As the ethnic face of America changes, so too does the population seen by palliative care nurses.

The
holistic care provided by nurses demands knowledge of the cultural beliefs and traditions of individual
patients. This article provides a description of nursing implications for the palliative care of Filipino
clients and presents pertinent cultural implications for three issues: managing the diagnosis, pain and
death, and dying. These three aspects of diagnosis, pain, and death are very specific to care of "kanser"
patients. "Kanser" is the word for cancer in the native Filipino language, Tagalog. By exploring the
nursing implications and Filipino customs, palliative care nurses can broaden their worldview of Filipino
clients and learn new methods in providing culturally sensitive, pertinent, and quality care.
Rosario is a native Filipino who moved to the United States about 12 years ago to start a family with her
husband. Although Rosario has lived in the United States for an extended amount of time, she relates
never feeling more foreign than the time she spent in a hospital. After being diagnosed with breast
"kanser," Rosario had many experiences in the hospital for "kanser" treatment. "Kanser" is the word for
cancer in native Filipino language, Tagalog.
[1]
In her experiences, Rosario felt that the care she received
by the hospital staff was to solely treat her illness and rarely acknowledged her as a Filipino person. For
instance, Rosario could not grasp why there was only one chair in her hospital bedroom and not several
chairs to accommodate her family members who stayed with her for several hours and spent some
nights with her. To Rosario, it was obscure that there was a policy in which the hospital allotted a
specified time when her family could visit. Rosario felt that it was essential that her family members
were present with her at all times to assist in her recovery. When asked to comment on her overall
hospital experience, Rosario said, "while my hospital experience was not terrible, the quality of care
received could have been enhanced if the nurses and doctors only knew about specific Filipino values."
Rosario's experiences illustrate that Western healthcare is not always accommodating to patients from
different cultures. Rosario's experiences stress how important it is for nurses to understand a patient's
cultural background because it can significantly impact assessments and medical interventions in
providing superior care for patients. According to the 2000 United States of America Census, almost 2
million Filipinos live in America. In 2003, 45,397 Filipinos immigrated and became legal residents of the
United States.
[2]
Although immigration statistics consistently increase from several countries, Rosario is
only one representative. There are many immigrants living in the United States who represent different
countries, and are seldom "culturally considered" in American hospitals.
Although individual differences exist within members of a group, an individual's cultural background and
teachings have an influence on worldview. Developing an understanding of the worldview of Filipino
clients helps nurses to provide culturally sensitive care. There are numerous issues that may negatively
affect culturally sensitive care. "When one assumes that all members of a culture or ethnic group act
alike, stereotyping is at work."
[3(p37)]
Some examples of negative stereotyping include ageism, racism, and
sexism.
[3]
The cultural diversity of our clients necessitates the need for nurses to avoid stereotyping,
recognize variations, and adjust their care to accommodate the values and customs for each patient.
Palliative care patients are seen in a vulnerable and critical time of uncertainty. This indefinite and
helpless time for patients demands culturally sensitive nursing care that understands and maintains
patients' psychological integrity to assist them in coping with their illnesses.
The purpose of this article is to describe nursing implications for providing nursing care to Filipino
clients and pertinent cultural information with recommendations for care. Finally, managing the
diagnosis, pain, and death and dying will be reviewed as well as strategies to provide culturally specific
care. As limited research is available pertaining to palliative care of Filipino clients, data from interviews
and Filipino culture research were applied to essential elements of nursing.
At the heart of most healthcare systems, nurses must thoroughly assess patients to identify physical and
psychosocial factors that may influence patients' perspectives regarding health and wellness. Taylor et
al
[3]
assert that a cultural assessment is the most efficient method to isolate ethnic values that may
influence a patient's behavior.
[3]
Whether it is through the use of a standardized tool or by simply asking
questions, a nurse can derive pertinent information regarding the patient's values and beliefs which
significantly influences and enhances the quality of care received by the patient. The primary source of
this information should be the patient; however, if not possible, a family member or friend can be
consulted.
[3]
As Rosario stated, "While my hospital experience was not terrible, the quality of care
received could have been enhanced if the nurses and doctors only knew about specific Filipino values."
