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Providing palliative care for cardiovascular disease from a perspective of sociocultural diversity

a global view

Davidson, Patricia M.a,b; Phillips, Jane L.a,b; Dennison-Himmelfarb, Cheryla,b; Thompson, Sandra C.c; Luckett, Timb; Currow, David C.d

Author Information
Current Opinion in Supportive and Palliative Care: March 2016 - Volume 10 - Issue 1 - p 11-17
doi: 10.1097/SPC.0000000000000188
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Cardiovascular disease (CVD) is not only the number one cause of death globally but is also responsible for considerable suffering and disability. An estimated 17.5 million people died from CVD in 2012, representing 31% of all global deaths. Of these deaths, an estimated 7.4 million were due to coronary heart disease and 6.7 million were due to stroke [1]. Heart failure is a major source of morbidity and disability and the final common pathway for many cardiovascular conditions. Heart failure is the most common reason that patients with advanced heart disease require palliative care [2]. More than 5 million Americans, 15 million Europeans and 350 000 Australians have a diagnosis of heart failure [3–5]. Over three-quarters of CVD deaths take place in low- and middle-income countries, signaling the need to develop policies and workforce capacity to reduce suffering and meet the needs of individuals and their families [1]. Whether deaths from CVD are sudden and premature or expected and prolonged, there is an important place for palliative care to decrease suffering for individuals and their families. Considering sociocultural factors beyond the individual, within a broader ecological context, requires consideration of a range of dynamic and interactive factors [6]. A constellation of symptoms, including breathlessness and gastrointestinal symptoms, prompts presentation to the emergency department and admission to the hospital in the advanced stage of CVD [7–9]. Not only do many of these admissions fail to address symptom burdens but also necessitate that individuals die in acute care settings often receiving futile treatments that are distressing to individuals, their family members and health professionals alike [10▪].

Box 1:
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Originating from alleviating the suffering of cancer, contemporary palliative care has emerged as an evidence-based, multidisciplinary approach to care for individuals and their families living with serious, life-limiting illnesses [11]. Increasingly, the importance of palliative care for both malignant and nonmalignant conditions is recognized but access is not consistent either across patient populations or geographical boundaries [12]. In order to improve health outcomes and to address inequities, it is important to consider access from the perspectives of the healthcare system, provider and patient levels [13▪].

Cultural diversity and pluralism are the hallmarks of most contemporary societies, with both forced and voluntary migration having important implications for health services and outcomes [14–16]. Individuals from culturally and linguistically diverse groups are most vulnerable to marginalization because of language barriers and socioeconomic factors and, as a consequence, are less likely to access services across the lifespan [17,18]. A range of service characteristics influences accessibility including approachability, availability, accommodation, affordability and appropriateness [19▪]. These factors address not just cost and geographical proximity but also how the characteristics of the health service fit with the users’ attitudes, values and beliefs. The complexity of factors driving access also emphasizes the need to accommodate cultural beliefs at the level of the individual, healthcare provider and society. Service characteristics further interact with an individual's beliefs, health literacy, health-seeking behaviors, culture and language and may influence not only healthcare access but also satisfaction [20▪]. The interplay between the health system, service and patient characteristics means that access to healthcare will require multidimensional consideration both of individual, provider and policy issues.

The core palliative care capabilities that every health professional (nursing, allied health and medical) requires to better support patients and their families at the end of life [21] are termed as palliative approach. It also requires that health professionals’ recognize when people with more complex needs should be referred to specialist palliative care services [22]. Consideration of ethnic and cultural issues poses a challenge for palliative care internationally [23]. Palliative care as a philosophy and service model is not always readily embraced. Confronting mortality is a taboo across many cultures and commonly not discussed which can make providing palliative care challenging [24]. Death and dying are highly ritualized in many cultural groups and require specific consideration in palliative care [25▪]. For historical reasons, there may also be skepticism about palliative care among many minority groups, such as African-Americans and Australian Aboriginals and Torres Strait Islander people, who may be suspicious that withdrawing and withholding treatment is related to reducing costs rather than focusing on improving individual well-being [26,27]. Particularly, in indigenous populations, there is a critical importance to engage community leaders in developing palliative care services [28▪,29].

