I just finished speaking to a group of medical and nursing students on end of life care and cultural competency.

It’s a big topic.

In health care the two areas where cultural beliefs are profoundly obvious are during birth and during death. In other areas the belief systems are more subtle, the differences not always obvious.

But birth and death? These moments of coming into and going out of the world are rich with tradition, ritual, meaning, and emotion.

The first thing I ask people to do is to think back to their first memory of death in their family or community. Who was it? What were the circumstances of the death? What is their most vivid memory? What rituals and behaviors were observed by the family and/or community?

The answers are fascinating, particularly if it’s a diverse group. There are people who remember all the church bells in the town ringing — they knew someone had died because the bells were ringing at a time when they were usually silent. Others remember wailing waking them during the night. Still others will talk about death being a celebration, a party of sorts.

The important piece is that they talk. Most have never thought about this, let alone processed it in a group. And talking about their experience puts us in the best possible place to continue the discussion.

Because telling their stories helps them realize how significant those moments are, and how critical it is for them to hear the stories of their patients, to be fully present with their patients during the end of their lives.

We move forward into the discussion on the western view of the body as a machine, on how culture affects views of illness, expectations of care, and views of the process of death. We look at possible points of cultural collision – patient autonomy, organ donation, body preparation, the differences in both meaning and expression of pain and so much more.

I usually end the time with a short video telling the true story of a gentleman from Afghanistan named Mohammad Kochi. Mr. Kochi immigrated to the United States with his family and settled in California. At the time of the film he was diagnosed with stomach cancer. The film details some of his care and the disconnect and misunderstandings that occurred, resulting in his refusal of chemotherapy through a pump into his body — ultimately his death because of lack of treatment.

It is sobering and hard to watch. We sit somewhat stunned at the end and there is no gap in conversation.

How could this happen?

So preventable!

Such a misunderstanding!

But these types of cultural misunderstandings occur far too often despite the best of intentions.

There are so many things that come up in conversation, and so much to learn from each other. But we end talking about three areas where we can develop skills.

The first is in self-reflection – How do I react to cultural differences? How do I manage my own reactions? How do I negotiate with patients and families in the face of cultural differences?

The second is active listening – Listening to and with the body, listening in with self reflection, listening out by learning from others; listening with the mind by hearing facts and stories; listening with the heart by being willing to hear emotions and feelings.

The third is bearing witness – being fully present with the person, letting them know they’re not alone, listening to their stories and their symptoms. 

As is usually the case, I leave contemplative, thinking about life in its entirety, life from birth to death. And I also leave with a renewed resolve to continue developing skills in the areas of self-reflection, active listening, and bearing witness.

Skills not only important in end of life but through all of life.