Buddhism beliefs

Honoring Long-held Cultural Beliefs for End-of-Life Care: Are We Prepared in Modern Western Society?

The Hippocratic oath lays down the principle of primum non nocere or “first do no harm” in Western medicine. This not only includes physical health, but also encompasses emotional and spiritual health. Various end-of-life care (EOLC) practices exist in different societies, and it is challenging but vital for the healthcare community to be aware of these practices in order to enable their patients with healthy care that is emotionally and spiritually fulfilling.

A 57-year-old man with a history of metastatic squamous cell carcinoma of the head and neck region presented to the emergency department after an out-of-hospital cardiac arrest. After proper post-cardiac arrest care, the patient remained unresponsive and the family decided to transition to comfort-oriented care. Based on their religious and cultural preferences, they preferred palliative extubation to a place where the patient would not have a roof over their head at the time of death, as well as sought help in arranging funeral the same day. After coordination with various hospital departments, the patient was taken to the hospital heliport and extubated there in the presence of his family. The patient’s remains were returned to the family within an hour of death for a timely funeral.

This case is an example of the cultural and religious diversity that exists within our community. Healthcare is a complex field and EOLC is a crucial part of patient care. With a multidisciplinary approach to EOLCs, death-related distress can be reduced among families as well as care teams.


Primum not noxious is Latin for “first do no harm” in the original Hippocratic Oath. This oath is one of the earliest expressions of bioethics in Western medical literature and continues to be one of the integral tenets of modern medicine. This principle concerns not only the physical well-being of patients, but also their spiritual and emotional well-being. In medicine, all of these aspects of patient care are addressed at the end of a patient’s life. End-of-life care (EOLC) is a shift from prolonging life to symptom control, comfort, dignity, quality of death, and care after death. Patients at the end of life generally receive care in four main areas: mental and emotional care, physical care, spiritual care and practical tasks. Depending on the cultural and religious practices of the patient, EOLC is different when it comes to honoring the needs of the dying [1]. Additionally, families and communities of deceased individuals have different traditions and cultures affecting EOLCs.

In an increasingly multicultural society, cultural competence and sensitivity are necessities for EOLCs but can be easily compromised by the lack of knowledge of the care teams or the barriers linked to the hospital system, the latter referring to facilities lacking facilities for cultural diversity and favoring a universal approach. EOLC approach. Obstacles within the hospital system limit equipment and staff, preventing the facility from adapting patient care in their approach to dying and dying [2]. For places such as the intensive care unit (ICU), many accommodations cannot be accommodated due to logistics and acuity of patient care, and often lead to adverse outcomes and interactions. Arguably, the limitations of the EOLC violate the notion of nonmaleficence and beneficence due to the failure of health care providers to care for the emotional and spiritual well-being of their patients. This ethical dissonance draws attention to the difficulty that the critical care health care team faces in providing holistic, quality care to their patients and highlights the need for our health systems to take into account the cultural, religious and spiritual diversity. We present a case where the routine functioning of the health care system has been modified to accommodate the religious and cultural practices of the patient and his family.

Presentation of the case

A 57-year-old man was brought to the emergency room after an out-of-hospital cardiac arrest. The family found him unresponsive on his bed; he was last seen normal about an hour ago. Cardiopulmonary resuscitation (CPR) was performed by the family for about 10 minutes before paramedics arrived. The patient had a return of spontaneous circulation at the time of the arrival of the paramedics. En route to the hospital, the patient had repeated episodes of cardiac arrest, with an estimated cumulative downtime of 25 minutes. The patient had a history of primary head and neck cancer (state post partial glossectomy and lymph node dissection, followed by chemoradiotherapy), followed by metastatic recurrence, for which he was under immunotherapy. Medical history was also significant for type II diabetes mellitus, hypertension, hepatitis C, coronary artery disease, unilateral below-knee amputation, renal cell carcinoma (post-nephrectomy partial condition), and dysphagia . The patient was admitted to the intensive care unit and treated with targeted temperature management (TTM), broad-spectrum antibiotics, and mechanical ventilatory support. During hospitalization, the patient had poor neurological recovery and entered status epilepticus after rewarming and discontinuation of sedation. Aggressive crisis management was carried out. Family meetings were held to discuss goals of care based on a poor neurological prognosis in a patient with multiple medical conditions. The family decided to make the transition to comfort-focused care.

