Abstract and Introduction

The purpose of this qualitative study was to describe practices surrounding death of a loved one by European, Asian, Caribbean, Central American, and South American families living in the United States. A focus group with 14 masters nursing students from a wide variety of cultural and religious backgrounds was conducted to gain a better understanding of the beliefs, ceremonies, and rituals surrounding death. Many commonalties were found across cultures and religions. A pervasive theme was that beliefs about the soul of the deceased lead families to perform rituals and ceremonies that foster passage to God, the "light," or another life. The stronger their beliefs, the more dedicated the family is in completing the rituals and ceremonies in the way dictated by their religion or culture. Participants had difficulty separating the influence of culture and religion on these practices.

Grieving and death rituals vary across cultures and are often heavily influenced by religion (Chachkes & Jennings, 1994; Younoszai, 1993). How and when rituals are practiced vary depending on the country of origin and level of acculturation into the mainstream society. The duration, frequency, and intensity of the grief process may also vary based on the manner of death and the individual family and cultural beliefs (Clements et al., 2003). Although cultural practices surrounding the death of a loved one have been described, there are limited research descriptions from key informants within cultures. The purpose of this qualitative study was to describe beliefs and practices of death and dying in selected cultural groups living in the United States (U.S.). Nurses from those groups were interviewed to gather data about their personal experiences with death and their experiences with deaths of patients from the selected cultural groups. Similarities and differences in the beliefs and practices of death and dying among these groups were identified.

Researchers have found greater outward expression of grief and more physiologic reactions among Mexican American college students compared to Anglo college students (Oltjenbruns, 1998) and greater grief intensity among Latinos from Puerto Rico who experienced a sudden unexpected death than other Latinos and Anglos (Grabowsky & Frantz, 1992). However, Brandhorst (2000) found no differences in bereavement for White, Black, and Hispanic adult children whose parent died from cancer. Talamantes, Lawler, and Espino (1995) identified similarities during the period preceding the death in case studies of a Mexican American family, a Cuban American family, and a Puerto Rican family experiencing the death of a family member, including the caregiver's not wanting to burden or impose on family; experiencing depressive symptoms; and relying on faith, hope, and prayer to cope with the impending death.

In another case study report, Rivera-Andino and Lopez (2000) reported that Hispanics believe it is detrimental to patients to let them know about the seriousness of the illness in order to spare them unnecessary pain and that it is the family's obligation to take over control of the situation. African Americans may hold mistrust of the health care system, especially regarding advanced directives and end-of-life care, and both Mexican Americans and African Americans verbalize a preference for decision making as a family (Perkins, Geppert, Gonzales, Cortez, & Hazuda, 2002; Waters, 2001).

Latino death rituals are described as heavily influenced by Catholic beliefs where spirituality is very important and there is a continuing relationship between the living and the dead through prayer and visits to the grave. Grief is expressed by crying openly where women may wail loudly but men may act according to "machismo" where there is a belief that men should act strong and not show overt emotion. There is preference for burial rather than cremation, novenas for 9 days, mass for the deceased during the first year and then yearly, family gatherings with food (like a wake), and lighting candles. (Clements et al., 2003; Munet-Vilaro, 1998).

Descendents from Caribbean nations and Mexico may practice a blend of Catholicism and African or indigenous folk medicine known as Santeria in Cuba, Espiritismo in Puerto Rico, or Voodoo in other Caribbean nations, and Curanderismo in Mexico (Grossman, 1997; Spector, 2000; Younoszai, 1993). Santeria death rituals are governed by the saints (orishas) as told by the santero (a clergy or holy man) and often include animal sacrifice (Grossman, 1997). Younoszai (1993) asserts that Mexicans have more understanding and acceptance of death because their country is primarily rural, poor, religious, and very young on average. Death is portrayed in Mexican statues, art, literature, and history, and Mexican children are socialized early to accept death, giving Mexicans a "cultural familiarity with death." Mexicans and other Latinos celebrate "Dia de los Muertos" (Day of the Dead) to remember and honor the dead (Talamantes et al., 1995).

Death rituals for Black Americans vary widely, perhaps because of the diversity in religious affiliations, geographic region, education, and economics (Perry, 1993). Researchers suggest that emotional expression varies, with some Black Americans crying and wailing while others are silent and stoic (Hines Smith, 2002). Perry describes large gatherings and an expressed obligation to pay respects to the deceased as common. Southern and rural blacks may maintain the custom of having the corpse at the house for the evening before the funeral. Friends and family gather at the house to help out where they can. Church "nurses" help family members to view the body. Women "flower girls" escort the casket with the pallbearers and pay special attention to the family (Perry, 1993). Strong religious beliefs - seeing the death as a reflection of God's will or plans, believing the deceased is in God's hands, and being reunited in heaven after death - help many Black Americans to grieve while maintaining a connection with the deceased (Hines Smith, 1999, 2002). Bereaved African Americans are more likely to seek help from clergy than health care professionals (Neighbors, Musick, & Williams, 1998). For Baptists, heaven is a place where the redeemed go to and it is described as filled, a beautiful place, and there is belief in resurrection (Spector, 2000).

