rites.

Italian culture

Pain and illness:

In Italian culture, the medical profession is highly regarded and carries authority. Serious illness is rarely discussed and is often downplayed to avoid discussion.

Palliative Care:

For people of Italian culture, accepting help from external services may be seen as a sign of weakness. They may find having strangers in the house unsettling. It is Important to include the family in discussions and recognise their role in the care of their loved one.

In Italian culture, for some people a home death may be avoided due to the notion that an impressione can be left where the person died.

Macedonian culture

Pain and illness:

In Macedonian culture, the medical profession is highly regarded and use of modern medicines accepted. The use of an interpreter is recommended when explaining opioid use in palliative care.

Palliative Care:

People of Macedonian culture generally have a fatalist attitude that illness was ‘meant to happen’. They may be less accepting of aged care, although their acceptance of help from other services is growing as the extended family disappears over time.

In Macedonian culture, dementia is associated with stigma and may be covered up until the advanced stages of the disease.

For those of Orthodox faith, a priest administers last rites and provides final communion. Cremation is not permitted.

Maltese culture

Pain and illness:

In Maltese culture, medical professionals are highly regarded. However, cancer and mental illness are taboo subjects. Stigma around serious illness may make them feel that they are being punished or tested. As a consequence, to avoid discussions they may not share a diagnosis.

Palliative Care:

It important to include family and recognise their major role in providing care with those of Maltese culture. There is a strong Roman Catholic culture around rituals and rites at the end of life that may need to be considered.

Polish culture

Pain and illness:

People of polish culture generally have a high regard for doctors and their advice. Although this is the case, they will often seek alternative treatments but may not tell the doctor.

For those of Polish culture, mental illness is associated with stigma. It is important to consider this when providing psychological support throughout the disease process.

Palliative Care:

Family are seen to have a moral obligation to care in Polish culture. Consequently, help is often resisted until crisis point.

Most people prefer to stay in their own home with the support of their family. Families will generally stay with the dying person throughout so that they don't feel abandoned at the end of life.

Turkish culture

Pain and illness:

In Turkish culture, medical professionals are highly regarded. Most are comfortable with pain relief which aligns strongly with Islamic faith teachings. Note that people of Islamic faith do not consume pork or alcohol, including in medications and this should be considered. Some may prefer to endure pain to maintain a higher level of consciousness towards the end of life.

There is a stigma associated with mental health and people of Turkish culture may prefer speaking with religious leaders over counsellors.

Palliative Care:

The reality and necessity of death and dying is accepted by people of Turkish culture. However, families are likely to downplay the seriousness of illness and avoid discussions relating to palliative care.

For those of Turkish culture, care should be provided by someone of the same sex, except for the case of husbands and wives providing care. There is also a preference for the discussion of sensitive subjects not to take place in mixed company.

After death there are rituals to be considered around burial.

Pain - North America

People from North American cultures vary in their views on pain and palliative care. Here we provide some examples to show this variation. Click on a country to find out more.

Cuban Culture

Pain and illness:

Those of Cuban culture may be stoic regarding pain. This may lead to a reluctance to accept pain medication.

Palliative care:

In Cuban culture, people may be reluctant to accept palliative care. They may feel that everything possible should be done to save life.

Jamaican Culture

Pain and illness:

In Jamaican culture, responses to pain are highly variable.

Palliative Care:

Those of Jamaican culture will generally seek health care but may believe in a possible cure despite terminal illness. Generally, end-of-life care is accepted within their culture. Towards end-of-life they may be very emotional with crying and mourning.

Native American Culture

Pain and illness:

In Native American culture, people may be under-treated and may not be willing to discuss their terminal status as it is thought to hasten death. Pain and illness might only be expressed privately to family or friends.

Palliative care:

Those of Native American culture may avoid contact with those who are dying. At end-of-life, grieving may be verbal and include wailing.

Native Hawaiian Culture

Pain and illness:

People of Native Hawaiian culture may only accept treatment for severe pain. Non-verbal cues may be the only way to interpret pain levels.

Palliative care:

When discussing an unfavourable prognosis, people of Native Hawaiian culture may prefer to have a family member present. They are generally accepting of palliative care services. In Native Hawaiian culture, they tend to celebrate life rather than death.

Pain - South America

People from South American cultures vary in their views on pain and palliative care. Here we provide some examples to show this variation. Click on a country to find out more.