Due to their cultural and religious practices, the family preferred home extubation with a request for no roof over the patient’s head at the time of death. Cultural preference also required burial before sunset on the same day. Several palliative care agencies were contacted and they expressed a lack of support to facilitate home extubation. After a new engagement, the family agreed to palliative extubation in hospital. To honor the religious/cultural beliefs of the patient and family, the patient was taken to the hospital heliport (after clearance from emergency, security, and the emergency flight crew) and the palliative extubation was performed without a roof over his head. With family present at the patient’s bedside during this time, the patient died peacefully. In coordination with hospital staff, the patient’s remains were released to the family within an hour to facilitate the same-day funeral. Religious and cultural practices have not been verified due to the sensitive nature of the subject and to support the spiritual well-being of the family.


Various EOLC practices exist among different cultures and religions, which have also changed according to current global scenarios. Difficulties arise in hospitals when staff are unfamiliar with these practices with minority populations.

People around the world observe burial traditions and burial rites in a way that is unique to their culture. Despite the different ways of honoring a peaceful death, fundamental core values ​​of human society such as community, collaboration, and respect for the dead remain evident in all cultures. In Haiti, Catholic and West African customs are followed simultaneously. Death is considered a social affair to celebrate the life of the deceased. Over the course of nine days, family, friends and neighbors sang songs, played music, shared food and prayed, before the body was finally laid to rest. [3]. The nine-day celebration of “raising the dead” is also followed in the Philippines, and this funeral tradition highlights the indigenous belief in the continuum of life after death and that with the community, even the most difficult difficulties become bearable. [4]. In Samoa, people celebrate death through economic and community reciprocity where family members are contacted from overseas for material and monetary donations as part of the funeral arrangement process [5]. In some Buddhist cultures, the dying repeat Buddha’s names or ask someone to whisper Buddhist scriptures or Buddha’s names into their ear if they are unable to speak. [6]. In Hinduism, the signs of impending death begin with the chanting of holy scriptures and the putting of holy water from the Ganges and Tulsi leaves (Indian basil) in the mouth of the dying. The body is then prepared for cremation the same day or the next day while family members initiate the cremation fire and prefer to observe the cremation [7]. In the Muslim religion, the face of the deceased is turned towards Mecca (Ka’bah), the arms and legs are straightened, the eyes and jaw closed, all clothing is removed by a Muslim person of the same sex, and the deceased is then covered with a sheet. The body is then bathed by respected Muslim elders, preferably of the same sex as the deceased, and dressed in white. Family members of the deceased are responsible for all transportation and immediate burial after death [8].


Honor death in accordance with primum non nocere begins with the family and asks about cultural beliefs and practices specific to death and funeral rites. With the collaboration between the family of the deceased and the hospital staff, certain arrangements can be made to allow the family to spend more time with the deceased and to perform the last rites necessary for the cultivation of the family, contact other family members to engage in the funeral arrangement process and educate hospital staff on diversity, equity and inclusion from a palliative care perspective. Much like how providing a roofless environment for our patient in this case meant performing a terminal extubation at the hospital heliport, this type of work involves the entire hospital thinking about the different ways our community healthcare providers can help adapt to these unique approaches to EOLC. This enhances the overall patient and family experience from an emotional, mental, religious and spiritual perspective. By creating a system where we can accommodate the diversity of EOLCs, we can better provide holistic, quality, and comfortable care to patients nearing the end of their life.