Cultural and spiritual beliefs play a key role in the grief process for the dying patient and their family. Grief is a universal human experience that all share at some point in their life. Although grief is universal, there is considerable disagreement about what is “normal” in terms of the process, duration, or outcome (Howarth, 2011). There is a common concept that the person experiencing the grief will eventually accept the loss and move on with their life. However, the process by which this happens differs and is influenced by many factors, including cultural and social factors.

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The DSM-IV-TR distinguishes between complicated and uncomplicated grief. Uncomplicated grief is where the person accepts the loss and moves on. Complicated grief is where the person becomes stuck and unable to process the emotions associated with the loss (Howarth, 2011). End of life nursing must encompass culturally sensitive practices into the decision making and support services for the patient and family (Hebert, 2011). Cultural and social differences can complicate the ability to distinguish the normal grieving process from determining that a need exists for additional services. The nurse needs to recognize the uniqueness of each person and their cultural and spiritual beliefs. The nurse can act as a liaison to assert the unique wishes and beliefs of the family and patient into the treatment plan and intervention (Hebert, 2011).

The five stages of grief may be difficult to recognize in different cultural settings, but they are still present (Herbert, 2011). In the United States many immigrants may have grown up in a different culture than they are in now. Customs and reactions to grief vary from country to country. Providing culturally sensitive care is a one of the most important tasks that end of life nurse must do. There is sometimes a conflict between a person’s individual grief response and what is expected by their culture. Grief should be distinguished from mourning customs. Grief is the purely emotional reaction to the experience. Mourning is a set of prescribed behaviors in response to a loss. Mourning is outward and grief is inward.

One example of this comes from interactions with the Japanese culture. The Japanese often have difficulty opening up about their emotions. The Japanese are known for their resiliency in the face of disaster. The display of emotions in public is considered to unacceptable and shameful. An experience with a Japanese family whose Grandfather was dying of cancer demonstrated this principle and the difficulties that it can cause for an end of life nurse. I watched as the entire family, including the grandfather seemed quite stoic, almost to the point of nonchalance about the passing. Yet, the family members would often be seen crying or expressing emotions in private. They would pull themselves together when they feared they would be spotted in this state of grief and sadness. I feared that the family’s emotional needs were not being met due to their inability to express their emotions and provide each other support.

The Japanese are an example where cultural norms dictate that one covers up their emotions. This can leave family members inwardly isolated and unable to reach out for support. They encourage each other to be strong and to remain positive, even though one knows that the person is feeling anything but positive. Being aware of the cultural responses to grief can help the nurse understand the families and to know how to best provide the care that they need. The nurse must be able to understand the grief process and how it can effect treatment and support decisions in the care plan. The nurse is an important advocate for the family and their traditions. They can also help to bridge the cultural gap between the family’s spiritual beliefs and what it considered to be the normal grief process in western culture.

  • Hebert, K. (2011). The Nurse Advocate in End-of-Life Care. The Ochsner Journal. 11(4): 325-329.
  • Howarth, R. (2011). Concepts and Controversies in Grief and Loss. Journal of Mental Health Counseling. 33(1): 4-10.