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How Has Our Culture Evolved Regarding Death and What Is the Impact of These Changes on Healthcare?

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Human cultural traits—behaviors, ideas, and technologies that can be learned from other individuals—can exhibit complex patterns of transmission and evolution, and researchers have developed theoretical models, both verbal and mathematical, to facilitate our understanding of these patterns

Many of the first quantitative models of cultural evolution were modified from existing concepts in theoretical population genetics because cultural evolution has many parallels with, as well as clear differences from, genetic evolution. Furthermore, cultural and genetic evolution can interact with one another and influence both transmission and selection.

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Although preserving life is a central goal of medicine, in the end, death is an unavoidable outcome. Professionals in palliative and hospice care, working within the landscape of death and dying, are able to provide insight into death-related experiences and have the opportunity to incorporate these experiences into their personal and professional lives. The ability for death to foster meaning in life has been attested to by wisdom traditions and palliative care professionals alike. The latter usually provide rich accounts of the struggles of dying individuals, and in some instances, accounts of individuals who discovered meaning and purpose within this landscape. Although an expansive body of literature has evolved exploring the spiritual and existential impact of death and dying, these studies focused predominately on the impact on patients and occasionally on family members. A small number of studies discussed the residual impact of end-of-life care within a localized group of health care providers; however, there is limited cross-sectional research explicitly investigating the long-term effect of death and dying on the personal and professional lives of individuals who are exposed to death and dying on a frequent basis

To address these gaps in the literature, this study explored the impact of death and dying on the lives of key leaders and frontline professionals in palliative and hospice care — individuals who arguably provide society and health care practitioners with the most authoritative discourse on end of life and its effect on life in general.

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With help and support from family, friends, and others in the community, many people can live their lives, while dying, with some or considerable independence from the health care system. Many, if not most, however, draw heavily on that system for care—and caring—in the form of clinical services, counseling, and practical assistance with both medical and nonmedical needs. Thus, while the role of family and community resources should be acknowledged and strengthened, it is also essential to understand how care systems serve patients well and poorly and to identify the system characteristics that contribute to poor care. Such understandings, which will depend on better data and research than now exist, will help provide the basis for steps to remove the impediments to good care and to fortify the foundations for reliably excellent care. In general, care systems—both as discrete organizations and as unevenly connected arrays of community institutions and services—require people (supported by facilities and processes) who are prepared to determine what care is appropriate, to arrange its provision, and to monitor performance for consistency with organizational and external norms. More generally, the committee heard some concerns from hospice or ganizations about the practices (actual or feared) of managed care organizations. One concern expressed to the committee involved the "micromanagement" by some HMOs of care for non-Medicare patients enrolled in hospice (Brown, 1983). Practices mentioned included denial of certification for appropriately intensive home care or for appropriate hospitalization for palliative care. Such practices have quality as well as financial implications. They may reflect that newer managed care organizations serving mainly younger patients are unfamiliar with hospice

Thus, just as those in fee-for-service medicine may need education about palliative care and hospice programs, so may those in managed care (Brown, 1983).

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In a word, a nurse must always remember that the focus should remain on the patient’s well being and recovery. It is necessary to understand that individuals will never be the same. A patient’s health status and treatment is directly influenced by their culture and it is this reasoning, which has been proven through testing and the development of theories that has led to the conclusion that culture cannot and will not be ignored. “Human diversity makes tolerance more than a virtue; it makes it a requirement for survival”

Healthcare will not suffice without negotiation, adjustment, and respect of differences. Transcutlural concepts in nursing care have made cultural competency an expected standard and it is the duty of every nurse to help maintain this standard.

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Brown, 1983; IOM, 1993a, 1996b, 1997; Miles et al., 1995; Jones, 1996b.

U.S. Bureau of Labor Statistics, there were 666,000 "degreed Human Services Workers" in 1995 (Gibelman, 1997)

42 CFR Section 418.70[e]

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