Philosophically, palliative care embraces the physical, social, psychological and spiritual dimensions of care. It is often the sentinel events in life, such as birth and death, where sociocultural factors are most pronounced and requires the astute attention of healthcare providers. Sociocultural dimensions of care refer to the knowledge, attitudes, beliefs, customs, practices and behaviors that exists within a specific population [30]. These factors are also moderated by the social, political and economic factors influencing healthcare delivery and policy and financing models are of a great significance for the delivery of palliative care. Increasingly, the need to consider culture within the context of palliative care has been recognized and creates an important agenda for the quality of care [31].

Culture is the backdrop against which to consider the needs of individuals, families and communities and can be a powerful force for engagement and understanding, however, it can also fuel stereotyping and prejudice [32,33]. Sociocultural approaches to considering palliative care can sometimes be perceived as superficial by focusing on behaviors such as rituals surrounding death [34]. Although it is important to consider rituals, spiritual and religious needs, standardized policies and procedures risk stereotyping individuals and groups, although general practices can also serve as a valuable basis for ensuring culturally competent care [35]. Cultural competence refers to the behaviors, attitudes and policies that come together in a system to facilitate effective interaction in cross-cultural situations [36]. This article synthesizes available data on palliative care for CVD within the lens of culture and addresses the need for cultural competence in palliative care for cardiovascular disease, challenging health professionals to move from ritualistic considerations in care delivery to issues of access and equity in an environment of cultural competence. We have integrated the available literature within the context of a social-ecological model.


The social-ecological model is a theory-based framework for understanding the reflexive, dynamic and interactive effects of factors [37]. This approach promoted by Bronfenbrenner has been widely adapted in the health and social services to provide an understanding of the reciprocal transactions occurring between individuals and their social environments. Such an approach is particularly important when considering the influence of culture within the context of the healthcare system. Using this model, we consider that factors at the level of the individual, provider and healthcare system can influence how culture impacts on palliative care services and uptake (see Fig. 1). In the section that follows, we apply the social-ecological framework to highlight the interaction of forces that drive cultural factors and influence access to palliative care and the capacity to meet the needs of individuals and families.

Social-ecological framework for palliative care.

The first level of the social-ecological model identifies personal characteristics at the level of the individual. In addition to unique biomedical characteristics, this sphere pertains to the individual's knowledge, attitudes, beliefs and behaviors that influence acceptance of palliative care. Individual's knowledge, attitudes and beliefs are moderated by sociocultural factors as well as peer experiences and prior exposure to palliative care services. However, it is essential not to lose sight of individual variability among people of the same sociocultural background and to avoid making generalizations based on perceived group characteristics. Specific approaches to changing individual's knowledge, attitudes, beliefs and behaviors may include education and information sessions [38], strategies such as question prompt lists [39], as well as creating awareness through social marketing strategies undertaken by professional organizations. Other examples of individual-level interventions include strategies to decrease stigma and increase the acceptability of assessment by a palliative care team and the interventions they suggest [40]. An important consideration in some culturally and linguistically diverse populations is that the needs of the individual (and particularly decision-making) may be deferred to family members based upon social mores [6,32]. Moreover, it is also important to consider the use of traditional medicines in specific population groups [41].