In the Asian culture, the death of an infant or child is deeply mourned. Family members may wear white clothing or headbands for a period of time. Traditional elaborate funeral ceremonies were the norm for marking the soul's passing to the afterlife. Sadness and grief may be expressed as somatic complaints, since mental illness is often considered a disgrace to the family (Lawson, 1990). Buddhist belief uses death as an opportunity for improvement in the next life. To enter death in a positive state of mind and surrounded by monks and family helps the deceased to become reborn on a higher level. Local family customs require a display of grief, wearing of traditional white cloth, openly showing grief, and even wailing at times. The body should be handled in a worthy and respectful way (Dimond, 2004; Truitner & Truitner, 1993). Hinduism is unique as a religion because its roots do not spring from single scripture, founder, or sacred place but is seen as more of an umbrella term to describe a set of philosophies, cultures, and way of life. However, the approach to death is fairly uniform because the belief in the laws of karma and reincarnation suggest that each birth is linked to actions taken in previous births, and that births and deaths are part of a cycle that each person is seeking to transcend through the accumulation of good Karmas (actions) ultimately leading to liberation of the soul.

When a Hindu dies, the body is bathed, massaged in oils, dressed in new clothes, then cremated before the next sunrise to facilitate the soul's transition from this world to the next. Rituals are conducted for 10 days while the deceased member's soul watches over the family. On the 11th day, the soul releases its attachment to the former life (Clements et al., 2003; Spector, 2000).

Yick and Gupta (2002) conducted multiple focus groups with Chinese participants to describe Chinese Americans' beliefs and practices regarding death and dying. They suggested that many of the current descriptions of cultural bereavement practices are portrayed in a static manner and noted that it is important to understand the evolving nature of culture over time and based on history. Cultural dimensions of death, dying, and bereavement in the Chinese culture included the following themes: (a) Saving Face (the more people who cry for the deceased, the more the person was loved), (b) Filial Piety (duty to one's relative), and (c) Invoking Luck, Blessing, and Fortune (Belief in life, after-life, and presence of spirit).

Death rituals for other groups identified by religious belief such as Judaism have also been described. There are several major groups within Judaism and the interpretation of Jewish law and practice may allow for wide variation in rituals. Funerals are generally performed as soon after death as possible because there is a belief that the soul begins a return to heaven immediately after death. There is also a belief that the body is a holy repository of the soul and should be treated and cared for with respect. A black ribbon or torn clothing symbolizing mourning or grief is worn by mourners. Shivah is the process of receiving guests during the grieving process. Families are cared for by their friends and the religious community while they contemplate their loss. Mourners may stay seated on low stools, mirrors may be covered, and mourners may perform only minimal amounts of grooming and/or bathing. Families may not place a headstone at the gravesite until the first year anniversary of the death coinciding with the end of the traditional year of mourning. There is a daily recitation of the kaddish, a life-affirming mourning prayer by mourners. It is important to understand the religious beliefs often change and observant people may become more or less observant when death occurs or may wish to break with tradition when faced with death (Clements et al., 2003).

In addition to Judaism and Christianity, Islam is a third major monotheistic religion that guides death practices. At the time of death it is believed that the soul is exposed to God. There is a belief about afterlife, and Islam dictates that the purpose of the worldly life is to prepare for the eternal life. The dying patient should be positioned facing Mecca, the room is perfumed, and anyone who is unclean should leave the room. Passages for the Quran are read to the dying patient. Organ donation is permissible with family permission when a patient is determined to be brain dead. Family members prepare the body for burial following the pronouncement of death. Muslim culture does not encourage wailing but crying is permissible. Personal prayers are recited while standing but prayers from the Quran may not be recited near the corpse. Women are traditionally prohibited from visiting cemeteries (Ross, 2001).

Little research has been done regarding nurses' perceptions of cultural practices surrounding death. Engler et al. (2004) described neonatal nurses' perception of bereavement/end-of-life care of families of critically ill and/or dying infants. Although this study included the nurses' role, comfort and involvement with bereavement/end-of-life issues, findings only noted that "providing culturally sensitive bereavement/end-of- life care was an issue of some discomfort for all respondents" (p. 496). The authors also noted that most of the respondents indicated that language and culture were barriers that significantly influenced their level of involvement with patients' families. There was no mention of the type of nurses' involvement with cultural practices surrounding the death of the infant in the Neonatal Intensive Care Unit (NICU) or what the role of the nurse was in facilitating cultural practices. The researchers found that there was a significant relationship between culture and grief after a perinatal loss.

In summary, grieving and death rituals vary widely across cultures and are often heavily influenced by religion (Chachkes & Jennings, 1994; Clements et al., 2003; Younoszai, 1993). The literature suggests that there are many similarities across cultures, but also some important differences. The purpose of this study was to describe beliefs and practices of death and dying in selected cultural groups living in the United States. Nurses from those groups were interviewed to gather data about their personal experiences with death and their experiences with deaths of patients from the selected cultural groups. Similarities and differences in the beliefs and practices of death and dying among these groups were identified. It is hoped that the insights gained can help all nurses provide more culturally competent care when working with dying patients and their families.