Death is a universal experience regardless of race, culture and country of origin. The manner in which individuals approach death, suffering and grief depends on their culture, spiritual beliefs and religion.1,14,15 These beliefs significantly influence end-of-life concepts. For instance, humanists, comprising agnostics and atheists, believe death to be the end of life. Unlike humanists, Hindus believe that death is not the end of life, but rather the start of a new cycle. Then, it should be noted that about half Indian immigrants are present in the United Arab Emirates (UAE), Pakistan, and the U.S. Approximately 3.5 million Indians reside in the UAE, which is the top destination for Indian immigrants.2 Hinduism is India’s oldest religion, dating back to the 2500BC.3 The estimated Hindu population in the UAE is 6-10%.4 Therefore, with the Hindu population still growing in the UAE, it is crucial for healthcare providers to be aware of the faith and Hindu culture to provide culturally competent care.4 This paper addresses a particular issue that nursing professionals might be confronted with while caring for Hindu patients receiving end-of-life care. It will also illustrate the philosophy of Hindu beliefs that are associated with death and dying.
Hindu Culture Related to Death and Dying
The law of karma, also known as the moral law of cause and effect, influences life cycles from birth to rebirth.3 It is a spiritual advantage or disadvantage that people obtain during their lives. Life forms ensue a series of incarnations, and therefore, assume numerous positions in a hierarchy during their different lives, and their moral behaviour influences this.5 Perfection of karma results in the liberation from the burdens of birth and rebirth. The karma doctrine profoundly affects Hindu attitude towards life. There is a notion that suffering is inevitable, thus some might not approve of symptom control and offers of comfort.6 If such a scenario takes place, nurses should confer with family members and organize for a Hindu priest to visit the patient. The priest performs prayers or rituals and offers the patient a sacred pudding, “prashad”.7 Afterwards, some of the patients might accept treatment.
Decision-making and end-of-life care
In the Hindu culture, the care of the dying and associated decisions is considered as the obligation of the family members, especially the elder members.8 Honesty and informed consent are critical elements of end-of-life care, particularly in matters associated with intravenous infusion, cardiopulmonary resuscitation, and nutrition and oxygen administration. Many Hindu houses comprise of extended families with as much as three generations.3,10 The eldest son in the family is highly respected and valued as they are expected to take up the responsibility for taking care of their parents when they become aged and sick. Sometimes there is a thin line between balancing family culture and local legislation. Thus, efforts should be made to reduce the conflict between patients, their families and clinicians.
Ceremonies and Rituals Performed During The Dying Phase and After Death
The dying patient might desire to have a picture or a statue of the family god placed at their bedside. Older patients are often religious, thus begin their morning with prayer; this escalates when they are almost approaching death.7 Nursing professionals should facilitate such activities. Moreover, Hindus regard the Ganges to be a holy river and its water sacred; hence, family members might place a few drops of the water and a basil leaf in the mouth of the dying person.5,12 This is an act of purification as their souls will be purified, and they will achieve the “moksha”, which is the release from the cycle of birth and rebirth and suffering of the worldly existence.5 Sometimes, the families might opt to burn incense and light small oil lamps. It is believed that the light brings their god closer; hence allow the person to move to the after-life. Most Hindus, prefer to die at home, yet, in some cases, this might be impossible. Therefore, nurses should aim to allow families to conduct their rituals with much-needed privacy. If the patient dies in hospitals, the deceased should be released soonest to the family so that they can perform their rituals.
If relatives are absent at the time of death, they must be immediately alerted to make preparations for a Hindu Brahmin priests to lead the death rituals and ceremonies.5 Moreover, the medical team should try and minimize the touching of the body. It should be emphasised that only family is allowed to touch the body. Touching the body is also gender restrictive as it is culturally inappropriate for the deceased to be touched by a person from the opposite gender.3 There are no religious objections towards autopsies; nevertheless, it would be more preferably if they are avoided.9
Evaluation of the Case Study
Based on the before-mentioned statements regarding the cultural beliefs, values and practices of the Hindus, as well as the review of the UAE Nursing and Midwifery Council, it can be established that the hospital and I did not deliver culturally competent care. Therefore, the healthcare professionals in the hospital fell victim to improper management and poor compliance. For instance, since the 48-year-old man was dead, he was receiving end-of-life care in the hospital, which was irreversible. Therefore, the patient’s brother’s request to release him to die at home appeared to be doable. This is because based on their culture, most Hindus prefer to die in such a way. Thus, the hospital’s refusal to release the patient due to the existence of a policy addressing the end-of-life and resuscitation seemed to be culturally incompetent. Furthermore, it can be stated that the family was not fully informed of their relative’s health condition and medical procedures that would have been conducted. Due to the laws of karma, most Hindus are hesitant about putting their families in ventilators and being cardiopulmonary resuscitated.6 Suffering is inevitable, thus for a person to be relieved of the burdens of birth and rebirth. If the health professionals had informed the family, in the best-case scenario, they would have organized for a Hindu priest to visit the patients and offer them “prashad”.
