By Stacey Kusterbeck
What is a “good death?” The definition is unique to each individual patient. “However, immigrants — in the U.S., but also immigrants globally — often come with experiences and preferences related to their immigrant experiences that nuance their own definitions of what a good death should look like,” says Edward Christopher Dee, MD, a cancer researcher at Memorial Sloan Kettering Cancer Center.
Clinicians have an ethical obligation to determine patients’ preferences. “To do so for diverse groups — including individuals for whom their immigrant history is a key part of their identities and values — first requires the recognition that decisions surrounding end-of-life preferences may not be the same across various cultures,” says Dee.
The healthcare team must approach end-of-life with cultural humility, assert Dee and colleagues in a recent paper.1 “Ethicists may help by drawing the rest of the team’s attention to nuances that may not be so obvious,” suggests Dee. Some patients prefer being surrounded by family, with as minimal sedation as possible, even if it means less pain control. Other patients have religious traditions or belief systems that affect their receptiveness to medical intervention. “Those values are not always congruent with what the majority of patients in the healthcare setting value,” says Dee.
Likewise, in many East Asian cultures, it is common to share a serious diagnosis with the patient’s family members first. The expectation is that the family will decide how much (if any) information to share with the patient about the diagnosis. “The reasons for this approach are multifaceted,” says Khushi Kohli, the paper’s lead author and a student in the Department of Molecular and Cellular Biology at Harvard University.
The family wants to protect the patient from unnecessary emotional suffering and a loss of hope. There also is an emphasis on family-centered decision-making and a reluctance to broach the subject of death. There also may be a culture of deference to doctors or to family members in a position of authority. All these factors come into play in cases where a patient receives a terminal diagnosis, but the family wants to inform the patient that their condition is manageable. “These cultural preferences often conflict with Western medical ethics, which often prioritize patient autonomy and individual informed consent,” says Kohli.
Another aspect of end-of-life care that is somewhat unique to immigrants is location of death. For some individuals, dying at home — perhaps in a home country — is more important than freedom from pain or duration of remaining time. “Within the bounds of patient safety, efforts are needed to explore how death at home may be made possible for those who desire it,” says Dee.
To avoid end-of-life conflicts between clinicians and family members, Kohli recommends the following practices:
- Engage in proactive discussions about the patient’s end-of-life preferences. “Ideally, these discussions would happen before the patient’s condition advances significantly, although this is not always possible,” says Kohli.
- Involve traditional, religious, and community leaders in discussions on end-of-life preferences if the patient or family wishes.
- Ask open-ended questions, such as “Are there any family members or spiritual advisors you would like to include in our discussion?” “This can ensure that these discussions are patient-centered,” says Kohli.
- Regularly revisit the topic of patients’ end-of-life preferences. “The goals of care, for the patient and their family, may evolve over time,” explains Kohli.
Reference
1. Kohli K, Feliciano EJ, Swami N, et al. Dying with dignity: How can we deliver values-concordant end-of-life care for immigrant patients in the United States? Lancet Reg Health Am. 2024;35:100776.
What is a “good death?” The definition is unique to each individual patient.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content