11 Diversity in Dying: Death across Cultures
Whether it is seen in personal terms or trans-personal terms, whether it is Heaven or Nirvana or Happy Hunting Ground or the Garden of Paradise, the weight and authority of tradition maintains that death is just an alteration in our state of consciousness, and that the quality of our continued existence in the afterlife depends on the quality of our living here and now.-John Smith
Learning Objectives
- Identify the role of the nurse in providing culturally competent care to patients nearing the end of life.
- Examine the basic components of funeral traditions in the United States.
- Describe beliefs and traditions associated with death and dying among various religions and cultures.
Cultural competence is a term that nurses have learned is a necessary part of providing good nursing care to patients. The population of the United States is becoming more diverse, and nurses should be both knowledgeable and comfortable providing care to a diverse range of patients. Diversity includes issues related to a person’s ethnicity, sexual orientation, age, gender, and socio-economic class (ELNEC, 2010). Nurses who care for patients nearing the end of life should have a good understanding about the various beliefs and traditions held by various cultures about death and dying. This is something that is not always thought of in nursing school, but it is essential information to know when caring for patients who are dying.
The role of the nurse in end-of-life care includes providing care that is individualized and culturally competent for each patient. As mentioned before, the care that is provided to patients during their final hours will be remembered forever by the family members who were present. If the patient is from an ethnicity or religion that is different from the nurse, it is important to provide care that is respectful and appropriate within that particular faith or cultural tradition. Any nurse who will be caring for a patient whose particular culture differs from theirs is strongly encouraged to take the time to learn some basic information that will help to inform them about that culture and the practices they hold with regard to death and dying.
Funeral Traditions in the United States
The energy and stamina which young adults who are studying nursing bring to the profession is invaluable; however, life experience with death and dying or funerals is often lacking in younger people. This next section was written to provide the young nursing student or novice nurse, who may not have had any previous experience with attending a funeral service, some basic information about funerals. Although most cultures and religions have their own unique rituals and traditions associated with funeral practices and mourning, we will identify some basic components found in the traditional funeral in the United States.
Options for final arrangement: Burial or cremation
One of the reasons that people should discuss their wishes before they become ill is so their family will know what final arrangements they would like to have after they die. Although some believe it is morbid to talk about end of life and funeral wishes while one is young and healthy, it can be a very important conversation to have. The family has had to make many difficult decisions while their loved one was dying, and then, after death, they have to plan the funeral. This is one of the most difficult things that people have to do in their lives. Although most people who die are older, there can be death that occurs in people of all ages, including newborn babies, infants, children, adolescents, and young adults. While the majority of nurses who are reading this book will care for adults or older adults, it is imperative to understand the perspective of the family who are undergoing the planning process.
One of the greatest decisions the family will have to make (unless specified in advance by the patient) is whether their loved one will be buried or cremated. Both methods have been around for thousands of years, and it is really a matter of personal preference (and sometimes family history). When burial is elected, the deceased will be interred in the ground in a cemetery, entombed in a vault in a mausoleum, or, more recently, have a “green burial.” Burials can be expensive; the average median cost of a funeral is over $8,000. (National Funeral Directors Association, 2012). The deceased will need to have their body prepared and/or embalmed. Embalming is the process in which the blood is removed from the body via the veins and replaced with an embalming solution via the arteries, usually containing formaldehyde and other chemicals (National Funeral Directors Association, 2012). The body will be prepared cosmetically and dressed before being placed in the casket. Along with the casket, there is usually a vault that is placed into the ground that encompasses the casket. There are also fees associated with the grave or mausoleum space and opening up the ground/vault for internment. The funeral director has a fee for their services and use of the funeral home for visitation. A hearse is the vehicle that transports the deceased from the funeral home to the church (if applicable) and to the cemetery. The family will obtain a death certificate and may write an obituary for the local newspaper. Lastly, if burial is used, often there will be a headstone or marker purchased for the grave.
Although both burial and cremation can be costly, cremation is usually less expensive than a burial. Cremation is the process by which the deceased body is burned into ashes using heat and fire. Any fragments that remain after the procedure, including bones, are ground down to a finer consistency with special tools at the crematorium. When selecting this method, the body does not get embalmed. The body is placed into an approved container, such as a wooden casket, for the cremation. Certified crematoriums have special policies and procedures in place to ensure that the highest quality care and dignity are provided during the cremation process. The remains are placed into a special container called an urn. There are many choices available to families for urn styles as well as caskets. There can still be formal visitation and funeral practices that take place before the deceased is cremated, or a memorial service can be held with the ashes of the deceased after cremation occurs. Cremated remains are then either buried in the ground or mausoleum in a cemetery, kept by the family, scattered in an outdoor location or divided up between family members (although this practice is not used in some religions who believe that the remains of a person should not be divided).
Visiting hours
Visiting hours, also called visitation or a wake, is when the deceased person’s body is prepared and placed on display in a casket. Formal visiting hours are held at the funeral home in which family and friends of the deceased can come and say their final good-byes and offer condolences to the family. Visiting hours usually occur 1-2 days before the funeral or memorial service. Many times there is a formal book that visitors can sign. Flowers and other memorial displays often are part of this time. Many families will display photos or prized possessions of their loved one or have favorite music played in the background. More recently, families are using technology to make video displays of pictures or home videos of their loved one during visitation.
