The Factors That Can Affect An Individual

The factors that can affect an individual’s views on death and dying and include social factors, cultural, religious and spirit
I believe one's religion plays a big part. Many suicide bombers believe that if they fight the religious war and become a hero through death they will get many virgins as a reward in the afterlife. Therefore they don't mind killing themselves. Most people view the idea of death through the glasses of their trained religion teachings.

Death is a personal event that man cannot describe for himself. As far back as we can tell, man has been both intrigued by death and fearful of it; he has been motivated to seek answers to the mystery and to seek solutions to his anxiety. Every known culture has provided some answer to the meaning of death; for death, like birth or marriage, is universally regarded as a socially significant

Event, set off by ritual and supported by institutions. It is the final rite de passage. The social and psychological aspects of death have been studied by anthropologists, sociologists, psychologists, and psychiatrists; and the main outlines of their understandings can be summarized on three levels—cultural, social, and individual. The meanings which have been attached to death in most cultures include beliefs in some kind of existence after death; most peoples—save the no literate—have entertained theories of personal salvation; and religion, philosophy, and political ideology have provided some answers to man’s quest for the meaning of death. The relationship between death and the social structure has received little systematic attention from social scientists, although there is much research on the social prescriptions for bereavement, especially as these relate to ritualistic mourning and individual grief. Scattered empirical studies suggest that, for the individual in the contemporary Western world, matters of death are less salient than those of living, although there are clear traces of a latent and underlying ambivalence.

Spiritual, religious, and cultural beliefs and practices play a significant role in the lives of patients who are seriously ill and dying. In addition to providing an ethical foundation for clinical decision making, spiritual and religious traditions provide a conceptual framework for understanding the human experience of death and dying, and the meaning of illness and suffering Death is a personal event that man cannot describe for himself. As far back as we can tell, man has been both intrigued by death and fearful of it; he has been motivated to seek answers to the mystery and to seek solutions to his anxiety. Every known culture has provided some answer to the meaning of death; for death, like birth or marriage, is universally regarded as a socially significant event, set off by ritual and supported by institutions. It is the final rite de passage. The social and psychological aspects of death have been studied by anthropologists, sociologists, psychologists, and psychiatrists; and the main outlines of their understandings can be summarized on three levels—cultural, social, and ind

Adults experiencing a death feel a whole range of emotions including panic, shock, disbelief, hopelessness, irritability, isolation, and sometimes even relief if the death comes after a long, painful, lingering illness. They need time to go through different stages of grief. Just as with teens, adults may become depressed, and their physical and mental health may suffer. They also may worry about the practical effects the death will have on their life. For example, their financial security may change. Having friends who are good listeners and who offer practical help when needed can ease adults through difficult emotional times. Many people, both children and adults, find short term professional counselling and grief support groups helpful in understanding their emotions and knowing that they are not going through the grief process alone.

After death, virtually all religions and cultures perform some ceremony to mark the death and celebrate the life and memories of the person who has died. There ceremonies and rituals are very important to the survivors. Occasionally before a funeral can occur, an autopsy must be done to determine precisely the cause of death. Autopsies are usually done in the event of an unexpected death or where criminal activity is suspected. The idea of an autopsy may be very disturbing to the survivors.

During an autopsy, a specialist medical doctor called a pathologist examines the body and submits a detailed report on the cause of death. Although an autopsy can do nothing for the individual after death, the information it provides can benefit the family and, in some cases, medical science. For example, the link between smoking and lung cancer was confirmed from data gathered through autopsy.

10.Respect the physician's professional responsibility to discontinue some treatments when appropriate, with consideration for both patient and family preferences;
11.Promote clinical and evidence-based research on providing care at the end of life.

Cultural Aspects of Death and Dying

Posted by Marcia Carteret, M. Ed. in Cultural Health Beliefs + Behaviors, Special Topics

While the end of life experience is universal, the behaviors associated with expressing grief are very much culturally bound. Death and grief being normal life events, all cultures have developed ways to cope with death in a respectful manner, and interfering with these practices can disrupt people’s ability to cope during the grieving process. While health care providers cannot be expected to know the mourning ceremonies and traditions of each family’s culture, understanding some basics about how different cultures may prepare for and respond to death is important. Though difficult to ask, there are crucial questions that need to be part of conversations between doctors and nurses and families. For example:

What are the cultural rituals for coping with dying, the deceased person’s body, the final arrangements for the body and honoring the death? What are the family’s beliefs about what happens after death?
•What does the family consider to be the roles of each family member in handling the death?
•Who should the doctor talk to about test results or diagnosis?
•Are certain types of death less acceptable (for example, suicide) or are certain types of death especially hard to handle for that culture (for example, the death of a child – this example may seem too obvious, but in countries with high infant mortality, there are indeed different attitudes about the loss of children.)3

This list of questions is so important because patients and families should be viewed as a source of knowledge about their special/cultural needs and norms – but health care professionals sometimes are at a loss about what to ask under such trying circumstances. There is perhaps no area where reliance on cultural reference books is less useful. The degree of acculturation is absolutely paramount in determining the beliefs and traditions a family will follow when coping with impending death, post-death arrangements and mourning. While we can find many similarities across cultures, such as wearing black as a sign of mourning, there are always exceptions. In China, for example, white is the color of death and mourning. Part of why the degree of acculturation is highly significant is that blending belief systems becomes more pronounced in highly acculturated persons. There are places in the world where accommodation is made for multiple faiths. For example, in Nigeria there is a triple heritage of Christianity, Islam, and ancestor worship2. Similar blending can be found in Caribbean nations and Mexico where Catholicism can be mixed with indigenous folk beliefs like Voodoo and Curanderismo. Another layer of expectation comes with living in the United States culture and relying on the Western medical culture. The mix of cultural/religious attitudes and behaviors surrounding death and dying can become very complex indeed. And when a death actually occurs, some individuals suddenly choose to break with tradition entirely, often creating chaos within families.

What follows in this article are some important points of consideration, but the list is introductory in nature at best. There is a strong focus on religions because religion can be thought of as a cultural system of meaning that helps to solve problems of uncertainty, powerlessness, and scarcity that death creates. In placing death within a religious perspective, bereaved persons find meaning for an event that for many is inexplicable.1 (Each underlined heading is a link to further resources for readers.)

Monotheistic Religions: Especially since the events of 911 changed many people’s views of Muslims, it is important to be aware that Christians and Muslims both believe death is a transition to a more glorious place and both believe in the sovereignty of a God (Allah) in matters of loss and take consolation in phrases such as “Allah giveth and Allah taketh away.” Both are also faiths springing from a single scripture, founder or sacred place. Readings from the Koran or Bible are important parts of the recognizing the departure of a loved one from this life. Similarly, in the Jewish faith, there is the expression mourners recite a few minutes before a funeral begins: “The Lord has given and the Lord has taken, blessed be the name of the Lord.” Both Muslims and Christians believe in the afterlife and view worldly life much in terms of preparing for eternal life. In the Jewish tradition, the focus is on the purpose of earthly life, which is to fulfill one’s duties to god and one’s fellow man. Succeeding at this brings reward, failing at it brings punishment.

The traditions around death and dying differ greatly across all three major monotheistic religious systems (as well as within different branches of each faith, i.e. Jehovah’s Witnesses and Mormonism in Christianity). They are highly nuanced and very hard for outsiders to understand thoroughly. Key rituals and practices that differ widely between religions include the preparation of the deceased person’s body, the permissibility of organ donation, and the choosing of cremation vs. burial.

Ancestor Worship: The premise of ancestor worship is based on understanding that the course of life is cyclical not linear. Those who are dead may not be seen physically, but are alive in a different world and/or can reincarnate in new births. Ancestor worship in various forms can be found in many parts of the world and is very strong in parts of Africa and Asia. Many Native Americans and Buddhists alike believe that the living co-exist with the dead. A central theme in all ancestor worship is that the lives of the dead may have supernatural powers over those in the living world – the ability to bless, curse, give or take life. In some cultures, worship of the dead is important, and includes making offerings of food, money, clothing, and blessings. In China there is the annual observance of “sweeping the graves” and as its name denotes, it is a time for people to tend the graves of the departed ones. In Mexico, there is The Day of the Dead (Dia de los Muertos), a holiday that focuses on gatherings of family and friends to pray for and remember those who have died. The Day of the Dead is also celebrated by many Latin Americans living in the U.S. and Canada. The intent of the celebration is to encourage visits by the souls of the departed so that those souls will hear the prayers and the comments of the living directed at them. It makes sense that in cultures where ancestor worship is common, the acceptance of organ donation and cremation may be low.