To avoid patient complaints such as Rosario's, refer to Table 1 for Andrews and Boyle's Transcultural
Nursing Assessment tool illustrated in a Focused Assessment Guide.
[4]

When assessing a client's ethnic, cultural, and religious background, it is also important to determine
how strictly this patient adheres to these cultural beliefs or if he or she integrates other cultural
practices. A priority in transcultural nursing care is to recognize a patient's individuality. To honor this
individuality and avoid typecasting, a heritage assessment can assist in determining the many variations
among one cultural group. The factors that recognize heritage consistency are listed in Table 2 .
[5]

Although culture may keep one rooted in his or her heritage despite the country in which one resides, it
is essential that nurses recognize varying degrees of acculturation among families. Friedman et al
[6]
label
this variance in a family as a "cultural conflict" family and further state that this is common among Asian
families in which the parents and grandparents were born and raised in a different country than their
children.
[6]
The concept of "cultural conflict" families greatly contrasts with Friedman and colleagues'
category of Americanized families in which all members of the family are high acculturated to American
customs.
[6]
These varying degrees of acculturation among generations of families demand that nurses
intervene with family meetings and discussions to sensitively care for and accommodate all generations
of one family.
In 2002, the World Health Organization (WHO) amended their definition of palliative care into an
approach. This approach aims "to improve the quality of life of patients and their families facing the
problems associated with life-threatening illness, through the prevention and relief of suffering by
means of early identification and impeccable assessment, and treatment of pain and other problems,
physical, psychosocial and spiritual."
[7(p83)]
To encourage oncology nurses to embrace and practice
diversity in the healthcare setting, the Oncology Nursing Society (ONS) developed a multicultural tool
kit. It provides strategies addressing specific domains of culture such as "ethnic identity, communication,
health beliefs, and death and dying, etc., to integrate beneficial information in practice care,
educational, administrative, and research settings."
[8(p3)]

To demonstrate the principles of palliative care, it is vital for nurses to overcome ethnocentric
tendencies and define one's own perspective with the assistance of cultural self-assessment tools.
Although coping with a terminal illness, bereavement, grief, and death are very personal experiences,
they are also ingrained within one's cultural perspective. "By assessing and facilitating culturally
appropriate grieving practices, healthcare professionals can promote integration of the loss and
reinvestment in life for surviving family members."
[9(p25)]
By identifying one's own biases and
implementing cultural assessment strategies, palliative care nurses can focus their approach of care
consistent with the definition from WHO.
Nurses need to understand and incorporate significant aspects of Filipino culture into care provided. It is
undeniable that one of the most important considerations is to understand and respect the emphasis
that Filipinos place on family. Although family is important in many Western cultures, the central role
that the Filipino family plays in the lives of its members is far more significant.
[10]
To a native Filipino,
nothing takes priority over the well-being and happiness of each family member. To any Filipino, the
term "family" does not only involve immediate brothers and sisters; rather, the term extends to all
members within a lineage. Similar to American culture, the basic structure of the Filipino family unit is
composed of husband, wife, and their biological or adopted children. It is common in contemporary
Filipino families for the father to be acknowledged as the head of the household. The mother often plays
an equal role and is the primary decision-maker regarding health, children, and finances.
[11]
Whether the
family is traditional or contemporary, the Filipino family unit has a dual arrangement making it
"bilateral," meaning that one's relatives involve extended family members from both the fraternal and
maternal families.
[12]
This dual family structure emphasizes equality of respect and treatment from
descendants of both sides. According to Purnell and Paulanka, "a family visit to the hospital may take on
the semblance of a family reunion."
[19(p166)]
As in Rosario's case, it is unthinkable to any Filipino to have
only one chair in the room as well as to limit visitation periods for family. To assist in her recovery,
Rosario felt that she needed at least several family members to consistently stay with her throughout
her hospitalization. Girlie Claveria, a Manila native who has practiced nursing in the Philippines and
United States, commented that nurses must always consider that "when treating a Filipino patient, you
must treat the entire family tree." (G. Claveria, personal communication, October 21, 2004). Kathryn
Leonhardy, an international health expert, concurs that this concept of treating an entire family is
essential to providing nursing care that is in the best interest of the patient (K. Leonhardy, personal
communication, January 18, 2005). A foundational element of nursing involves treating all aspects of a
patient to enhance his/her overall well-being. To grasp the Filipino sociocultural perspective on health, it
is necessary to integrate religion. Historically, the Roman Catholic Church established itself in the
Philippines in collaboration with the Spanish Colonial Government.
