Critical and Theoretical Basis for Using Culturally Sensitive End-of-Life Counselling to Reduce

Emotional Distress Among Terminally Ill Persons

Part I: Educational Resource Background

The psychosocial symptoms of terminal illnesses are alarming and have been associated with a substantial psychological burden among terminally ill persons. Until now, healthcare professionals have not developed an effective intervention to reduce emotional distress in this population. Terminally ill persons suffer from overwhelming physical and psychological symptoms, which impair their thinking, quality of life, and interaction with others (Gao et al., 2019). The common psychotic symptoms observed in dying patients include overwhelming fear and anxiety, delirium, and depression (Park & Lee, 2019). Individuals might also exhibit suicidal ideation due to low physical performance, worsening physical symptoms, and losing control of the symptoms. Professionals use different interventions in palliative care, including pharmacologic agents, patient and family education, and psychotherapy to improve psychotic symptoms.

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Unfortunately, the effectiveness of these interventions varies from one patient to another. This report provides critical information about culturally competent end-of-life counselling to guide caregivers and other parties in palliative care on the best interventions to help terminally ill persons overcome emotional distress at this stage of life. The report will justify selecting the topic area and developing an educational resource to respond to the psychological needs of terminally ill persons. The other components addressed in the topic include integrating culturally competent end-of-life counselling into palliative care and the impact of counselling on terminally ill individuals.

Rationale and Educational Evidence

Palliative care is a crucial intervention established by healthcare professionals to address the physical and psychological needs of the terminally ill. This intervention aims to improve the quality of life of individuals facing life-threatening conditions. Unfortunately, this approach to care needs to address patients' psychosocial needs comprehensively. The proposed educational resource could therefore guide health professionals to incorporate culturally competent end-oflife counselling to address the psychological needs of patients. A critical aspect of palliative care is providing services to improve the psychological health of dying patients. It includes services like individual therapy sessions, meditation, and therapeutic services. Incorporating culturally competent counselling could broaden palliative care and reduce the psychological burden among dying patients.

Lee and Ramaswamy (2020) noted that emotional distress among terminally ill persons might go unnoticed, yet it is widespread. Numerous studies have revealed that after diagnosis with a terminal condition, over 40% of patients develop significant distress, including worry, anxiety, PTSD, and depression (Givler et al., 2020). Many patients have poor coping mechanisms with the notion that death is imminent. The challenge of coping with terminal conditions is further complicated by pharmacological interventions that induce psychological symptoms. Therefore, developing an educational resource that guides palliative care professionals in reducing emotional distress among patients would significantly improve the quality of life at this critical stage.

Palliative caregivers are responsible for creating a healing environment. These professionals incorporate services that enhance mental health outcomes among patients and family members. Unfortunately, most interventions focus on addressing the psychological needs of family members, and little attention is given to the terminally ill person. Though terminally ill patients are the ones that need psychosocial assistance the most, they are left to face overwhelming psychological struggles on their own. Therefore, palliative care professionals should integrate culturally-competence counseling into care processes to reduce emotional distress and make dying bearable for the terminally ill. Moreover, a study by Voon and Chan

(2021) disclosed that end-of-life counselling interventions helped reduce the psychological burden of physical symptoms. Counselling helped patients cope with the distressing thoughts of dying.

Based on the understanding of the emotional distress that terminally ill person experience, I decided to create an electronic educational resource that would increase awareness of culturally competent end-of-life counselling among healthcare professionals. This resource will help palliative care nurses provide counselling and other psychotherapeutic services that address the psychological needs of clients without contradicting their cultural values, norms, beliefs, and practices.

The electronic educational resource is part of health education which aims to promote the health of individuals, families, and the community. Health education helps improve knowledge and eradicate inappropriate beliefs that affect health outcomes. For instance, education enables care providers to identify interventions that promote healthy practices and modify healthcare delivery. Healthcare professionals use different modalities to deliver health education. The target audience, the health topic, and the anticipated impact influence the selected approach. Electronic educational resources are the newest strategies for delivering health education. These resources provide an interlinked approach to delivering comprehensive information to the target group.

Written educational materials such as leaflets are reliable tools for delivering health education. These materials contain valuable information about health issues facing specific groups. However, written materials are slowly being replaced with electronic materials. The increase in internet usage has created new dynamics in the healthcare industry. Health educators are increasingly using electronic resources to pass crucial information to students. For instance, paper leaflets and brochures have been replaced with electronic materials such as E-leaflets.

PART II: Critical Review

Patients with terminal illnesses undergo progressive physical and psychological decline, gradually leading to death. Kelly et al. (2016) confirmed that patients experience changing physical, psychological, and social needs as the terminal condition progresses to critical stages. They develop new habits to cope with the overwhelming changes. Research exploring the emotional distress in terminally ill patients has contributed to an increased understanding of the psychological and emotional needs and experiences of people approaching death. Soto-Rubio et al. (2018) noted that over 77% of individuals with terminal conditions experience depressions, which turns into emotional distress and uncomfortable psychological symptoms. These patients lose control of their emotions as their body progressively changes with the disease (Hartogh, 2017). Unfortunately, emotional distress is not always clearly identifiable, and the chances of being underdiagnosed in palliative care settings are high. This implies that terminally ill persons with distress are left untreated. Although understanding the emotional needs of these patients does not directly improve care outcomes, it enables palliative care nurses to develop personalised interventions focusing on specific health issues (Ullrich et al., 2017). Focused care also creates a platform to support the patients emotionally and psychologically, thus reducing distressful psychological symptoms.

