Physicians who practice in a multicultural environment have a responsibility to understand that family members from some cultures may have very different perspectives on the family’s role and on who should be involved in treatment decisions. Individuals from some cultures may not endorse tenets of Western clinical ethics, such as the equivalence of withholding and withdrawing life support or the definition of brain death. It is important to anticipate differences in perspectives and apply principles of culturally effective end-of-life care to these situations.

Several studies of patients’ attitudes toward end-of-life care identify values that vary by race, ethnicity, and geographic origin. On average, nonwhites are more likely to request life-sustaining therapy and are less likely to have advanced directives or do-not-resuscitate orders or accept hospice care. Much of this difference is influenced by patients’ and families’ lack of trust in physicians and health-care institutions. Although understanding ethnic variations in preferences will not solve all problems with end-of-life care, a clearer understanding of what contributes to patients’ and families’ understanding, fears, and preferences improves communication and is a crucial step in providing better end-of-life care.

Physicians have a responsibility to avoid stereotyping patients or making assumptions about their attitudes based solely on race, ethnicity, religion, or other demographic characteristics. Existing recommendations can help physicians provide end-of-life care that accommodates needs based on religion and culture.The dying process is one of the most important events in which ritual aspects of religion and spirituality play a role. During discussions of end-of-life care, time should be spent discussing, understanding, and accommodating cultural and religious perspectives, and reasonable efforts should be made to accommodate rituals associated with dying. Physicians should not assume that physician and hospital staff share the same values as patients and families of similar religious or ethnic background, and should not substitute statements from persons of similar background for a more thorough discussion with the patient and their family.

“Cross-cultural” Mnemonics

• Learn, listen
• Explain
• Acknowledge
• Recommend
• Negotiate

• Explanation
• Treatment
• Healers
• Negotiation
• Intervention
• Collaboration