This second level examines the relationships that may increase the uptake of palliative care, and it is in this sphere where culture plays a critical role [42▪]. In many culturally and linguistically diverse groups, decisions are made according to accepted principles, and nondisclosure of diagnosis is a particular challenge for palliative care health professionals and in some instances can create ethical dilemmas [32,43,44]. Programmes recognizing cultural influences on decision-making are pivotal for optimizing outcomes in many culturally and linguistically diverse communities [42▪]. In many communities, faith-based advisors are important thought leaders in setting community norms and proactively engaging them in supporting palliative care interventions is an important consideration. The role of primary care and general practice is particularly important because, in culturally and linguistically diverse groups, these healthcare professionals are commonly more sensitive to patient and family needs and exert more influence than specialist services [32,45]. General practitioners may be selected by the patient because they are from his/her cultural group and can communicate in the home language [32]. A critical consideration is ensuring that primary healthcare providers understand the value and importance of a palliative approach in CVD [46]. Likewise, there is a need to understand cultural influences on any power imbalances and sex-based roles and how these may influence access to healthcare.

Advance care planning (ACP) is a patient-centered communication process which allows patients to discuss their values and preferences for future care with their families and health professionals so that decisions can be made in accordance with their wishes in the event they become unable to speak for themselves [47]. Conversations about ACP can be challenging for health professionals, families and patients [48]. Such conversations ideally do not take place during a time of crisis. Engaging faith-based leaders in ACP has shown considerable promise [49]. Models of shared decision-making require the individual to be presented with options and their preferences elicited to enable collaborative decision-making [50]. In many cultural and religious groups, this process needs to be expanded to be inclusive of key decision makers in families and communities which may include community health workers and leaders of faith-based organizations [29,51]. Although similar acceptance of ACP across groups has been identified, this may depend on the level of acculturation [52▪]. In developing economies, the role of community health workers ought not be underestimated [53▪]. Leveraging interpersonal relationships and also the authority of key individuals can assist in improving approachability, availability, accommodation and appropriateness of palliative care models.


The third level of the social-ecological model in Fig. 1 describes the settings in which palliative care is delivered and also where individuals live. Strategies at this level focus on impacting the social environment, by reducing social isolation, and improving economic and social circumstances [25▪,54▪]. Awareness of palliative care is commonly lower among minority ethnic groups, and the most socioeconomically disadvantaged. Particularly, in indigenous or first-nation communities, skepticism and mistrust of health services and therefore of palliative care is most pronounced [55,56]. This is manifested by African-Americans who are less likely to accept a ‘Do Not Resuscitate’ order. However, at the community level, and particularly in diasporas, there is the capacity to leverage social capital and resources for providing palliative care through engaging resilience and cultural factors [57,58▪]. Engaging community navigators and community health workers is increasingly recognized as being important in engaging vulnerable populations [59,60].


Societal factors include the health, economic, educational and social policies that entrench economic or social inequalities between groups in society, including in the most extreme case discrimination and racism [61,62]. These factors also include social and cultural norms that support the role of palliative care as a credible, valuable and important dimension of healthcare provision. The policy context is critically important in funding and ensuring access to palliative care services [63,64]. Sadly, many individuals with CVD do not have access to a palliative approach or to specialist palliative care. This gap largely occurs because palliative care as funding models does not promote early access and/or many healthcare providers do not have the confidence to initiate a palliative approach and/or promote access to specialist palliative care. There is a critical need for development of healthcare systems to provide an appropriate level of palliative care for individuals with CVD in accordance with need, supported by enabling policy and funding models; individuals and communities who are willing to accept the input of palliative care; and by healthcare providers who are not only skilled in palliative care but are also culturally competent. Training of healthcare staff in understanding the palliative approach is critical to ensuring access to palliative care [65▪]. Although evidence-based guidelines emphasize the importance of integration of palliative care in cardiovascular management, in reality this is not routinely implemented [2,66,67]. Considering opportunities and challenges for improving palliative care at the level of the individual, interpersonal relationships, community and society is crucial in promoting access to individuals with CVD from diverse backgrounds. Table 1 provides recommendations for practice and culturally appropriate and competent care on the basis of available data and guidelines. These strategies are congruent with the person-centered and comprehensive approach to palliative care in both primary and specialist care [68].