Terminally ill persons are typically enrolled in palliative care since terminal conditions do not respond to treatment. The control of psychological and physical pain is an integral aspect of palliative care. The goal is to improve the patient's quality of life and eradicate the psychological burden associated with the fear of death. It seems practical to identify and focus on the psychosocial needs of terminally ill persons, which, when unmet, would negatively affect the quality of life of the dying (Hartogh, 2017). However, cultural differences affect care delivery in palliative care settings. For instance, patients from conservative communities rarely discuss endof-life issues. They believe that death is sacred and people should not discuss their death with others. Therefore, care providers experience difficulties interacting with these patients and reassuring them dying with dignity. Incorporating cultural factors into patient care is crucial in improving care outcomes. It reassures patients that the care provider considers their culture and values.

Terminally Ill Persons’ Understanding and Responses to Health Deterioration

Terminal illnesses are associated with uncertainty, fear, and grief. Breitbart and Chochinov (2022) clarified that many terminally ill patients are uncertain about how their bodies will change with time and how their condition will affect interpersonal relationships with family, friends, and colleagues. Knowing that they might die soon is overwhelming and upsetting for the patients. These feelings lead to emotional distress and an overwhelming psychological burden. A terminally ill person’s need to leave a legacy, cope with cultural, spiritual, and religious issues, and attend to their families is an important theme that influences their emotional well-being. The deterioration in physical health is the primary contributor to emotional distress in this population. Palliative care patients associate physical changes such as weight loss, breathlessness, increased sensitivity to heat and cold, renal problems, and weakness with death. The feeling that one's death is immediate causes emotional suffering and increases emotional distress. The psychological challenges of dying include creating a meaningful context to one's life, saying goodbye, grieving, and letting go. These tasks require psychological strength to accept rather than change. Therapists can serve as companions and walk with the patient as they negotiate these tasks. Fairman et al. (2016) pointed out that no one generates pleasure from thoughts of imminent death due to a terminal condition. Palliative care patients experience emotional numbness upon learning that their condition might lead to death. They experience mixed emotions typified by shock, fear, frustration, relief, helplessness, sadness, denial, and resentment (Breitbart & Chochinov, 2022). Many patients report that social and emotional isolation is too much for them. These feelings overwhelm even those brought up in cultures that train them to endure suffering.

Therapists address these issues by addressing fears, attending to physical pain, facilitating a culturally sensitive life review, differentiating between depression and grief, and helping the client make an appropriate decision. Talking to family, friends, and health practitioners helps ease tension among dying patients. Counsellors help patients develop appropriate coping mechanisms, thus overcoming emotional distress associated with their condition (Voon & Chan, 2021)

Culture and Palliative Care

Different factors, including life expectancy, culture, gender, and personal psychology, influence palliative care patients’ reactions to health deterioration. Lee and Ramaswamy (2020) pointed out that culture is the most crucial component of the context within which individuals make meaning of their world and how to respond. They clarified that culture influences how individuals make meaning of disease, suffering, and dying and thus influences their healthseeking and utilization behavior. Schill and Caxaj (2019) argued that encounters between palliative patients and healthcare professionals of different backgrounds are becoming increasingly familiar with increased diversity. Therefore, the possibility of cross-cultural misunderstandings surrounding palliative care is also increasing. Research has revealed cultural variations in beliefs and attitudes toward truth-telling, coping, life-prolonging technology, and decision-making approaches at the end of life (Semlali et al., 2020). However, culture is a dependent, nonhomogeneous, and non-dichotomous variable. Reducing it to a series of segregated acontextual practices or views categorised by ethnic backgrounds would create the risk of stereotyping due to the misguided belief that one person's thinking represents the entire group's thinking (Schill & Caxaj, 2019).

Each ethnic population is characterised by different beliefs and behaviors, which serve as the culture’s primary function of giving meaning to life, health, and disease. These behaviors also provide guidelines for living. Exploring cultural factors helps evaluate the values and value systems held by people of different backgrounds (Lee & Ramaswamy, 2020). Therefore, professionals must understand and integrate cultural values into treatment and care plans in palliative care settings. This approach helps increase cultural sensitivity and reduces inappropriate clinical outcomes. It also improves providers’ interactions with patients and families at this critical point of life (Crimmins et al., 2021). Unfortunately, palliative care professionals have not adequately invested in culturally sensitive measures to detect and treat distress. They only address minor cultural issues or avoid them entirely during care. However, they know that distress, which has significant implications for individuals and families, could be addressed with culturally sensitive interventions.

