Mental Health Near the End of Life Through Culture’s Lens

Palliative care and hospice clinicians face a considerable task: Assuage a patient’s pain, whether it comes from the body, mind, or spirit.

In the United States, most clinical training is devoted to the patient's physiology, leaving the rest of the wellness trinity to specialists—psychiatrists, psychologists, counselors, chaplains, and others.

A patient’s mental well-being, however, affects interactions with every member of the care team, regardless of their specialty or training. Any healthcare professional can improve these interactions and enrich their approach to care by learning not only how the patient feels psychologically, but also how they perceive their own mental health.

For most patients, their culture—a shared set of beliefs, norms, traditions, and values—is the primary lens through which mental health is viewed, defined, and even experienced. Culture can impact patients’ relationships with medical services and providers.

The clinician’s cultural identity plays a role too, influencing care from diagnosis to treatment and beyond.

Types of Pain Near the End of Life

The most commonly treated symptoms among palliative care patients are pain and shortness of breath, according to the World Health Organization.

However, psychiatric symptoms such as confusion, anxiety, and depression are often associated with physical distress. Clinical studies show that the areas of the brain that control emotions and the physical sensation of pain are altered in those who suffer from chronic pain.

Up to two-thirds of chronic pain patients also exhibit a psychiatric diagnosis.

Clinicians who are seeing a patient for overwhelming pain or breathing difficulty can provide more holistic care by asking how the patient perceives their own emotions, what they’re thinking, or how they would describe their mental health. The more the clinician understands about the patient’s culture, the better they can shape their questions, address specific concerns, and tailor care. 

Why Are Mental Health Services Underutilized?

Culture shapes many aspects of mental illness, both as a social construct and as a set of diagnosable conditions. It seems to have an impact on the types of symptoms people experience and how they interpret those symptoms—certain conditions may even be specific to a single culture. It can determine if, how, and from whom people seek help, and whether they carry the burden of stigma when doing so.

Related: 5 Best Practices for Providing Culturally Sensitive Care >

In minority communities, mental health services often go underutilized compared with the general population. Black, indigenous, and people of color in America are less likely to seek out or receive mental health care, and more likely to receive poor care.

Adam Kendall, MD, medical review physician for VITAS in Orange County, California, attributes this disparity to two causes:

1. The secondary status of mental health in the managed health and public health system
2. A sense of shame associated with psychiatric care

In some cases, he says, psychological pain or distress is perceived as a shortcoming. Members of recently immigrated families, for instance, may feel that their mental illness threatens to undercut the achievements of previous generations.

“You strive to achieve or over-achieve to live up to the expectations of elders who brought you to the United States,” says Dr. Kendall, who is Japanese American. “There’s a sense of wanting to arrive at the success that took generations for your ancestors to achieve.”

Cultural Stigma and Expectation Surrounding Mental Health

Stigma surrounds mental illness in many cultures, and clinicians aren’t necessarily any more immune to it than their patients.

Dr. Kendall says many healthcare professionals struggle to meet their own psychological needs through self-care, though he acknowledges that the medical community is increasingly benefitting from an “evolving awareness of mental illness as a true disease.”

Hinduism and Death and Dying

Mythili Bharadwaj, MD, medical director for VITAS in St. Louis, Missouri, suggests that broader cultural philosophies can determine whether certain symptoms are considered worthy of treatment.

She recalls her childhood in India, the birthplace of Hinduism, and the interplay between Hindu ideals and healthcare norms: “Back then, when I grew up in India, anxiety and depression [for example] were not openly acknowledged as ‘medical conditions deserving medical attention.’ They were treated more as routine cycles in the journey of life.”

Dr. Bharadwaj highlights the Hindu concept of karma, a Sanskrit term that refers to work, action, or deed, and more broadly describes a spiritual cause and effect. (Karma is also a fundamental concept in other Asian religions, such as Buddhism, Sikhism, and Taoism, though its interpretation and function differ between and within each.)

Hindus, she suggests, may be more likely to see negative experiences—anxiety, depression, or other forms of suffering—as the result of one’s karma accrued in the past, or even in past lives.

Thus, certain experiences deemed “pathological” within the Western medical tradition may represent an intrinsic part of existence in Hindu culture, best overcome with hope, prayer, and spiritual resilience rather than medical intervention.

“Yes, pain is a natural part of life, but we also believe in the fact that better things are coming,” says Dr Bharadwaj.

Palliative care, she notes, has overcome some cultural stigma in India since her childhood, but is still relatively absent from the country’s rural regions. “My hope is that one day palliative care would be a global phenomenon and communities would progress enough to accept, adopt, and adapt such practices without guilt.”