Ethical Issues Surrounding Ethical Issues Surrounding End of Life Care:End of Life Care:

A Perspective From the A Perspective From the Chinese CultureChinese Culture

By Ingrid See, RN BSN MEDBy Ingrid See, RN BSN MEDClinical Practice LeaderClinical Practice Leader

Vancouver Home Hospice Vancouver Home Hospice

Uniqueness of CultureUniqueness of Culture Each person has his/her Each person has his/her

own philosophy about own philosophy about health and illnesshealth and illness

Understand the Understand the experiences, traditions, experiences, traditions, and values that shape and values that shape each individual’s views each individual’s views about health and illnessabout health and illness

Important to find out about Important to find out about the individual’s perception the individual’s perception of health problems, of health problems, treatments, and goalstreatments, and goals

Is There An Easy Recipe?Is There An Easy Recipe?

No “cookbook” No “cookbook” for any culturefor any culture

Long ago, in a galaxy far, far, Long ago, in a galaxy far, far, away………..away………..

The universe was in a state of chaos, The universe was in a state of chaos, without form, force, or substancewithout form, force, or substance

Negative & Positive ForcesNegative & Positive Forces

Balance & HarmonyBalance & Harmony

Universe = ManUniverse = Man

5 Elements5 Elements

Yin Yang TheoryYin Yang Theory

Health exists Health exists when balance when balance occurs in yin and occurs in yin and yang, therefore, yang, therefore, the body is in the body is in harmonyharmony

YinYin

PassivePassive Dark Dark InsideInside QuietQuiet NegativeNegative FeminineFeminine NightNight ColdCold

YangYang

ActiveActive LightLight OutsideOutside NoiseNoise PositivePositive MasculineMasculine DayDay HotHot

QiQi

Known as the vital Known as the vital energy that pervades energy that pervades the entire universethe entire universe

eg. Heat, light, soundeg. Heat, light, sound

Regulates circulation Regulates circulation of blood, process of of blood, process of digestion, digestion, autoprotection of autoprotection of organisms and vital organisms and vital activitiesactivities

Human BodyHuman Body

A person has A person has certain amounts of certain amounts of Qi at birthQi at birth

Qi is depleted by Qi is depleted by ADLs, and ADLs, and augmented and augmented and rebuilt by food and rebuilt by food and airair

IllnessIllness

Depletion or Depletion or imbalance of Qi imbalance of Qi causes ill healthcauses ill health

Absence of Qi = DeathAbsence of Qi = Death

Western PhilosophyWestern Philosophy

Looks at diagnosis, Looks at diagnosis, causes of disease, causes of disease, treatments, and treatments, and symptomssymptoms

Yin Yang PhilosophyYin Yang Philosophy

When vital forces When vital forces of the body are in of the body are in balance, positive balance, positive health occurshealth occurs

Diseases occurs Diseases occurs when imbalance is when imbalance is present and is seen present and is seen as a struggle as a struggle between Qi and between Qi and diseasedisease

6 Excesses6 ExcessesDiseases Originating from Outside the BodyDiseases Originating from Outside the Body

Wind:Wind: diseases that diseases that arise suddenly and arise suddenly and changes quicklychanges quickly

Cold:Cold: Part of the Part of the body or whole body body or whole body feels cold which feels cold which causes fluids to causes fluids to congeal in the bodycongeal in the body

Excesses (cont.)Excesses (cont.)

Heat: Heat: Part of the Part of the body or whole body body or whole body feels hot. Heat feels hot. Heat injures the bodyinjures the body

Dampness:Dampness: damp damp weather or comes weather or comes in contact with in contact with moisture for a long moisture for a long timetime

Dryness:Dryness: attacks attacks fluids of bodyfluids of body

Summer heat:Summer heat: pronounced fever pronounced fever and sweating. and sweating. Dampness always Dampness always accompanies this accompanies this excessexcess

7 Excessive Emotions7 Excessive EmotionsDiseases arising from inside the bodyDiseases arising from inside the body

HappinessHappiness AngerAnger PensivenessPensiveness SadnessSadness FearFear AnxietyAnxiety WorryWorry