[12]
As a mostly Christian culture,
Filipinos' social, political, and health beliefs are adapted around these traditions, specifically Roman
Catholicism.
[5]
When seeking medical care, most Filipinos trust that part of a treatment's success is by
God's will or by some mystical power.
[11]
The central role in which religion has influenced the Filipino
society historically and presently has transcended decades.
Considering that many Filipinos have immigrated into the Western hemisphere, it is important to
preserve their religious beliefs, especially when afflicted with illness. According to Davidhizar and
Giger,
[16]
many Filipinos believe that illnesses are a result of God's ultimate plan. This often has two
different effects in how Filipinos cope with illness. One reaction is of acceptance. In accepting their faith-
determined destiny, some Filipinos may abstain from seeking medical treatment to leave their health
issues in "the hands of God."
[10]
Just as Rosario prayed through her pain, many Filipinos cope with their
illness by praying and hoping that whatever God's will, it is best for that individual. In addition to prayer
and hope, it is possible that others choose to suffer silently and avoid complaining. Claveria attested to
this incorporation of religion when Filipinos cope with illness stating that many Filipino patients tend to
focus their illness around their religious beliefs. "No matter how bad the pain is, they may never
complain. They just pray" (G. Claveria, personal communication, October 21, 2004). According to Purnell
and Paulanka, "many Filipinos view pain as part of living an honorable life. In accepting pain they see it
as opportunity to augment their spirituality or to atone for past sins."
[11(p74)]

Hope is another reaction, which reflects a traditional Filipino belief in combination with a Western
philosophy towards illness. Despite how poor the prognosis and severity of illness, one is optimistic for a
cure.
[10]
Healthcare is viewed as a panacea that can cure and fix all. Overall, it is important for nurses to
understand the foundational beliefs when witnessing a Filipino patient cope with an illness, nonetheless
"kanser."
In the healthcare setting, there are many cultural considerations that nurses should be sensitive to when
working with Filipino clients. In a traditional hospital setting, there are routines and policies that are
instituted to ensure the well-being of all patients but also involuntarily violate various customs of other
cultures. Although most Filipinos speak English, nonverbal language is extremely powerful. Nurses
should consider the value placed on modesty, privacy, and confidentiality.
[10]
Filipinos are polite people
who are not confrontational, especially when it comes to questioning authority figures such as nurses.
When asking a Filipino patient if he or she has any questions, nurses should reassure the patient that
any concern is worth asking, leaving ample time for a reply. Establishing a friendly rapport with Filipino
patients to develop the comfort level necessary to address concerns and ask questions is a nursing
priority. Giger and Davidhizar
[10]
suggest that nurses should first address serious topics followed by
"safe" topics such as the weather, sports, and/or family. It is also vital to note that many Filipinos feel
uncomfortable expressing emotions in a group setting for fear of losing public face. As a result, group
therapy or support groups that are normally beneficial to oncology patients may not be beneficial in
helping a Filipino client express emotions because he or she would more than likely remain silent.
As worldwide immigration continues, it is important that nurses remain sensitive to the cultural
background that influences each patient. Cultural values that are pertinent to most Filipino patients
include the extended family unit, faith-determined destiny and health, as well as the patient's emotional
concerns whether or not they are verbalized.
After Rosario's biopsy procedure, her physician approached her room to find Rosario accompanied by
her parents, husband, two sisters, aunt, cousin, and brother. The physician kindly asked the family
members to leave Rosario's room so that they could talk in private. In this private meeting, the physician
revealed to Rosario the malignancy of her tumor, its metastases to her brain, and possible options for
treatment. Rosario's response was silence. She made no eye contact with the physician and asked no
questions. The physician left Rosario with some pamphlets about breast kanser and assured her that he
would be available in the morning if she had any questions.