Hispanic Culture

Pain and illness:

In Hispanic culture, people are less likely to complain of pain and may only provide non-verbal clues. The family may not want to inform the patient that they are nearing the end-of-life.

Palliative care:

People of Hispanic culture may have reservations regarding accepting end-of-life care. Many family members are likely to be present at end-of-life and how to manage this should be considered.

Pain - Africa

People from African cultures vary in their views on pain and palliative care. Here we provide some examples to show this variation. Click on a country to find out more.

Egyptian/Arab Culture

Pain and illness:

In Egyptian/ Arab culture, the response to pain is very expressive. The use of drugs that affect intellectual and cognitive functions must be justified. Towards the end of life, a higher level of consciousness is usually preferred.

It is important to note that people of Islamic faith do not consume pork or alcohol, including in medication and this needs to be considered.

Palliative care:

For those of Egyptian/Arab culture, the diagnosis of serious illness is often given to the closest family member first. Often the patient is not told. The discussion of impending death may be avoided. Death is seen as predestined by God and is accepted but preservation of life overrides everything. There is a preference within this culture to be cared for at home.

Unless doctors are certain that death is the only outcome, then life preserving equipment cannot be turned off. They are usually not willing to accept do not resuscitate orders. Those of Islamic faith have specific rituals and rites that need to be followed. Cremation is not permitted.

Ghanaian Culture

Pain and illness:

In Ghanaian culture, physical pain is often described as emotional or spiritual.

Palliative care:

For those of Ghanaian culture, dying at home is often the preference. With this they often prefer little or no medical assistance.

In Ghanaian culture, telling a patient they are going to die is considered unacceptable. It is more culturally acceptable to say, 'It is time to put your home in order.'

Kenyan Culture

Pain and illness:

In Kenyan culture, pain medicine is often avoided.

Palliative care:

There is a preference towards the preservation of life at all costs. Commonly, those of Kenyan culture, will wish to die at home.

Libyan/Arab Culture

Pain and illness:

For those of Arab culture, the response to pain is very expressive. They prefer a higher level of consciousness towards the end of life. Therefore, the use of drugs that affect intellectual and cognitive functions must be clearly justified.

It is important to note that those of Islamic faith do not consume pork or alcohol, including in medication.

Palliative care:

For those of Libyan/Arab culture, the diagnosis of serious illness is often given to their closest family member first. Often the patient is not told, and the discussion of impending death may be avoided. Death is seen as predestined by God and is accepted, but preservation of life overrides everything. Usually, they are not willing to accept 'do not resuscitate' orders. Life preserving equipment will only be turned off if doctors are certain that death is the only outcome. There is often a preference for care at home.

It should be noted that people of Islamic faith have specific rituals and rites that need to be followed throughout palliative care and end-of-life care. Cremation is not permitted.

Sudanese

Pain and illness:

In Sudanese culture, herbal and traditional health remedies are often used. Many people may be unfamiliar with western medicines and the formal health system of their adopted country.

Sudan is a very heterogeneous country with many cultural influences. For those of Arab culture, their response to pain is often very expressive. They often prefer a higher level of consciousness towards the end of life. Therefore, the use of drugs that affect intellectual and cognitive functions must be clearly justified.

It is important to note that people of Islamic faith do not consume pork or alcohol, including in medication and this needs to be considered.

Palliative Care:

Sudanese people may be unfamiliar with palliative care and the associated services.

For those of Arab culture, the diagnosis of serious illness is often given to their closest family member first. Often the patient is not told. Discussion of impending death may be avoided although it is seen as predestined by God and is accepted. However, preservation of life overrides everything.

There may be a preference for palliative care at home. People of Islamic faith have specific rituals and rites that need to be followed. Cremation is not permitted.

South African Culture

Pain and illness:

Those of South African culture are generally accepting of pain medication.

Palliative Care:

Usually, there is a preference to die at home with limited involvement of health professionals. People of South African culture may avoid talking about death due to a belief that it will hasten the process.

Pain - Asia

People from Asian cultures vary in their views on pain and palliative care. Here we provide some examples to show this variation. Click on a country to find out more.

Afghan culture

Pain:

In Afghan culture, doctors are held in high regard and traditional treatments may be preferred. Mental health conditions are seen as a sign of weakness.

Note that Afghan people of Islamic faith do not consume pork or alcohol, including in medication.

Palliative care:

There is a preference among older people for care from same sex health care providers.

