Dealing with Death & Dying in Medical Education and Practice
© 2001 Kirsti A. Dyer, MD, MS
AMSA Convention March 30, 2001
Cross-Cultural Responses to Grief and Mourning

Grief is...a normal emotion, with significant differences to be expected from one culture to another…

Averill and Nunley
Handbook of Bereavement

Grief, whether in response to the death of a loved one, to the loss of a treasured possession, or to a significant life change, is a universal occurrence that crosses all ages and cultures. However, there are many aspects of grief about which little is known, including the role that cultural heritage plays in an individual's experi-ence of grief and mourning.[1,2] Attitudes, beliefs, and practices regarding death and grief are characterized and described according to multi-cultural context, myth, mysteries, and mores that describe cross-cultural relationships.[2] 
The potential for contradiction between an individual's intrapersonal experience of grief and his or her cul-tural expression of grief can be explained by the prevalent (though incorrect), synonymous use of the terms grief (the highly personalized process of experiencing reactions to perceived loss) and mourning (the socially or culturally defined behavioral displays of grief).[3,4] 
An analysis by Cowles of the results of several focus groups, each consisting of individuals from a  spe-cific culture, reveals that individual, intrapersonal experi-ences of grief are similar across cultural boundaries. This is true even considering the culturally distinct mourning rituals, traditions, and behavioral expressions of grief experienced by the participants. Cowles concludes that health care professionals need to understand the part cultural mourning practices may play in an individual's overall grief experience if they are to provide culturally sensitive care to their patients.[1]
In spite of legislation, health regulations, customs, and work rules that have greatly influenced how death is managed in the United States, bereavement practices vary in profound ways depending on one's cultural back-ground. When assessing an individual's response to the death of a loved one, clinicians should identify and appre-ciate what is expected or required by the person's culture. Failing to carry out expected rituals can lead to an experi-ence of unresolved loss for family members.[5] This is often a daunting task when health care professionals in the United States and Canada are predominantly white in race and Christian in religion, yet serve patients of many ethnicities.[2] 
Helping family members deal with the death of a loved one includes showing respect for the family's cultural heritage and encouraging them to decide how to commemorate the death. McGoldrick, et al., identified five questions clinicians consider particularly important to ask those who are dealing with the emotional aftermath of the death of a loved one. 
1. What are the culturally prescribed rituals for managing the dying process, the deceased's body, the disposal of the body, and commemoration of the death? 
2. What are the family's beliefs about what happens after death?
3. What does the family consider an appropriate emotional expression and integration of the loss?
4. What does the family consider to be the gender rules for handling the death?
5. Do certain types of death carry a stigma (e.g., suicide), or are certain types of death especially traumatic for that cultural group (e.g., death of a child)?[6]
Death, grief, and mourning are universal and natural aspects of the life process. All cultures have evolved practices that best meet their needs for dealing with death at any point in time. Hindering these practices can disrupt the necessary grieving process. Understanding these prac-tices can help clinicians to identify and develop ways to treat patients of other cultures who are demonstrat-ing atypical grief.[7] Given current ethno-demographic trends, health care professionals need to address these cultural differences in order to best serve these populations.[2]
To really understand a person’s grief, you have to walk a while their shoes. 

1. Cowles KV: Cultural perspectives of grief: an expanded concept analysis. Journal of Advanced Nursing 23(2): 287-294, 1996. 
2. Irish DP, Lundquist KF, Nelson VJ, Eds.: Ethnic Variations in Dying, Death, and Grief: Diversity in Universality.  Washington, DC: Taylor & Francis, 1993. 
3. Rando TA: Treatment of Complicated Mourning. Champaign: Research Press, 1993. 
4. Cowles KV, Rodgers BL: The concept of grief: a foundation for nursing research and practice. Research in Nursing and Health. 14(2): 119-127, 1991. 
5. McGoldrick M, Hines P, Lee E, et al.: Mourning rituals. Family Therapy Networker 10(6): 28-36, 1986. 
6. McGoldrick M, Almedia R, Hines PM, et al.: Mourning in different cultures. In: Walsh F, McGoldrick M, Eds.: Living  Beyond Loss: Death in the Family. New York: W.W. Norton & Company, 1991, pp 176-206. 
7. Eisenbruch M: Cross-cultural aspects of bereavement. II: ethnic and cultural variations in the development of bereavement practices. Cultural, Medicine and Psychiatry 8(4): 315-347, 1984.

CancerNet. Loss, Grief, and Bereavement (PDQ®) Supportive Care - Health Professionals. National Cancer Institute. Last Modified: 03/2001.  Available through link at:

Compilation of resources for this presentation and Website © 2001 Kirsti A. Dyer, MD, MS. 
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