The casket can be open or closed during visiting hours. An open casket is where the deceased body is visible to family and guests; a closed casket means that the deceased body cannot be seen by family or guests. Often if the death resulted from severe trauma, a closed casket is the preferred method. In certain religions, such as Judaism, deceased are never displayed in an open casket, nor is embalming allowed.
The funeral or memorial service
A funeral is the formal ritual that takes place which is often officiated by clergy from the decedent’s religion. This can take place at the funeral home or in a church. The Catholic faith usually has a funeral mass that takes place at a church officiated by the priest. The casket is often closed at church funerals. Sometimes, family or friends of the deceased will speak or give a eulogy about their loved one during the funeral or memorial service. Internment follows the funeral service and a procession of guests usually follow the hearse carrying the casket or remains of the deceased to the cemetery.
The burial or internment
The burial or internment of the deceased can take place right after the funeral or memorial service or at some later date. The clergy will often accompany the deceased and family to the cemetery and provide a small service at the grave. Many times the grave or mausoleum will be blessed as the deceased is interred. If the deceased was a member of the military, a special military service may be conducted at that time. The casket is usually wrapped in the American flag and then given to the decedent’s next of kin. In the U.S., gatherings are commonly held following a funeral service in which family and friends gather for a meal.
Diversity of Beliefs and Traditions across Religions and Cultures
Now that we have discussed the basics that comprise the traditional funeral in the United States, we will focus on some more specific practices and traditions from various cultures and religions. Table 11.1 outlines traditions associated with several selected religions.
Religion |
Beliefs pertaining to death |
Preparation of the Body |
Funeral |
| Catholic | Beliefs include that the deceased travels from this world into eternal afterlife where the soul can reside in heaven, hell, or purgatory. Sacraments are given to the dying. | Organ donation and autopsy are permitted. | Cremation historically forbidden until 1963.The Vigil occurs the evening before the funeral mass is held. Mass includes Eucharist. If a priest is not available, a deacon can lead funeral services. Rite of committal takes place with interment. |
| Protestant | Belief in Jesus Christ and the Bible is central, although differences in interpretation exist in the various denominations. Beliefs include an afterlife. | Organ donation and autopsy are permitted. | Cremation or burial is accepted. Funeral can be held in funeral home or in church and led by minister or chaplain. |
| Jewish | Tradition cherishes life but death itself is not viewed as a tragedy. Views on an afterlife vary with the denomination (Reform, Conservative, or Orthodox). | Autopsy and embalming are forbidden under ordinary circumstances. Open caskets are not permitted. | Funeral held as soon as possible after death. Dark clothing is worn at and after the funeral/burial. It is forbidden to bury the decedent on the Sabbath or festivals. Three mourning periods are held after the burial, with Shiva being the first seven days after burial. |
| Buddhist | Both a religion and way of life with the goal of enlightenment. Beliefs include that life is a cycle of death and rebirth. | Goal is a peaceful death. Statue of Buddha may be placed at bedside as the person is dying. Organ donation is not permitted. Incense is lit in the room following death. | Family washes and prepares the body. Cremation is preferred but if buried, deceased should be dressed in regular daily clothes instead of fancy clothing. Monks may be present at the funeral and lead the chanting. |
| Native American | Beliefs vary among tribes. Sickness is thought to mean that one is out of balance with nature. Thought that ancestors can guide the deceased. Believe that death is a journey to another world. Family may or may not be present for death. | Preparation of the body may be done by family. Organ donation generally not preferred. | Most burials are natural or green. Various practices differ with tribe. Among the Navajo, hearing an owl or coyote is a sign of impending death and the casket is left slightly open so the spirit can escape. Navajo and Apache tribes believe that spirits of deceased can haunt the living. The Comanche tribe buries the dead in the place of death or in a cave. |
| Hindu | Beliefs include reincarnation, where a deceased person returns in the form of another, and Karma. | Organ donation and autopsy are acceptable. Bathing the body daily is necessary. Death and dying must be peaceful. Customary for body to not be left alone until cremated. | Prefer cremation within 24 hours after death. Ashes should be scattered in sacred rivers. |
| Muslim | Muslims believe in an afterlife and that the body must be quickly buried so that the soul may be freed. | Embalming and cremation are not permitted. Autopsy is permitted for legal or medical reasons only. After death, the body should face Mecca or the East. Body is prepared by a person of the same gender. | Burial takes place as soon as possible. Women and men will sit separately at the funeral. Flowers and excessive mourning are discouraged. Body is usually buried in a shroud and is buried with the head pointing toward Mecca. |
(ELNEC, 2010; Health Care Chaplaincy, 2009).
What You Should Know
- Visiting hours, the funeral, and the burial are the main components in most traditional U.S. funerals.
- Different cultures have varying traditions pertaining to death and when caring for patients belonging to a particular faith or culture, the nurse should become familiar with the traditions the patient and family would like to observe.
References
End of Life Nursing Education Consortium (2010). ELNEC – core curriculum training program. City of Hope and American Association of Colleges of Nursing. Retrieved from http://www.aacn.nche.edu/ELNEC
Health Care Chaplaincy (2009). A dictionary of patients’ spiritual and cultural values for health care professionals. Retrieved from http://www.healthcarechaplaincy.org/userimages/doc/Cultural%20Dictionary.pdf
National Funeral Directors Association (2012). General funeral service facts. Retrieved from http://nfda.org/about-funeral-service-/trends-and-statistics.html