Table 1:
Recommendations for clinical practice


Palliative care access and delivery is known to be poor across many nations and cultural groups, particularly for those with nonmalignant conditions. Death and dying is an important consideration in health service planning and delivery and because it is a highly culturally laden experience it presents both an opportunity and a challenge. Conceptually and philosophically, the holistic philosophy of palliative care is enabling of being inclusive of culture and the emphasis placed on communication is an important dimension of engagement. In addition, palliative care providers are experienced in working through ethical dilemmas and conflicts. What is apparent from a review of contemporary literature is that culture is a critical dimension and should be part of the individual assessment of the needs of the individual and their family. The need for deliberation and seeking of solutions is an international phenomenon and underscores the growing importance of cultural pluralism in a globalized society. Extending the consideration of culture beyond the individual patient encounter to one that also considers the characteristics of health providers and community values raises is critical in improving access to quality primary and specialist palliative care. This is particularly important in emerging economies wherein the importance of palliative care for CVD is less well recognized.



Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


Papers of particular interest, published within the annual period of review, have been highlighted as:

  • ▪ of special interest
  • ▪▪ of outstanding interest


1. World Health Organization. Cardiovascular diseases. 2015. [Accessed 11 November 2015]
2. Jaarsma T, Beattie JM, Ryder M, et al. Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2009; 11:433–443.
3. National Heart Foundation and Cardiac Society of Australia and New Zealand. Guidelines for the prevention, detection and management of chronic heart failure in Australia. 2011. [Accessed 11 November 2015].
4. Jessup M, Abraham WT, Casey DE, et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009; 119:1977–2016.
5. Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail 2008; 10:933–989.
6. Davidson PM, Macdonald P, Ang E, et al. A case for consideration of cultural diversity in heart failure management-Part 1: rationale for the DISCOVER Study. Contemporary Nurse 2004; 17:204–210.
7. Gavazzi A, De Maria R, Manzoli L, et al. Palliative needs for heart failure or chronic obstructive pulmonary disease: results of a multicenter observational registry. Int J Cardiol 2015; 184:552–558.
8. Campbell RT, Jackson CE, Wright A, et al. Palliative care needs in patients hospitalized with heart failure (PCHF) study: rationale and design. ESC Heart Failure 2015; 2:25–36.
9. Sidebottom AC, Jorgenson A, Richards H, et al. Inpatient palliative care for patients with acute heart failure: outcomes from a randomized trial. J Palliative Med 2015; 18:134–142.
10▪. Denvir M, Murray S, Boyd K. Future care planning: a first step to palliative care for all patients with advanced heart disease. Heart 2015; doi:10.1136/heartjnl-2014-306724.

Emphasizes the emerging evidence for palliative care is recommended for patients with end-stage heart failure and emphasizes the importance of future care planning provides a framework for discussing a range of palliative care problems with patients and their families.

11. Sepúlveda C, Marlin A, Yoshida T, Ullrich A. Palliative care: the World Health Organization's global perspective. J Pain Symptom Manage 2002; 24:91–96.
12. Dumanovsky T, Augustin R, Rogers M, et al. The growth of palliative care in US hospitals: a status report. J Palliative Med 2015; Epub ahead of print. doi:10.1089/jpm.2015.0351.
13▪. Routledge, Patel K, Rushefsky ME. Healthcare in America: Separate and Unequal. 2015.

This text examines the unique aspects of discrete sociocultural groups in the United States, the tensions between healthcare system and factors impacting on healthcare quality.

14. Lu Y, Qin L. Healthy migrant and salmon bias hypotheses: a study of health and internal migration in china. Social Sci Med 2014; 102:41–48.
15. Shishehgar S, Gholizadeh L, DiGiacomo M, Davidson PM. The impact of migration on the health status of Iranians: an integrative literature review. BMC Int Health Hum Rights 2015; 15:20.
16. Al Abed NA, Davidson PM, Hickman LD. Healthcare needs of older Arab migrants: a systematic review. J Clin Nurs 2014; 23:1770–1784.
17. Szczepura A. Access to healthcare for ethnic minority populations. Postgraduate Med J 2005; 81:141–147.
18. Todd J, Baldwin CM. Palliative care and culture: an optimistic view. J Multicultural Nursing Health; Summer 2006; 12 2:28.
19▪. Levesque J-F, Harris MF, Russell G. Patient-centred access to healthcare: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013; 12:18.