An ongoing debate among healthcare professionals is the ethical decision as to whether or not patients
should be informed of the severity of their diagnosis. According to Yun et al,
[13]
"kanser" patients were
more likely than family members to believe that patients should be informed of the terminal illness.
"Paternalistic decisions by the physician or family may lead to dissatisfaction with the medical system,
causing increased stress, financial strain, and prolonged and painful deaths as a result of unwanted,
invasive care."
[13(p312)]
The Western principle of patient autonomy demonstrated by this study is not,
however, universally applicable to all cultures. This research identified ethnicity as the primary factor
that influenced attitudes towards revealing prognosis and decision-making. As palliative care nurses
practice family-centered care, it is important to never lose sight of the patient's wishes.
When revealing a diagnosis to a Filipino patient, it is important to recall the cultural implications for this
illness. As stated above, many Filipino clients may be accepting of this illness as God's plan for them and
utilize prayer as their primary coping mechanism. On the other hand, others may accept their planned
destiny and strive to cope with this predetermined fate through medical treatment. Purnell suggests
that a family meeting should be arranged in which members can discuss whether or not to inform a
patient of his or her terminal illness. The outcome of this meeting is that they may request the physician
not tell the patient of his or her terminal prognosis.
[11]
Conflicts within families regarding patient care
may also be attributed to the varying levels of acculturation among generations within a family.
Friedman et al
[6(p578)]
advise healthcare professionals to be "attentive to the socio/environmental
problems and institutional barriers faced by less-acculturated Asian-American families." Regardless of
attitude, acculturation, and coping mechanism, relevant resources in which a Filipino client may seek
support and guidance include a trusted family member or a religious counselor.
[10]
Considering the
emphasis Filipinos place on modesty, confiding in a trusted individual may also be difficult for Filipino
patients despite universal fears and emotions. Considering this internalization of emotions and
reluctance to ask questions, it may be beneficial to discuss the implications of the disease and treatment
options with both the patient and his or her family.
When in pain, Rosario did not want to ask the nurse for medications because she thought the nurse was
busy with other patients. Instead, Rosario dealt with the pain by closing her eyes and praying for relief.
There is nothing more universal among human beings than the experience of pain.
[14]
Pain is perhaps the
one thing that transcends all global cultures and economic classes. Considering the prevalence of pain in
all cultures, it is essential for healthcare professionals to understand that the Western world copes with
pain much differently from other cultures. One's sociocultural background molds one's perception of
pain and its various implications. Taking this concept one step further, it is clear why some people avoid
pain whereas others accept it as a part of life.
[15]
With "kanser," pain often becomes a hardship and a
struggle. It is important to teach patients that pain should not be an unmanageable aspect of a terminal
illness. In discussing these options, it is important for nurses to address common concerns that patients
experience in regard to pain relief such as fear of becoming addicted, fear of appearing to be a
"complainer," and the fear of losing control.
[10]
Patients should be educated in how their pain will be
managed to dispel any of these concerns, which are relevant but unlikely.
McCaffery
[16]
defines pain as "what the patient says it is, and it's as bad as the patient says it is." Keeping
this Western definition in mind, how are nurses supposed to know the amount of pain that a patient is
experiencing if the patient does not directly tell them? Pain is an experience that nurses cannot ignore.
Therefore, it is important that nurses learn how to assess a patient's body language to predict pain,
especially if the patient does not speak English. Nurses must note that assessing a patient's level of pain
is not assigning it a number, but rather developing a relationship with that patient and family. Part of
this relationship development includes teaching patients and their family members the commonality of
pain with "kanser" as well as the benefits of pain management including a restful sleep. Pain manifests
itself in several forms and it is important for nurses to be aware of its various manifestations whether it
is through aching or fatigue or a disruption of daily tasks.
[15]

Developing a level of communication among nurses and patients is at the core of pain management. In
addition to coping with their illness autonomously, many Filipino patients internalize their pain and
suffer silently.
[11]
Kaegi
[17]
suggests that nurses learn to recognize clues of miscommunication such as
when a patient and family members suddenly begin speaking in their own language after a question is
asked. According to Claveria, no matter how severe the pain, it is rare for a Filipino patient to complain.
