Providing end-of-life care for people from culturally diverse backgrounds in intensive care
An article written by Prof. Melissa J Bloomer, A/Prof. Krishnaswamy Sundararajan and Dr Caroline Phelan
Australia is one of the most culturally diverse countries in the world. Cultural diversity encompasses ethnic and racial diversity, multiculturalism, diverse languages, religions, practices, identities, family structures and views and beliefs about health, illness and death. In an intensive care unit (ICU), ethnocultural biases and stereotypical assumptions can negatively influence ICU care. This is particularly evident at the end of life when language barriers limit understanding of a person’s values, beliefs, preferences and care needs.
We undertook a study [1] to explore the experiences of clinicians in providing care for patients and their family members from culturally diverse backgrounds. Conducted in two ICUs in Adelaide, South Australia, 20 clinicians (8 doctors, 7 registered nurses, 2 physiotherapists, 2 social workers and one pharmacist) participated in individual interviews.
In their reflections, participants emphasised the importance of cultural sensitivity and responsiveness in ICU care. Acknowledging that medicine, as a whole, tends to focus on the “black and white, right and wrong”, looking beyond unconscious biases and assumptions was critical to responding sensitively to the needs of patients who are culturally diverse. Clinicians talked about the importance of considering:
“Who are those people when they come through the front door? Who are they? What does that mean for care?”
This approach was considered essential because each person’s cultural identity underpins their values, trust in Western medicine, and expectations of care.
At the end of life
It was at the end of life, that care was most challenging. Clinicians shared that language barriers, religious beliefs and expectations could manifest as a disconnect between clinicians and family members. This was most apparent when a patient was declared brain dead.
Brain death was described as a very foreign concept to explain, particularly because biological and legal definitions of death and not synonymous with cultural and religious understandings of death. [2] Hence, when family members witness the patient’s chest rise and fall, see that their heart is beating on the monitor, and they are warm to the touch, understanding the person has died is challenging. In talking about removing organ support, such as a mechanical ventilator, clinicians shared that family members often mistakenly assumed care was being withdrawn:
“… like with the withdrawal of life-sustaining therapies, doesn’t mean withdrawal of care, and that withdrawal of treatment doesn’t cause or hasten death”
Cultural nuances
It was unanimously acknowledged that clinicians typically have a limited understanding of the vast range of cultural and religious beliefs and practices surrounding life and death. Thus, asking about views on life and death and expectations about the intensity of care is important. For example:
“… some groups require you to keep going with the treatment. You can’t stop. You have to let them go on their own. So religiously to them, their spirit continues…it’s different between different cultures”
Clinicians also acknowledged that whilst people from Western cultures may view death as a private event, for other cultures, death is a communal event. As such, an openness and willingness to facilitate large family gatherings was culturally important to facilitated farewells. Similarly, grief may look different, with some cultural groups wanting to grieve openly, and pray over the deceased. Cultural beliefs may also dictate essential practices, such as leaving the body untouched for a period of time, facilitating time for family to pray or chant or perform important rituals, dressing the deceased in clothing of cultural or religious significance, or positioning the deceased person to face Mecca.
In essence, dying and death are sociocultural events, not just biological events. Even when death cannot be avoided, time spent understanding the patient and family’s culture and religious beliefs is valuable and appreciated by families. Thus, taking time to bridge communication gaps, to ask questions and understand each person’s culture and what it means for care, particularly at the end of life, is time well spent.
Reference
- Sundararajan K, Subramaniam A, Hanson-Easey S, Thompson C, Phelan C, Doherty S, et al. “Who are they? What does that mean for care?”: An exploratory descriptive study of clinicians’ experiences of caring for patients and family members from culturally diverse backgrounds. Intensive Crit Care Nurs. 2026;93:104291.
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Australian and New Zealand Intensive Care Society. The Statement on Death and Organ Donation. Camberwell: ANZICS; 2021. Available from: https://www.anzics.org/death-and-organ-donation/
Authors
Professor Melissa J Bloomer
Professor in Nursing, School of Nursing and Midwifery
La Trobe University
Associate Professor Krishnaswamy Sundararajan
Director of Intensive Care
Royal Adelaide Hospital
Dr Caroline Phelan
Senior Lecturer, College of Nursing and Health Sciences
Flinders University