This article conceptualizes and demonstrates the dynamic characteristic of access and how this influences healthcare outcomes and the quality of care.

20▪. Lee JJ, Long AC, Curtis JR, Engelberg RA. The influence of race/ethnicity and education on family ratings of the quality of dying in the ICU. J Pain Symptom Manage 2015; doi:10.1016/j.jpainsymman.2015.08.008.

This study undertaken in the ICU showed that minority race/ethnicity was associated with lower family ratings of quality of dying. This association was mediated by factors that may be markers of patient and family preferences.

21. Hegarty M, Currow D, Parker D, et al. Palliative care in undergraduate curricula: results of a national scoping study. Focus on Health Professional Education 2010; 12:97–109.
22. Waller A, Girgis A, Johnson C, et al. Facilitating needs based cancer care for people with a chronic disease: evaluation of an intervention using a multicentre interrupted time series design. BMC Palliative Care 2010; 9:2.
23. Crawley L, Koffman J. Ethnic and cultural aspects of palliative care. Oxford Textbook of Palliative Medicine; Cherny N, Fallon NM, Kaasa S, Portenoy RK, Currow DC, eds. 2015; 84–92.
24. Cheng HWB, Li CW, Chan KY, et al. Bringing palliative care into geriatrics in a Chinese culture society: results of a collaborative model between palliative medicine and geriatrics unit in Hong Kong. J Am Geriatr Soc 2014; 62:779–781.
25▪. Andrew EVW, Cohen J, Evans N, et al. Social-cultural factors in end-of-life care in Belgium: a scoping of the research literature. Palliative Med 2013; 27:131–143.

This review identifies how sociocultural factors influence end-of-life care in Belgium and emphasizes the importance of considering the dynamic influence of culture.

26. Shahid S, Finn L, Bessarab D, Thompson SC. Understanding, beliefs and perspectives of Aboriginal people in Western Australia about cancer and its impact on access to cancer services. BMC Health Serv Res 2009; 9:132.
27. Crawley L, Payne R, Bolden J, et al. Palliative and end-of-life care in the African American community. JAMA 2000; 284:2518–2521.
28▪. Brown A, O'Shea RL, Mott K, et al. Essential service standards for equitable national cardiovascular care for Aboriginal and Torres Strait Islander people. Heart Lung Circulation 2015; 24:126–141.

This article provides service standards for Aboriginal and Torres Strait Islander groups in Australia and emphasizes the importance of culturally competent and appropriate care.