Yin Yang Perception of IllnessYin Yang Perception of Illness

Looks at signs and symptoms to find Looks at signs and symptoms to find energetic imbalancesenergetic imbalances

Looks for disease originating from Looks for disease originating from outside the bodyoutside the body

Looks for diseases originating from Looks for diseases originating from inside the bodyinside the body

Emotions are linked to the five Emotions are linked to the five elements – excess results in illnesselements – excess results in illness

Nature of FoodNature of FoodHot Hot

LycheeLychee CookiesCookies MangoMango Sugar/candySugar/candy BeefBeef Chili/pepperChili/pepper LambLamb GingerGinger Deep fried foodsDeep fried foods

Cold FoodsCold Foods HoneydewHoneydew TomatoTomato BananaBanana PearPear MelonMelon CucumberCucumber SeaweedSeaweed Cold drinksCold drinks

Neutral FoodsNeutral Foods

AppleApple GrapeGrape PapayaPapaya RiceRice FlourFlour ChickenChicken MilkMilk Soy drinkSoy drink TeaTea

End of Life Issues:End of Life Issues:A Cultural PerspectiveA Cultural Perspective

Chinese culture is very hushed about Chinese culture is very hushed about talking about illness and deathtalking about illness and death

Seen as a “weakness”Seen as a “weakness” To openly discuss death and dying is To openly discuss death and dying is

taboo and disrespectfultaboo and disrespectful Important not to generalize the Important not to generalize the

cultureculture

To Tell or Not to TellTo Tell or Not to Tell

Don’t want to cause Don’t want to cause worry/anxietyworry/anxiety

Don’t want to cause Don’t want to cause fearfear

Worried that the Worried that the person will give up person will give up hope and be hope and be upsetupset

Stigma of the illnessStigma of the illness Person will become Person will become depresseddepressed and and stop eatingstop eating

StrategiesStrategies

Focus on the hope of getting better Focus on the hope of getting better but prepare for the worsebut prepare for the worse

Take the person’s perspective ie. Take the person’s perspective ie. what happens if the client doesn’t what happens if the client doesn’t see him/herself get better? This see him/herself get better? This adds to more worry/anxiety adds to more worry/anxiety because person has been told because person has been told he/she would get betterhe/she would get better

Use non-threatening terms ie. Use non-threatening terms ie. tumor instead of cancertumor instead of cancer

What If I Get Asked?What If I Get Asked?

Family has requested that health Family has requested that health care provider does not tell client that care provider does not tell client that he/she has a serious illnesshe/she has a serious illness

Ethical dilemma – should health care Ethical dilemma – should health care provider tell the client if asked by the provider tell the client if asked by the client?client?

StrategiesStrategies Ask yourself, what is your agenda?Ask yourself, what is your agenda? Let the family know that you will not talk Let the family know that you will not talk

directly about the illness but if asked, you directly about the illness but if asked, you will ask the client what he/she will ask the client what he/she understandsunderstands

Paraphrase the client’s wordsParaphrase the client’s words Also, ask client what he/she wants to knowAlso, ask client what he/she wants to know If client indicates information regarding If client indicates information regarding

illness, ask client “Who do you want to illness, ask client “Who do you want to hear the information from?”hear the information from?”

And if the family continues to And if the family continues to choose not to tell?choose not to tell?

SO WHAT?SO WHAT?

Talking About the IllnessTalking About the Illness

Illness is very private. Cancer is seen Illness is very private. Cancer is seen as contagious by many of the elderlyas contagious by many of the elderly

Talking about illness brings the spirit Talking about illness brings the spirit downdown

Talking about illness can lead to Talking about illness can lead to depressiondepression

Illness is seen as a weaknessIllness is seen as a weakness

StrategiesStrategies

Try to get the client’s understanding Try to get the client’s understanding of the illness.of the illness.

Assess what the client’s past coping Assess what the client’s past coping mechanisms were for other illnesses.mechanisms were for other illnesses.