Buddhism and Hinduism: Hinduism does not have roots springing from a single scripture, founder or sacred place. It is more like an umbrella term describing a set of philosophies and ways of life. Buddhism has a single founder, but the Buddha is not prayed to in the same sense as a God or Allah. Buddhism is also a set of philosophies for living. There are marked differences between the two, or course, but in both death is not seen as the end of life; it is merely the end of the body we inhabit in this life. The spirit remains and will seek attachment to a new body and a new “life” – in Buddhism it is called a “kulpa,” which is a unit of time. Where a given person will be born again is a result of the past and the accumulation of positive and negative action, and the result of karma. Followers of both traditions keep in mind the impermanence of life. The transition of a soul to a new life is very important so both traditions observe specific rituals at the time of dying and the handling of the body. The corpse of a Buddhist should not be touched for 3-8 hours after breathing ceases as the spirit lingers on for some time. Hindus believe the body of the dead must be bathed, massaged in oils, dressed in new clothes, and then cremated before the next sunrise. It follows that cremation would be acceptable in a faith where the soul will be released to find another body to inhabit.

Truth-telling to Patients: In collectivist cultures, the good of the individual is often so enmeshed with the good of the family or in-group that family members may have a greater say in health care decisions than the patient does in some circumstances. In many countries, family members may become very upset if a physician reveals bad news directly to the patient. Families and patients may place great value on the right NOT to know! This is completely at odds with the standards set forth in the Patient Self Determination Act http://en.wikipedia.org/wiki/Patient_Self-Determination_Act which secures certain rights legally for all patients in the U.S. The health care system needs to be flexible enough to accommodate communication patterns that look different from those within the informed-consent tradition which insists doctors and nurses tell patients everything. So, a key question in cross-cultural health care situations would be: Who do you want me to talk to about test results or diagnosis?

Expressions of Grief: In some cultures, showing grief, including wailing, is expected of mourners because the more torment displayed and the more people crying, the more the person was loved. In other cultures, restraint is expected. Rules in Egypt and Bali, both Islamic countries, are opposite; in Bali women may be strongly discouraged from crying, while in Egypt women are considered abnormal if they don’t nearly incapacitate themselves with demonstrative weeping. In Japan, it is extremely important not to show one’s grief for a number of reasons. Death should be seen as a time of liberation and not sorrow, and one should bear up under misfortune with strength and acceptance. One never does anything to make someone else uncomfortable. In Latino cultures, it may be appropriate for women to wail, but men are not expected to show overt emotion due to “machismo.” In China, hiring professional wailers may be customary in funerals, which may sound odd, but this was also a common practice in Victorian England.

Conclusion: For health care professionals, providing culturally sensitive bereavement/end of life care is understandably an issue of discomfort. Language and cultural barriers obviously compound the challenges of being professionally appropriate and compassionate. Patients and families may be in need of compassion, advice, and guidance from doctors and nurses, but often the realities of a given situation include a press for time and both physical and emotional exhaustion among providers and families. It happens – sometimes we simply fail, in the moment, to express sufficient sensitivity and warmth when critical decisions must be made. The clinical facts are immediate and demand logical linear thinking which is natural for those trained in the Western medical tradition. For many cultures, such a direct approach may seem harsh, and decisions about something like organ donation might be experienced as inhumane immediately upon death. The questions suggested in this article can be used to ease some of the communication challenges and facilitate more openness between health care professionals and families around death and dying. Of course they should be tailored to the context of a given situation