For those of Islamic faith, it may be customary to reduce medication at the time of death so that they can hear the final blessing, Kalima.

Arab Culture

This includes people from Lebanon, Egypt, Iraq, and Sudan. However, influences will vary across this diverse group.

Pain and illness:

For those of Arab culture, the response to pain is often very expressive. They may prefer a higher level of consciousness towards the end of life. Therefore, the use of drugs that affect intellectual and cognitive functions must be clearly justified.

It is important to note that people of Islamic faith do not consume pork or alcohol, including in medication and this needs to be considered.

Palliative care:

For those of Arab culture, the diagnosis of serious illness is often given to the closest family member first and the patient not told. Discussion of impending death may be avoided although it is seen as predestined by God and is accepted. There is a preference for palliative care at home and preservation of life overrides everything. Unless doctors are certain that death is the only outcome then life preserving equipment cannot be turned off. Usually, they are not willing to accept 'do not resuscitate' orders.

People of Islamic faith have specific rituals and rites that need to be followed at the end-of-life. Cremation is not permitted.

Burmese/Myanmar culture

Pain and illness:

In Burmese/ Myanmar culture, Buddhism is the most common faith. Black magic is suspected in the case of illness that cannot be cured. A healer may be brought in to help with the spiritual aspects of care.

Palliative Care:

Beliefs and spells are widely held in Burmese/ Myanmar culture.

In Buddhist culture the state of mind at the time of death is important as it determines the person’s next rebirth. A Buddhist monk or minister should be present when someone of Buddhism faith is dying.

Chinese culture

Pain and illness:

In Chinese culture, the opinion of doctors is highly valued and Western and Eastern medical advice often combined. Older people may be very stoic about pain as they may believe that suffering is part of karma and their spiritual journey.

Palliative Care:

People of Chinese culture can be reluctant to accept services as this may suggest that they have failed in their family responsibility of caring. The seriousness of an illness may be kept from a parent. Death and dying is often not discussed, however, planning for death is common.

In Chinese culture, towards the end of life, hospital or hospice may be preferred.

East Asian Culture

Pain and illness:

Those of East Asian culture may be stoic about pain. Therefore, they may show non-verbal signs of being in pain as opposed to describing it.

Palliative care:

In East Asian culture, palliative care services are generally accepted although there is a reluctance to talk about death. Some believe that dying at home may bring bad luck and so hospital or hospice preferred.

East Indian Culture

Pain and illness:

In East Indian culture, western and traditional treatments are commonly combined. Some people may prefer to endure pain to maintain a higher level of consciousness towards the end of life. However, others will accept pain medication for severe pain.

For intravenous insertions to the arm, there may be a preference for left or right as it is customary to use different hands for specific tasks.

Palliative care:

Those of East Indian culture may accept palliative care services. There is a tendency to discuss death with the family first and they may choose not to inform the patient. There may be a preference for same sex health care providers.

Often, ritualistic armbands, necklaces and torso threads are worn and should not be cut or removed without family consent.

At time of death, family may request that the body be positioned in a specific direction and follow Hindu rituals and rites. It is important for family members to be at the bedside of a dying patient.

Filipino Culture

Pain and illness:

In Filipino culture, pain is often expressed as being 'cold' or 'hot'. People will usually accept pain control.

Palliative care:

Those of Filipino culture will generally accept palliative care services. There may be an avoidance of discussing death. A loud grieving process is quite typical.

Indonesian Culture

Pain and illness:

In Indonesian culture, people may request that pain medicine is stopped near death so that they remain conscious.

Palliative care:

It is common for those of Indonesian culture to wish to die at home. Grief in Indonesian culture may be filled with emotion.

Iranian Culture

Pain and illness:

In Iranian culture, there is a tendency to express pain loudly. They may accept pain medications.

Palliative care:

For those of Iranian culture, it is preferred that discussions of death with the patient are avoided.

Iraqi/Arab Culture

Pain and illness:

In Iraqi culture, the medical profession and system are held in high regard. There is a preference for male doctors by both men and women, except for the case of pregnancy or gynaecological needs. There is a tendency for mental health conditions to be stigmatised, therefore, they may be kept hidden.

For those of Arab culture, their response to pain is very expressive. They prefer a higher level of consciousness towards the end of life. Therefore, the use of drugs that affect intellectual and cognitive functions must be clearly justified. Those of Islamic faith may prefer to reduce medication at the time of death as this enables them to hear the final blessing, Kalima.