29. Oetzel JG, Simpson M, Berryman K, Reddy R. Differences in ideal communication behaviours during end-of-life care for Māori carers/patients and palliative care workers. Palliative Med 2015; doi: 10.1177/0269216315583619.
30. Anderson LM, Scrimshaw SC, Fullilove MT, et al. Culturally competent healthcare systems: a systematic review. Am J Prev Med 2003; 24:68–79.
31. Gysels M, Evans N, Meñaca A, et al. Culture is a priority for research in end-of-life care in Europe: a research agenda. J Pain Symptom Manage 2012; 44:285–294.
32. Davidson PM, Macdonald P, Moser DK, et al. Cultural diversity in heart failure management: findings from the DISCOVER study (Part 2). Contemporary Nurse 2007; 25:50–62.
33. Olarte JMN, Guillén DG. Cultural issues and ethical dilemmas in palliative and end-of-life care in Spain. Cancer Control 2001; 8:46–54.
34. Nielsen LS, Angus JE, Howell D, et al. Patient-centered care or cultural competence: negotiating palliative care at home for Chinese Canadian immigrants. Am J Hosp Palliative Med 2015; 32:372–379.
35. McNamara B, Martin K, Waddell C, Yuen K. Palliative care in a multicultural society: perceptions of healthcare professionals. Palliative Med 1997; 11:359–367.
36. Campinha-Bacote J. The process of cultural competence in the delivery of healthcare services: a model of care. J Transcult Nurs 2002; 13:181–184.
37. Harvard University Press, Bronfenbrenner U. The ecology of human development: experiments by nature and design. 2009.
38. Gibbs J, McCoy A, Gibbs L, et al. Living with and dying from heart failure: the role of palliative care. Heart 2002; 88:ii36–ii39.
39. Clayton JM, Butow PN, Tattersall MH, et al. Randomized controlled trial of a prompt list to help advanced cancer patients and their caregivers to ask questions about prognosis and end-of-life care. J Clin Oncol 2007; 25:715–723.
40. Holland JC, Kelly BJ, Weinberger MI. Why psychosocial care is difficult to integrate into routine cancer care: stigma is the elephant in the room. J National Comprehensive Cancer Network 2010; 8:362–366.
41. Ben-Arye E, Israely P, Baruch E, Dagash J. Integrating family medicine and complementary medicine in cancer care: a cross-cultural perspective. Patient Education Counseling 2014; 97:135–139.
42▪. Deek H, Noureddine S, Newton PJ, et al. A family-focused intervention for heart failure self-care: conceptual underpinnings of a culturally appropriate intervention. J Adv Nurs 2015; DOI: 10.1111/jan.12768.

This article emphasizes the importance of shifting the focus on self-care strategies from the individual to the collective structure and process which is common in many cultural groups.

43. Back MF, Huak CY. Family centred decision making and nondisclosure of diagnosis in a South East Asian oncology practice. Psycho-Oncology 2005; 14:1052–1059.
44. Daly J, Davidson P, Chang E, et al. Cultural aspects of adjustment to coronary heart disease in Chinese-Australians: a review of the literature. J Adv Nurs 2002; 39:391–399.
45. Baker AE, Procter NG, Ferguson MS. Engaging with culturally and linguistically diverse communities to reduce the impact of depression and anxiety: a narrative review. Health Social Care in the Community 2015; doi: 10.1111/hsc.12241.
46. Sampson R, Cooper J, Barbour R, et al. Patients’ perspectives on the medical primary–secondary care interface: systematic review and synthesis of qualitative research. BMJ Open 2015; 5:e008708.
47. Kirchhoff KT, Hammes BJ, Kehl KA, Briggs LA, Brown RL. Effect of a disease-specific advance care planning intervention on end-of-life care. J Am Geriatr Soc 2012; 58:1233–1240.
48. Luckett T, Bhattarai P, Phillips J, et al. Advance care planning in 21st century Australia: a systematic review and appraisal of online advance care directive templates against National Framework criteria. Aust Health Rev 2015; 39:552–560.
49. Bullock K. Promoting advance directives among African Americans: a faith-based model. J Palliative Med 2006; 9:183–195.
50. Allen LA, Stevenson LW, Grady KL, et al. Decision making in advanced heart failure a scientific statement from the American Heart Association. Circulation 2012; 125:1928–1952.
51. Treloar C, Gray R, Brener L, et al. I can’t do this, it's too much’: building social inclusion in cancer diagnosis and treatment experiences of Aboriginal people, their carers and health workers. Int J Public Health 2014; 59:373–379.
52▪. Detering K, Sutton E, Fraser S, et al. Feasibility and acceptability of advance care planning in elderly Italian and Greek speaking patients as compared to English-speaking patients: an Australian cross-sectional study. BMJ Open 2015; 5:e008800.