Level 2 Certificate in Understanding End of Life Care Introduction
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NCFE Level 2
Certificate in Understanding
End of Life Care
Part A
SAMPLE
Disclaimer:
All references to individuals, groups and companies contained within these resources are fictitious and do not relate to any person or company.
These learning resources and assessments have been reviewed and approved by NCFE as meeting the requirements of the Level 2 Certificate in Understanding End of Life Care. SAMPLE
Level 2 Certificate in Understanding End of Life Care Introduction
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Welcome to this Level 2 Certificate in Understanding End of Life Care.
Understanding End of Life Care
We hope you find all of the information contained in this resource pack interesting and informative. This learning resource and the assessment questions have been approved by NCFE as a great way to meet the learning outcomes for this qualification. (A complete list of the learning outcomes can be found on the last page of this resource.)
The course is made up of two parts (A and B). This is Part A which contains two units:
UNIT 1: Understand how to work in end of life care
UNIT 2: Understand how to provide support to manage pain and discomfort As you start to read through each page you will be able to make notes and comments on things you have learnt or may want to revisit at a later stage. At the end of each section, you will be asked to go to your assessment booklet and answer the relevant questions.
Once you have answered the questions go to the next section and continue studying until all of the assessments have been completed.
Please make sure that you set aside enough time to read each section carefully, making notes and completing all of the activities. This will allow you to gain a better understanding of the subject content and will help you to answer all of the assessment questions accurately.
Good luck with your study. Now let’s begin!
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Level 2 Certificate in Understanding End of Life Care Unit 1
Unit 1: Understand how to work in end of life care
Welcome to unit one.
This unit is split into four sections. These are:
Section 1: Different perspectives on death and dying
Within this section you will learn about:
• The factors that can affect an individual’s views on death and dying
• Your own views on death and dying
• How factors affecting views on death and dying can impact on practice
• How attitudes of others may influence views on death and dying.
Section 1: Different perspectives on death and dying
Section 2: Aims, principles and policies of end of life care
Section 3: Communication in end of life care
Section 4: Accessing support services SAMPLE
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Level 2 Certificate in Understanding End of Life Care Unit 1
The factors that can affect an individual’s views on death and dying Many different factors can affect an individual’s views about death and dying, and therefore their needs and preferences for their end of life care. These factors include:
• Social factors
• Cultural factors
• Religious factors
• Spiritual factors
• Psychological or emotional factors.
Social factors
Social factors that can influence peoples’ views about death and dying are:
• Age: Most young adults and adult people prefer to be cared for at home as long as high quality care can be assured and as long as they do not place too great a burden on their families and/or carers. However research has shown that some people, particularly older people who live alone (65 years onwards), wish to stay at home as long as possible, although they wish to die elsewhere so they are not alone when they die. Attitudes to death and dying can change over the course of a person’s lifetime. As people grow older, death becomes more relevant and people may become less comfortable discussing these issues.
• Gender: Gender is a factor in how people view death and dying because research has indicated that the greatest worry for females is being a burden to their family and carers, whilst males worry more about the financial implications of their death and dying for their family.
• Social attitudes to death: People tend to live longer and often die in hospitals or hospices, so death has become ‘hidden’ in today’s society. It is removed from everyday life and people become more reluctant to talk about it or plan for it.
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Level 2 Certificate in Understanding End of Life Care Unit 1
Religious factors
Q. What is ‘religion’?
A. Religion is an established system of symbols, beliefs, rituals and text shared by a community of faith.
A person’s religion can be an enormous source of support and strength for dying people and their families. In relation to end of life care, an individual’s religion may define how they deal with the process of dying, death and bereavement. Some religions believe in an afterlife, whilst some religions believe in re-incarnation. These beliefs will have an important effect on how they view their own death.
Cultural factors
Q. What is ‘culture’?
A. Culture in its broadest sense, refers to the worldview, values, norms and behaviour guidelines shared by a group of individuals.
Some of the cultural factors that affect peoples’ views on death and dying include:
• Culture may define how a person acts and grieves when death has occurred
– for example, in some cultures death is not viewed as the end but a new beginning. • Some cultures believe that open discussions about dying and death are disrespectful and impolite, whilst other cultures believe that speaking about death makes it ‘real’. SAMPLE
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Level 2 Certificate in Understanding End of Life Care Unit 1
Spiritual factors
Q. What is ‘spirituality’?
A. Spirituality is related to human needs for the meaning and purpose of life, hope, forgiveness, for acceptance and peace of mind.
There is close association between religion and spirituality, but even those without religious beliefs may have spiritual needs related to regret, the meaning, value and purpose of their lives. Ways in which spirituality can affect peoples’ views of death and dying include their feelings about:
• The meaning, value and purpose of their life. Some people may look back and feel a sense of pride in their life achievements. Some people may have regrets about their life, the things they wanted to achieve and never had.
• Important relationships they have had in their lives - for example; being a father, mother, a wife, a daughter. Their sense of well-being and purpose revolves around these roles.