The hospital also proved culturally incompetent when they denied the elder brother’s request not to conduct a post-mortem. The family intended to take the deceased home for the Hindu ritual and cremation of the body. Although there are no religious objections towards autopsies, some Hindus prefer it when the body of their deceased is not dissected for autopsy and organ donations. Furthermore, the hospital refused to allow the family to put milk into the mouth of the deceased as this was central to their culture and belief. It claimed that the refusal was because there were no defined policies in place governing the provision of care. In this context, the milk can be equated to the water of the Ganges, a holy river, which is put into the mouth of the dying. This is to purify their souls and enable them to be released from the cycles of birth and rebirth, and suffering of the worldly existence.
Given the discussion above, it can be declared that the hospital, including the health care professionals, violated the competency standard revolving around the ethical practice.10,11 The medical personnel did not respect the family’s right to make them fully aware of their relative’s health condition, thus were unable to give informed consent. In addition, they were incapable of maintaining the client’s right to dignity. As the family was not given a chance to perform the necessary rituals and ceremonies essential to helping their loved one move into the after-life, they can be viewed as desecrated the dignity of the deceased. As a result, he was unable to have a dignified death. Lastly, the competency standard of ethical practice was infringed as the nursing professionals were unable to display sensitivity to cultural diversity.12 For instance, I prevented the family from putting milk into the mouth of the deceased as it conflicted with my Arabic culture.
Nevertheless, the only thing that the hospital did right was to adhere to the legislative, regulatory and policies guidelines that were then relevant to registered nursing practice.13 During the year 2000 in the UAE, there was no policy, care of provision, code of conduct and law to support multicultural death. Specifically, there was policy allowing for the ending of life and resuscitation. Moreover, it was a requirement for post-mortem to be performed on all deceased individuals.
The currently registered nursing policies in the UAE aim to provide skilled, holistic, safe and culturally competent care to patients and their families. However, in some cases, this is sometimes not the case. The UAE is a multicultural society comprising of people from different religions and cultures; therefore, nurses need to have knowledge of the culture of various individuals to facilitate the delivery of culturally competent care. Nurses caring for Hindus should be aware that people from the religion believe in karma and reincarnation.
Furthermore, decisions in healthcare are mostly made by the senior family members or the eldest son; thus, these people must be made at the centre of all discussions regarding the health of their loved one. Hindus believe that death can neither be sought nor extended, hence, persevering physical suffering at the end of life might reverse bad karma. They would also prefer to die at home where they surrounded by family. All these cultural beliefs regarding death and dying are central to the completion of a spiritual assessment and care, to enable their loved one escape the burdens and suffering of worldly existence due to bad karma. As a result, they will enjoy the next hierarchical position in their lives. Finally, it seems reasonable to claim that the above investigation shows the importance of the provision of high-quality healthcare services in developing regions around the globe. It is also essential to conduct researches in the framework of various bias that may hinder this provision in order to identify the best ways to overcome such obstacles.
- Gielen J, Bhatnagar S, Chaturvedi SK. Spirituality as an ethical challenge in Indian palliative care: a systematic review. Palliat Support Care, 2016: 561-82.
- Conor P. India is a top source and destination for world’s migrants [Internet]. Pew Research; 2020. Web.
- Sengupta J, Chatterjee SC. Dying in intensive care units of India: commentaries on policies and position papers on palliative and end-of-life care. J Crit Care. 2017;39: 11-17.
- Al-Alfi N. Cultural thoughts on palliative care in UAE. Palliat Med Hosp Care Open J, 2017; SE(1): 51-55.
- Davies TM. Death and dying: End-of-life care in Nepal Buddhist and Hindu cultures [Internet]. Sigma; 2020. Web.
- Avci E. A comparative analysis on the perspective of Sunni Theology and Hindu tradition regarding euthanasia: the impact of belief in resurrection and reincarnation. J Relig Health, 2019.
- Bhuvaneswar CG, Stern TA. Teaching cross-cultural aspects of mourning: a Hindu perspective on death and dying. Palliat Support Care, 2015.
- Gentry T. The culture connection: Hindu end-of-life practices – healthcare professionals blog [Internet]. Crossroads Hospice and Palliative Care; 2020.
- Weaver K. Religions and the autopsy [Internet]. Medscape; 2020. Web.
- Weston Area Health. Hinduism [Internet]. Weston Area NHS Health Trust; 2020. Web.
- Swihart D, Naga S, Martin R. Cultural religious competence in clinical practice. Florida: StatPearls Publishing; 2020.
- UAE Nursing & Midwifery Council. Nursing and Midwifery Scope of Practice [Internet]. UAE Nursing & Midwifery Council 2020.
- Ortega-Galán Á, Ruiz-Fernández M, Carmona-Rega M, Cabrera-Troya J, Ortíz-Amo R, Ibáñez-Masero O. The experiences of family caregivers at the end of life: suffering, compassion satisfaction and support of health care professionals. J Hosp & Palliat Nurs, 2019.
- Al-Yateem N, AlYateem S, Rossiter S. Cultural and religious educational needs of overseas nurses working in the Kingdom of Saudi Arabia and the United Arab Emirates. Holist Nurs Pract, 2015; 29(4): 205-215.
- Cuevas AG, O’Brien K, Saha S. What is the key to culturally competent care: reducing bias or cultural tailoring? Psychol Health, 2017.