"Filipino patients seldom ask for pain medication for two reasons. One, they fear becoming addicted to
the medications. Two, they fear that they will be a nuisance to the nurse" (G. Claveria, personal
communication, October 21, 2004). Leonhardy again concurs and stresses that Filipino patients will be
reluctant to ask the nurse for pain medication for fear of creating unnecessary work for the nurse (K.
Leonhardy, personal communication, January 18, 2005). Kaegi
[17(p33)]
states that in teaching patients to
talk about pain, "all comes down to communication." Research has shown that helping minority patients
communicate with their providers-and vice-versa-is the first step in successfully collaborating on
appropriate pain management.
[17]

The University of Wisconsin-Madison School of Nursing developed a program called Representational
Intervention to Decrease Cancer Pain (RIDcancerPain). This program provided nurses with a framework
to help "kanser" patients to delve deep into their own belief systems about health, disease, and pain
and to add sound concepts that will work for them. The empirically tested RIDcancerPain guides nurses
through a culturally sensitive process to educate patients about pain and its management. Nurses can
use this tool to help patients verbalize their beliefs, customs, and fears, and in becoming an integral
member of their pain management care plan.
[18]

In advising nurses how to care for Filipino patients in pain, Claveria suggests that nurses become
extremely vigilant in reading and interpreting each patient's body language. "Nurses must observe and
continually assess the patient. Observe facial expressions and consistently reassess for physical signs of
pain. Nurses must almost develop a sense of paranoia to know when the patient is in pain and help
them in any way that they can" (G. Claveria, personal communication, October 21, 2004). Perhaps if
Rosario's nurses were more conscientious of Rosario's body language and implemented a culturally
sensitive pain assessment tool, the nurses may have noticed that whenever Rosario had her eyes closed
other than when she slept, it was a physical sign of discomfort and pain. For more information regarding
nursing interventions to overcome cultural and communication barriers as well as pain assessment
tools, visit www.minoritynurse.com .
As Rosario's condition rapidly declined, a family meeting was arranged without the presence of Rosario.
In this meeting there was a discussion as to revealing to Rosario her predicted prognosis of one month.
Rosario's parents insisted that her prognosis be kept a secret. Conversely, Rosario's husband agreed
with the oncologist that Rosario should be directly involved in the discussions concerning her mortality
and possible end-of-life options. Despite these differences, Rosario's oncologist made exceptions to
ensure that Rosario's family could provide the majority of intimate caregiving while she spent her last
days in the hospital.
"In ancient times, the physician's role and the priest's role were fulfilled by the same person.
Simultaneously, dying patients were treated by a doctor of the body and a doctor of the soul."
[19(p93)]
This
dual role allowed the practitioner to care for patients medically but also emotionally and prepared
patients for death as a natural and passionate event. Today, this dual role no longer exists and it has
become a daily challenge for healthcare professionals to participate in a patient's dying process. By
incorporating the fundamentals of palliative care, nurses can assist in emotionally preparing patients for
a dignified death. To actively prepare for dying in an artful and fulfilling way, Fahnestock
[19]
believed that
it takes collaboration between the dying patient, the nurse, and the physician. As a nurse who was dying
from "kanser," Fahnestock used her final months to speak with healthcare personnel about effective
interventions of basic human care to assist their patients in the dying process.
Fahnestock
[19(p93)]
suggested that, "beyond pain control, the three elements we [dying persons] most
need are feeling cared about, being respected, and enjoying a sense of community, be it in relationships
or in terms of spiritual awareness." These elements that Fahnestock considered paramount in the dying
process are the key elements that, more often than not, are unseen when caring for patient from
another culture. It is nearly impossible to exhibit caring, demonstrate respect, and establish a
community unless the nurse understands each patient's cultural background. Therefore, for nurses to
meet Fahnestock's challenge, each nurse caring for a patient must learn the patient's values so that they
can appropriately prepare the patient for death, beyond the medical limitations of pain control and
disease progression.