Culturally Sensitive End-of-Life Counselling

Counselling is a critical psychotherapeutic intervention that helps improve psychotic symptoms, mental well-being, and the quality of life of an individual. This intervention helps improve communication and interaction between patients and therapists (Saracino et al., 2020). It focuses on mental health issues affecting an individual and creates a platform to challenge them to change their behaviours and adopt positive thinking patterns. Therapists understand that listening to their clients and identifying areas to focus on are critical for enhanced counselling outcomes. They also understand that different counselling tactics produce different results for different persons. Therefore, they employ different counselling tactics to achieve the intended outcomes. For instance, Brooks et al. (2019) noted that counselling psychologists use a broad range of culturally competent practices to help individuals improve their well-being and prevent relapse into antisocial behaviours.

Culturally sensitive counselling describes interventions emphasizing the therapist’s comprehension of a client’s culture and background. This intervention also involves a comprehensive understanding of the client’s belief system, gender, sexual orientation, rituals, religious beliefs, and other practices relating to their culture (Crooms & Gelfman, 2020).

Incorporating cultural sensitivity into therapy helps accommodate and reverence differences in different cultures' views, beliefs, values, and attitudes. It creates a platform for effective treatment to eradicate emotional, social, and psychological distress associated with mental health issues. Murali (2020) clarified that culturally competent counselling helps prevent and reduce distress and maladjustment besides resolving the psychological crisis. These interventions also improve an individual’s capacity to function better.

Cultural sensitivity enables therapists to acquire and retain cultural competence typified by the ability to acknowledge the potential influence of one’s culture on practice. Culturally competent therapists understand how cultural differences influence client relationships (Colón & Wladkowski, 2019). Therefore, they adjust their practice to suit the cultural needs of their clients. Therefore, they comprehensively assess their client’s culture to identify the aspects to incorporate into the treatment plan.

Scholz et al. (2020) argued that culturally competent counselling is critical in the care of patients from conservative groups. These groups uphold unique customs and cultural values.

They are also reluctant to abandon their beliefs even if they contribute to poor health outcomes. Therefore, therapists must learn how to tailor therapy to address the needs of these people.

Culturally sensitive counselling comes in handy and creates an environment where patients feel understood, valued, and respected (Cox, 2022). By contrast, patients may feel alienated and disrespected if the therapist undermines their beliefs and values. Therefore, therapists must understand the culturally sensitive issues that could improve mental well-being if incorporated into therapy.

Culturally sensitive counselling involves using a language the client can understand, displaying personable traits, and avoiding behaviors the client dislike (Crooms & Gelfman, 2020). Understanding the client’s life outside the therapy room is also a critical element of culturally sensitive counselling. During counselling, a culturally competent therapist deviates from the standard approach to care. However, they must comply with professional and ethical guidelines to avoid inappropriate outcomes.

Integrating Culturally Sensitive Counselling into Palliative Care

Using culturally sensitive counselling in palliative patients could reduce the emotional distress associated with dying. Monette (2021) noted that culturally sensitive interventions in palliative care provide a holistic base where care providers address all health issues facing their clients, including physical, psychological, emotional, and spiritual aspects of health. In conservative communities, the perceptions of what reflects good life and good death are influenced by cultural beliefs, values, and norms (Brooks et al., 2019). Therefore, attention to cultural norms facilitates culturally appropriate care for the terminally ill.

Successfully integrating culturally sensitive practice into palliative counselling indicates that the therapist recognises and respects differences and takes the necessary approach to communicate and interact with patients from culturally diverse backgrounds (Colón & Wladkowski, 2019). The therapist recognises that every patient is unique and that even two patients from the same cultural backgrounds may still demonstrate different values, beliefs, and preferences. A culturally sensitive therapist keeps their mind open and interacts with the client and family to determine the best approach to deliver care.

Managing emotional distress is often a significant challenge for healthcare providers, which is complicated in palliative care settings. Since communities worldwide are becoming increasingly multicultural, healthcare professionals must consider culture when developing care plans Murali (2020). Healthcare teams that learn the distinctions of culture are rewarded with better outcomes in managing physical, psychological, and emotional pain. They can also incorporate care aspects that help patients and families adjust to dying (Givler et al., 2021).

Incorporating cultural values into counselling and other therapeutic interventions improves the quality of palliative care provided. Monette (2021) noted that to provide holistic care, healthcare professionals must understand the impact of culture on palliative care needs. Unfortunately, existing guidelines need to understand how culture influences palliative care comprehensively.

Emotional distress is a subjective component of health perceived by the patient. Only patients can explain how their emotional health is affected by illnesses. Distress can be challenging to report depending on the verbal skills of the patient. Putting emotional distress into perspective requires a degree of self-awareness pegged on an individual's cultural background. Research has shown that psychological distress is a common symptom of terminal conditions (Cox, 2022). Most terminally ill patients experience overwhelming emotional disturbance in the final moments of life. For palliative care nurses, this highlights the significance of frequent emotional distress assessment, distress management, and adjustment of therapeutic interventions.