Find out what the client’s goals are.Find out what the client’s goals are. Assess how they perceive you can Assess how they perceive you can

help them.help them.

DNRDNR

Greatest fear is that health care Greatest fear is that health care professionals will do nothing (ie. no professionals will do nothing (ie. no treatment) to help loved onetreatment) to help loved one

Fear that health care professionals Fear that health care professionals have given up hope when family still have given up hope when family still has hopehas hope

StrategiesStrategies

Explain that DNR does not mean “Do Explain that DNR does not mean “Do Not Treat”Not Treat”

Explain that all will be done but after Explain that all will be done but after one dies, no CPR will be performed. one dies, no CPR will be performed. Give specific examplesGive specific examples

Support the use of home remedies, Support the use of home remedies, medicinesmedicines

View of Health Care View of Health Care ProfessionalsProfessionals

Chinese view doctors an an Chinese view doctors an an authority figureauthority figure

Some do not question the Some do not question the views of doctors and will go views of doctors and will go by what he/she saysby what he/she says

Nursing is not viewed as an Nursing is not viewed as an honourable profession honourable profession because it is “dirty”.because it is “dirty”.

Focus of the medical Focus of the medical profession in HK/China is on profession in HK/China is on cure.cure.

Nurses in HK/China are Nurses in HK/China are

trained differently thantrained differently than here (different philosophyhere (different philosophy))

StrategiesStrategies

Assist clients to understand what the Assist clients to understand what the roles are of your various team roles are of your various team membersmembers

Clients often will listen to you but Clients often will listen to you but may check your information with GP may check your information with GP or family member who is a physicianor family member who is a physician

Communication within your team is Communication within your team is important so that the same message important so that the same message is being givenis being given

Involving ChildrenInvolving Children Education commitments Education commitments

outweigh being with outweigh being with parents. Children are parents. Children are encouraged to visit but not encouraged to visit but not to take on tasks because it to take on tasks because it may interfere with schoolmay interfere with school

School is a strong value in School is a strong value in the Chinese culturethe Chinese culture

Doing well in school Doing well in school maintains integrity and maintains integrity and parents’ peace of mindparents’ peace of mind

Good grades and success Good grades and success save the face of the familysave the face of the family

StrategiesStrategies Children may be reluctant to talk to health care Children may be reluctant to talk to health care

professionals as they are viewed as outsiders. professionals as they are viewed as outsiders. Involve school counselors, public health nurses Involve school counselors, public health nurses with permission of the parents (and children if with permission of the parents (and children if old enough) old enough)

Honor the value of education. Be careful of Honor the value of education. Be careful of your own judgements and the judgements of your own judgements and the judgements of staff if the children do not visit very much.staff if the children do not visit very much.

When children do visit, parents tend to find When children do visit, parents tend to find tasks that they can help withtasks that they can help with

Feel out if the children wantFeel out if the children want to talk to youto talk to you

Family StructureFamily Structure Many elderly people Many elderly people

choose to live with the choose to live with the eldest soneldest son

Role of eldest son is to Role of eldest son is to look after the parentslook after the parents

Role of D-I-L is to help Role of D-I-L is to help look after the in-lawslook after the in-laws

Daughters are Daughters are expected to help out expected to help out because the son’s because the son’s work must not be work must not be disturbeddisturbed

Decision MakingDecision Making Related to the family structure. In a traditional Related to the family structure. In a traditional

Chinese family, the eldest son is responsible Chinese family, the eldest son is responsible for decision makingfor decision making

Son may be overseas, therefore, decisions Son may be overseas, therefore, decisions may not be made here. Other sibling(s) will may not be made here. Other sibling(s) will often contact oldest son to make decisionoften contact oldest son to make decision

If son is a child, husband may defer decision to If son is a child, husband may defer decision to client’s brother or a relative who may be in the client’s brother or a relative who may be in the medical professionmedical profession

StrategiesStrategies Assess for a clear overview of the family Assess for a clear overview of the family

structure. Spokesperson may not be structure. Spokesperson may not be the same person as the decision makerthe same person as the decision maker