• Any pets they may have had – giving them a feeling of being needed and loved unconditionally. • Leisure pursuits that have given them a sense of spiritual well-being - for example, music, fishing, the arts.
• Cultural, religious and family traditions. Some people view their spirituality as part of their religion, culture or family traditions and may experience feelings of longing for their family, culture or religion.
• Key life events which gave them feelings of well-being, happiness or achievement . Some people may focus on life events and view them negatively, feeling resentment, guilt or regret about past decisions.
Psychological or emotional factors
Psychological and emotional factors can influence how people view death and dying – in particular the experience of the recent death of a loved one. In these circumstances they are more likely to discuss issues around end of life such as planning and preferences.
As a care worker in end of life care, an important way to raise your awareness and understanding of individuals’ views on death and dying is to think about your own views and the factors that influence them.
STOP AND THINK!
Think about your own views about death and dying. What would be your wishes and preferences? What factors in your life have an influence on your views? This will help you to empathise with others.
!
Your own views on death and dying SAMPLE
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Level 2 Certificate in Understanding End of Life Care Unit 1
Activity 1: How views on death and dying can affect practice in end of life care
Review the information that you have learned so far and jot down some examples of how you think views about death and dying could affect end of life care practice.
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How factors affecting views on death and dying can impact on practice In today’s society death and dying are still taboo subjects not only for the public but also for many health and social care professionals. Many people have not seen a dead person. The care of the deceased is now commonly undertaken by funeral directors who perform the care tasks and rituals associated with caring for the deceased, whereas in previous centuries, this was undertaken by the family or the community. This has resulted in a lack of openness and discussion about death which has an impact on practice in the following ways:
• People fear death and the dying process
• Close relatives, or health and social care professionals may not be aware of the individual’s wishes and preferences for treatment and therefore not know how best to support and help them
• People may not want to discuss their funeral wishes
• People die without making a will because they think it is ‘tempting fate’
• There is a lack of public and professional discussion regarding the dying process and death
• There is a lack of knowledge and understanding of death, dying and the grieving process. SAMPLE
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Level 2 Certificate in Understanding End of Life Care Unit 1
Did you consider the following examples?
• Social factors, such as attitudes to different diseases, may lead to value judgements about dying and how people are therefore treated – for example, some diseases could be viewed as self-inflicted such as liver failure due to alcohol abuse, whereas a person dying from cancer may be viewed as just ‘bad luck’. • Social attitudes towards sexuality may lead to discrimination in end of life care. When people who are in a same sex relationship have not been declared in a civil partnership, they have no rights in relation to involvement in decision making and in some cases the funeral arrangements.
• Social attitudes to death as a ‘taboo’ subject may prevent people discussing and planning for end of life with care professionals.
• Cultural factors mean that end of life care workers need to be aware and sensitive to the different cultural needs of the person. The UK is a diverse society in relation to culture and ethnicity. Cultural factors also mean that care professionals must be more aware of language differences. If English is not the first language, the person may experience difficulties in accessing health care and understanding any information given to them.
• Religious factors impact on practice because the UK is not a purely Christian community. Healthcare professionals now need to have an understanding of the world religions in order to provide high quality end of life care and decision making. Religious factors also impact on practice because, for those with a strong faith, religious coping can result in less use of end of life care planning and less use of advanced decisions. People may view what is happening to them as the ‘will of God’.
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Level 2 Certificate in Understanding End of Life Care Unit 1
Activity 2: Attitudes towards dying
Use the link below to download a copy of, ‘Attitudes towards Death and
Dying in the East of England - Qualitative Report: Research to Inform the Development of Social Marketing Interventions on Palliative and
End of Life Care (Ipsos/MORI 2010)’. ww.ipsos-mori.com/Assets/Docs/Publications/attitudes-towardsdying- 2011-qualitative-report.pdf
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Key Fact
It is important not to make assumptions about a person’s perspectives on death and dying, but to undertake an assessment in order to be able to provide the person and their significant others with the support and help that they require. i CONGRATULATIONS, YOU HAVE NOW COMPLETED SECTION 1.
PLEASE NOW GO TO YOUR ASSESSMENT BOOKLET
AND ANSWER Q1 to Q4.
How attitudes of others may influence views on death and dying
The attitudes of others may influence an individual’s choices or perspectives concerning
Death and dying. The person who is reaching end of life may be influenced by others in
The following ways:
• The information that care professionals such as GPs, nurses and care workers tell them about their illness and its prognosis may influence people to make plans in the event of death.
• GPs and Practice and District Nurses can provide information on a one-to-one basis. Raising awareness, both of what is available and why it is important, could influence people to plan for end of life.
• Family, friends and significant others such as partners may have negative attitudes to their approaching death - for example, people who feel comfortable discussing death and their preferences may be prevented by relatives who are unwilling to engage in the discussion.
• Relatives can be reluctant to discuss plans for end of life as they do not want to consider a family member dying. Also, they sometimes prevent plans from being followed if they are not properly informed or supported.