The ancient role of both physician and priest would have been appropriate in caring for many oncology
Filipino patients. The Filipino philosophy concerning death is commonly connected to their spiritual
beliefs. As Catholicism teaches, death should not be feared if one has followed doctrine. Most Filipinos
follow this Catholic tradition that the same Lord who has created them will also reward them with
eternal life in heaven.
[14]
In a Filipino family, the decision to inform the patient about his or her terminal
condition should be discussed and agreed upon by all family members. It is not uncommon that family
members request that the physician not divulge the truth to protect the patient. Making preparations
for one's death is also considered to tempt fate. As a result, many traditional Filipinos are opposed to
advance directives or living wills.
[11]
If a patient's condition does start to decline, family members may
request to provide most of the care for the patient whether at home or in the hospital.
[11]

In researching death and dying in four Asian American cultures, Braun and Nichols
[14]
have pinpointed
appropriate strategies to encourage a natural death process when working with terminally ill Filipino
patients. Actions such as withholding life support or increasing pain medication are permissible in this
natural process. On the other hand, Filipinos were not in favor of more active measures or assisted
suicide.
What is essential when treating Filipino patients is understanding the essence of their value system. In
other words, the most important thing is to be respectful of a dying patient and his or her family.
Mainstreaming this respect includes having a Catholic priest available, providing an interpreter if the
patient does not speak English, making arrangements for having the family participate in care, and
having flexibility with visitation periods to ensure optimum family involvement.
[11]
In addition, the nurse
can encourage families to bring in food that the patient likes (even if it is against hospital rules) and not
wake a dying patient to draw blood or take vital signs. The above interventions can ensure that the
Filipino patient is not only pain-free but also as comfortable as possible. All of these dying rituals
emphasize the significant role that both family and faith take part in the dying process of a Filipino
patient.
Once death has occurred, death rituals revolve around the function of family and faith. The Novena is
the most common death ritual among Filipinos.
[14]
This is a tradition in which prayers are said every
night for nine nights following a death. Throughout this 9-day ritual, it is customary for family members
to take turns watching over the body. On the night of the ninth day, friends and family come to
an atang (prepared feast) at the house in which the favorite foods of the deceased are eaten.
[14]
It is
Filipino belief that a place at the table should be set for the dead so he or she can also eat.
[14]
To
accomodate Filipino traditions in the hospital, a nurse may consider expanding hospital visiting hours to
allow the Filipino family to mourn for the patient according to their customs. Information regarding
Filipino beliefs concerning death rituals is presented in Table 3 .
As "kanser" continues to afflict our society, it is pivotal for nurses to develop cultural awareness and
sensitivity so that quality care is provided to patients from all cultures. In investigating cultural
implications when treating Filipino oncology patients, it is important for nurses to understand the value
that Filipinos place on family, the relationship between religion and illness, as well as coping strategies
with being informed of a life-threatening diagnosis, pain, and eventually death. When caring for a
Filipino patient, palliative care nurses specifically must become accustomed to the cultural background
of these patients to be able to nurture the patient physically, emotionally, and spiritually. When
receiving a diagnosis of "kanser," patients must be informed of all of the implications, but must also be
educated that a statistical number does not determine a prognosis. In regards to pain management,
nurses must remember that pain is a subjective, universal experience that requires adequate patient
teaching as well as communication strategies. Finally, when preparing a Filipino patient to die, nurses
must create an environment that enhances the natural event of death by being accommodating to all
the patient's cultural beliefs concerning end-of-life care and religious practices. By exploring the Filipino
patients' ethnic background and understanding their value system, nurses can provide quality care to
Filipino oncology patients.
Although literature exists regarding cultural sensitive palliative nursing care, there is a need for research
specific to palliative care nursing for Filipino patients. To enhance their own awareness, nurses have the
opportunity to educate themselves on the implications for all cultures and how these practices should
influence their daily bedside care. For Filipino patients specifically, it is important for nurses to
remember the value of family, religious correlation to illness, coping mechanisms by confiding in family
or priest, denial of pain medication for fear of addiction or hindrance, and death attitudes, rites, and
rituals that enhance a spiritual and natural dying process. By completing thorough physical and cultural
assessments, a nurse can truly succeed in tending to all of the patients' needs.