This cross-sectional study with convenience sampling was conducted in Melbourne, Australia, and recruited hospital inpatients with medical decision-making capacity, aged 65 years or above, who spoke Greek, Italian or English and designed to assess completion of ACP discussions, their duration, advance care directive completion and utilization of interpreters. Investigators found that facilitated ACP in elderly Italian and Greek-speaking patients is feasible, acceptable and is similar to that for English-speaking patients.

53▪. Downing J, Grant L, Leng M, Namukwaya E. Understanding models of palliative care delivery in Sub-Saharan Africa: learning from program in Kenya and Malawi. J Pain Symptom Manage 2015; doi:10.1016/j.jpainsymman.2015.03.017.

This article reflects on palliative care in Africa. In 2004, only five African countries provided palliative care and now delivered in nearly 50% of African countries, yet 5% of people in need receive it. Considering how different models of palliative care interact within different health systems is important in determining efficacy and effectiveness.

54▪. Lewis JM, DiGiacomo M, Luckett T, et al. A social capital framework for palliative care: supporting health and well being for people with life-limiting illness and their carers through social relations and networks. J Pain Symptom Manage 2013; 45:92–103.

This review demonstrates that social relations and networks are vital for sustaining and enhancing end-of-life care. The social capital concept supports a framework to understand the association between social relations and well–being.

55. Hotson K, Macdonald S, Martin B. Understanding death and dying in select first nations communities in northern Manitoba: issues of culture and remote service delivery in palliative care. Int J Circumpolar Health 2004; 63:25–38.
56. McNamara B, Rosenwax L. Factors affecting place of death in Western Australia. Health Place 2007; 13:356–367.
57. Venkatasalu MR, Seymour JE, Arthur A. Dying at home: a qualitative study of the perspectives of older South Asians living in the United Kingdom. Palliative Med 2014; 28:264–272.
58▪. Sinclair C, Smith J, Toussaint Y, Auret K. Discussing dying in the diaspora: attitudes towards advance care planning among first generation Dutch and Italian migrants in rural Australia. Soc Sci Med 2014; 101:86–93.

This article emphasizes that Western cultural practices and values have largely shaped ACP policies across the world. Authors argue that the unique migration experience should be considered alongside culturally appropriate approaches to decision-making.

59. Fischer SM, Sauaia A, Kutner JS. Patient navigation: a culturally competent strategy to address disparities in palliative care. J Palliative Med 2007; 10:1023–1028.
60. McGrath PD, Patton MAS, Ogilvie KF, Rayner RD. The case for Aboriginal Health Workers in palliative care. Aust Health Rev 2007; 31:430–439.
61. Lewis JM, DiGiacomo M, Currow DC, Davidson PM. Dying in the margins: understanding palliative care and socioeconomic deprivation in the developed world. J Pain Symptom Manage 2011; 42:105–118.
62. Currow DC, Agar M, Sanderson C, Abernethy AP. Populations who die without specialist palliative care: does lower uptake equate with unmet need? Palliative Med 2008; 22:43–50.
63. Callaway M, Foley KM, De Lima L, et al. Funding for palliative care programs in developing countries. J Pain Symptom Manag 2007; 33:509–513.
64. Campion EW, Kelley AS, Morrison RS. Palliative care for the seriously ill. N Engl J Med 2015; 373:747–755.
65▪. Palliative Care for Older People: A Public Health Perspective; 2015; Gysels M. Van den Block L, Albers G, Martins Pereira S, Onwuteaka-Philipsen B, Pasman R, Deliens L. Cultural issues in palliative care for older people. 156–159.

The burden of chronic, progressive, life-limiting conditions is discussed within a context of providing appropriate symptom management and addressing socio-cultural factors.

66. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 2005; 112:e154–e235.
67. Page K, Marwick TH, Lee R, et al. A systematic approach to chronic heart failure care: a consensus statement. Med J Australia 2014; 201:146–150.
68. Quill TE, Abernethy AP. Generalist plus specialist palliative care: creating a more sustainable model. N Engl J Med 2013; 368:1173–1175.

cardiovascular; cultural competence; culture; palliative care; social ecological model

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