It is important to note that people of Islamic faith do not consume pork or alcohol, including in medication.

Palliative Care:

In Iraqi culture, prayer is important, particularly when ill and this can be frequent.

For those of Arab culture, the diagnosis of serious illness is often given to the closest family member first and the patient is not told.

There is a preference for palliative care at home. Discussion of impending death may be avoided. Death is seen as predestined by God and is accepted. Preservation of life overrides everything. Unless doctors are certain that death is the only outcome then life preserving equipment cannot be turned off. Usually, they are not willing to accept 'do not resuscitate' orders.

People of Islamic faith have specific rituals and rites that need to be followed. Cremation is not permitted.

Japanese Culture

Pain and illness:

In Japanese culture, people may be very stoic towards pain. Monitoring for non-verbal signs is important.

Palliative Care:

Discussions about death may be avoided by those of Japanese culture. They may accept assistance with palliative care and more often prefer to be at home for end-of-life care.

Korean Culture

Pain and illness:

Those of Korean culture may be stoic about pain. However, pain medicine and herbal medicines may be accepted and combined.

Palliative care:

There is usually a preference to die at home in Korean culture. Mourning and crying are common reactions to death.

Sri Lankan Culture

Pain and illness:

Those of Sri Lankan culture value western and traditional medicine for pain relief.

Mental illness has a strong negative stigma in Sri Lankan culture and this may effect access to psychological support.

Palliative Care:

Diagnosis and prognosis must be discussed with family present in Sri Lankan culture.

It can be customary to use different hands for specific tasks and so individuals may have a preference for left or right arm with intravenous devices and drawing blood.

Vietnamese culture

Pain and illness:

In Vietnamese culture, illness may be seen as karma and result in the rejection of pain management. The suffering is seen as atonement for, or part of, previous actions or sins. These cultural beliefs can lead to a stoic approach to pain. Some Vietnamese people practice cupping as an alternative therapy which leaves small bruises not to be confused with abuse.

Mental illness is considered shameful in Vietnamese culture. Psychological difficulties may instead be described as physical symptoms such as pain or headaches.

Palliative Care:

In Vietnamese culture, families may try to keep the seriousness of an illness from their parent. There is a preference for dying at home, if possible. Support from family in decision-making is important.

Those of Buddhism faith believe that a body should not be moved for 8 hours after death, and this may influence their decision to use palliative care services.

Pain - Oceania

People from Oceanic cultures vary in their views on pain and palliative care. Here we provide some examples to show this variation. Click on a country to find out more.

Aboriginal and Torres Strait Islander peoples

Pain and illness:

Aboriginal and Torres Strait Islander peoples may be distrustful of medications. They may not complain when in pain for many reasons, this includes fear of being separated from family. Instead, they may avoid contact, hide, or use ‘centering’ where they withdraw into themselves spiritually and psychologically to shut out the pain (this may look as though they are sleeping).

Palliative care:

Family is important to Aboriginal and Torres Strait Islander peoples. Before discussing serious or life-limiting illness consult with the local Indigenous health liaison officer to understand cultural protocols. Cultural practices at the end of life vary across groups. For many, being close to family and/or traditional homeland is important at the end of life.

Reference: Queensland Health. Aboriginal and Torres Strait Islander: Patient care guideline. Brisbane, QLD: Queensland Health; 2014.

Maori people

Pain and illness:

Traditionally illness was thought by the Maori people to be a consequence of some breach of spiritual lore and the person would be separated from others. Today life and death is accepted as a normal part of the life cycle. Combining herbal medicines and other complimentary therapies with western medicine may be preferred.

Palliative care:

Maori people prefer to care for their own and to do so when a person is dying is seen as an expression of aroha (love, compassion, concern). Palliative care is viewed as helping the dying person's spirit to transition through the arai to the afterlife. It might start at diagnosis or once the person is unable to care for themselves. For many, dying at home and being close to family and/or traditional homeland is very important. If more complex care is needed or there isn't enough space to host visitors then other arrangements may be acceptable. Hospitals are seen by many as a place to die in and this may mean a reluctance to be admitted.

Reference: Moeke-Maxwell T, Mason K, Toohey F, Dudley J. Pou Aroha: An Indigenous Perspective of Māori Palliative Care, Aotearoa New Zealand. In: MacLeod R., Van den Block L. (eds) Textbook of Palliative Care. Cham, CH: Springer; 2019.