Principles of Good End-of-Life Care
Good end-of-life care is based on the understanding that death is inevitable, and a natural part of life. As the final stage in a person’s life it is a uniquely important time for the dying person and their family and close friends.

The goals of end-of-life care are: to maintain the comfort, choices, and quality of life of a person who is recognised to be dying (in the terminal phase); to support their individuality; and to care for the psychosocial and spiritual needs of themselves and their families. Support for families, if needed, continues after death as bereavement care. End-of-life care also aims to reduce inappropriate and burdensome healthcare interventions and to offer a choice of place of care when possible.

What is known

There is a body of good evidence (mostly from the USA) which suggests that the factors that are most important to patients and families at the end of life are:
Pain and symptom management
Preparation for the end of life
Relationships between patients, family members and healthcare providers
Achieving a sense of completion.

Spiritual care is regarded as important by many patients and families at the end of life. Cultural differences also need to be identified and appropriately addressed.

The concept of satisfaction with end-of-life care has been studied in a recent systematic review. A number of aspects of patient and family satisfaction with care are identified in the literature; they are - accessibility, co-ordination, and competence of health care services, quality of communication and relationships with health care providers, personalisation of care, and support for decision-making. A meta-analysis of studies of end-of-life care showed that palliative care services improved satisfaction with end of life care.

Shared decision-making between clinicians and patients and their families is possible when all have an awareness of the patient’s approaching death. It increases the likelihood of a good death - one in which the patient’s needs, wishes and preferences can be addressed. [8] Reluctance by either clinicians or family to disclose information about a patient’s changing condition can worsen patient distress. Supporting patients’ and families’ acceptance of the inevitability of death is acknowledged as a central part of end-of-life care. [9] Discussing changing goals of care is an important part of this process. [10] The most common goals of care identified by patients as they approach the end of life are: to be cured; to live longer; to improve or maintain functionality / quality of life / independence; to be comfortable; to achieve life goals; and support for family / caregiver. [11] These goals may shift as patients become increasingly aware that their death is imminent.

Advance care planning aims to encourage people to consider, discuss, and document their future wishes for care – well in advance if possible. The impact of advance care planning is mixed, and uptake of advance care planning processes has not been widespread. In a very large US study of the impact of advance care planning on complex hospital care at the end of life, the SUPPORT trial, it appears that advance care planning did not significantly affect outcomes. However, there is also evidence from the SUPPORT study that a substantial minority of seriously ill patients wish to discuss their treatment preferences, and may not have the opportunity to do so. [12]

What it means in practice
The most effective end-of-life care is provided when there is skilful communication with patients and families about realistic goals of care, and attention to understanding the patient’s and family’s concerns [13-14] as well as competent symptom management.
In order to achieve the goals which are important to patients and families, and to provide good end-of-life care, it is essential to identify that a patient is imminently dying. [15]
It is sometimes difficult to identify when a person is close to the terminal phase with a prognosis of days to weeks but, where this is possible, this knowledge may be of great value to patients so that they can reorient their priorities. [15]

Core Principles for End-of-Life Care
Clinical policy of care at the end of life and the professional practice it guides should:
1. Respect the dignity of both patient and caregivers;
2. Be sensitive to and respectful of the patient's and family's wishes;
3. Use the most appropriate measures that are consistent with patient choices;
4. Encompass alleviation of pain and other physical symptoms;
5. Assess and manage psychological, social, and spiritual/religious problems;
6.Offer continuity (the patient should be able to continue to be cared for, if so desired, by his/her primary care and specialist providers);
7. Provide access to any therapy which may realistically be expected to improve the patient's quality of life, including alternative or non-traditional treatments;
8. Provide access to palliative care and hospice care;
9. Respect the right to refuse treatment;
10. Respect the physician's professional responsibility to discontinue some treatments when appropriate, with consideration for both patient and family preferences;
11. Promote clinical and evidence-based research on providing care at the end of life.