Advance Directives and End of Life Issues

Issues surrounding death and dying are always difficult regardless of cultural background, but attitudes toward end-of-life issues are diverse among different cultural backgrounds.

Attitude Toward Death

Many Vietnamese people see death as a natural phase of the life cycle. This attitude toward death may be influenced by the fact that older adults are highly respected in Vietnamese culture, and therefore, aging and death may not conjure up as many negative connotations as within Western cultures. Further, Vietnamese immigrants in the United States are influenced by spiritual beliefs linked not only to Catholicism or Buddhism, but also to Taoism, animism, and Confucianism. For example, reverence for ancestors and the use of home altars, where homage is paid to family ancestors, are common even among Vietnamese Christians. These religious and cultural/societal norms influence Vietnamese views of death, allowing them to reframe the process and the event. For instance, concepts of reincarnation prevalent among Buddhists, ancestor worship, and the belief of going to heaven after death, may cause death to be viewed as something fortunate, and fitting with life’s natural cycle. In addition, many Vietnamese people have lived through wars, witnessing deaths and suffering as results of such wars. This fact, as well as historically higher mortality rates among infants and adults in Vietnam, can make the Vietnamese view death more as a normal part of life.

End of Life Preparations

While general discussions about death and dying may be viewed as inauspicious and in poor taste to the Vietnamese family, it is a common practice among Vietnamese older adults to make concrete preparations for death. These preparations include setting aside money to pay for the burial, choosing a burial site with a favorable orientation in accordance with the laws of feng shui, buying a coffin, and even buying or having burial clothes made long before they are actually needed. In a study conducted in Hawaii by Braun and Nichols (1996), both Christian and Buddhist Vietnamese participants said that preparations for death included praying and preparing wills for distribution of property. The act of making concrete preparations for one’s own death is seen as a common responsibility that older adults carry out for themselves as well as their children. Even though Vietnamese older adults may prepare for the rituals of death, active end-of-life care planning is a foreign and unfamiliar undertaking for most Vietnamese families. It was reported in the Hawaii study that few Vietnamese older adults were aware of their options with regard to advance directives. Issues related to “Do Not Resuscitate” orders or removal of feeding tubes was usually not considered (Braun & Nichols, 1996). This is perhaps multifactorial, attributable to older adults’ reliance on their children for interpretation and the possibility that their children may be uncomfortable with the subject matter.

Diagnosis Disclose Issues

Some Vietnamese families may also prefer that the diagnosis of a serious or terminal illness not be disclosed directly to an older family member to prevent additional stress for the older adult, making informed consent and decisions regarding code status awkward. Whatever the intent, know that families may not be forthcoming with reasons. So the clinician may need to specifically inquire of the patient about presenting information and discuss the family’s preference for what information they feel the older adult may want to have. Again, because there is such variation in acculturation and beliefs among Vietnamese, clinicians and providers should remain attuned to these variations.

Cultural Beliefs

Cultural beliefs related to death and dying: There are a number of cultural beliefs that are likely to affect decisions at the end of life for Vietnamese older adults and their families. These include:

  • an aversion to dying in the hospital because of the belief that souls of those who die outside the home wander with no place to rest,
  • an avoidance of death and dying in the home for fear opening up one’s home to bad spirits,
  • the perception that consenting to end-of-life support for a terminally ill parent contributes to her death and is an insult to one’s ancestors and parent, and
  • Buddhist beliefs in karma that interpret difficult deaths as punishment for bad deeds in former lives by the dying person or another family member.