Find out what services are appropriate Find out what services are appropriate when planning discharge to homewhen planning discharge to home

Assess who is living at home and roles Assess who is living at home and roles that they play ie. childrenthat they play ie. children

Females may often have to do the Females may often have to do the personal care as the male client may personal care as the male client may not want strangersnot want strangers

To Feed or Not to FeedTo Feed or Not to Feed

Value of food is so Value of food is so important to important to maintain yin/yang maintain yin/yang balancebalance

Guilt suffered by Guilt suffered by family if the client family if the client is not eatingis not eating

Withholding food Withholding food and water and water contradicts the contradicts the need to replenish need to replenish QiQi

StrategiesStrategies Find out what the client and family’s Find out what the client and family’s

wishes/goals arewishes/goals are Help family feed the client for as long as Help family feed the client for as long as

possiblepossible Tube feeds and IVs - discuss pros and Tube feeds and IVs - discuss pros and

cons and let family decidecons and let family decide Be aware of your own agenda and Be aware of your own agenda and

valuesvalues Key is providing options, negotiating Key is providing options, negotiating

with client and family, and supporting with client and family, and supporting them with their decisionsthem with their decisions

DeathDeath Death is a bad omenDeath is a bad omen Death is not perceived as part of the Death is not perceived as part of the

natural life cycle – seen as the “enemy”natural life cycle – seen as the “enemy” Bad luck to die at homeBad luck to die at home If chooses to die at home, client can If chooses to die at home, client can

only die in the son’s home (preferably only die in the son’s home (preferably the eldest) the eldest)

Cannot die in the daughter’s homeCannot die in the daughter’s home Family cannot visit other people’s Family cannot visit other people’s

homes or give gifts until a month after homes or give gifts until a month after the deaththe death

StrategiesStrategies

Prepare client and families for the Prepare client and families for the emotional, spiritual, and emotional, spiritual, and physiological changes during the last physiological changes during the last days/weeks of lifedays/weeks of life

Provide options where the client may Provide options where the client may diedie

Support the family in their decisionsSupport the family in their decisions Refer family to resources in Refer family to resources in

community/hospital/residential carecommunity/hospital/residential care

After-lifeAfter-life Those who are Buddhist may follow the Those who are Buddhist may follow the

tradition that the body may not be moved tradition that the body may not be moved for 8 hours (some for several days)for 8 hours (some for several days)

Rituals – ie. special clothing for the Rituals – ie. special clothing for the deceased, money, jewelry, comb to deceased, money, jewelry, comb to accompany bodyaccompany body

7 days post-death: spirit comes home; turn 7 days post-death: spirit comes home; turn on all lights in home, leave food outon all lights in home, leave food out

49 days – wear white or blue flower in hair 49 days – wear white or blue flower in hair to display grief and mourningto display grief and mourning

To honor guests that come to the service, To honor guests that come to the service, give white envelopes with money and give white envelopes with money and candy; provide a 7 course mealcandy; provide a 7 course meal

StrategiesStrategies

Ask family if any special rituals or Ask family if any special rituals or religious requests after client dies so you religious requests after client dies so you can help prepare the unit ahead of time can help prepare the unit ahead of time or if at home, help family keep their or if at home, help family keep their loved one there until transport to funeral loved one there until transport to funeral homehome

Ensure privacy and allow the family to Ensure privacy and allow the family to spend time with their loved onespend time with their loved one

Allow time for questionsAllow time for questions regarding the regarding the deathdeath

SummarySummary

Be aware that many philosophies of illness Be aware that many philosophies of illness exist within cultures and within individualsexist within cultures and within individuals

Important to do an accurate cultural Important to do an accurate cultural assessment of each client, each family assessment of each client, each family membermember

Be aware of your own values/judgements Be aware of your own values/judgements when supporting families at end of life when supporting families at end of life

Find out what’s important to the client and Find out what’s important to the client and the family and help them move towards the family and help them move towards their goalstheir goals