The Turkish terminal patient
The narrator tells us:
“I am working as a nurse in a hospice in Copenhagen. In the hospice, over the years, we have had many patients from other countries, especially patients of Turkish origin.
Among the patients, we currently have a terminally ill man of Turkish origin. The patient speaks very poor Danish. He himself is only able to communicate in a very restricted way because of his illness.
When the patient initially arrived to the hospice, he prayed on his knees every day, while the wife was sitting in a chair, reading. But now he is too weak to pray outside the bed. I never saw his wife or his daughter praying in the hospice. The family intends to bury the patient in Turkey.
Even though we had other patients with other cultural backgrounds, this family has actually given rise to many cultural challenges which are difficult to deal with.
Firstly, the patient´s wife is staying in his room around the clock, literally – except for small breaks when she takes a walk. As soon as she leaves the room, the patient starts calling for her. She insists on doing everything for her husband, with the exception of functions and activities connected with his intimate parts.
This indicates that the wife is sleeping in the room every night. When she goes to sleep, she takes off her veil (headscarf). Of course, in a hospice, we are watching the patients carefully and regularly checking on them during nighttime, as well as when we are called for.
Thus, it was really a shock for us to experience that our male nurses and colleagues were not allowed to enter the patient´s room during the night, while his wife was sleeping without her veil (headscarf). This reaction was completely unexpected for all of us.
The hospice is divided into 2 departments as part of the total structure. So, until now, we have solved this problem by asking a female nurse from the other department to attend the Turkish patient during nighttime. But when his condition grows worse, more consistent professional care is needed, and then we cannot always count on calling nurses from the other department.
Secondly, in addition to the wife, the three daughters, living in the Copenhagen area, visit their father in the hospice every day. Likewise, the fourth daughter, who is living in Africa, calls her father and the family every day from Africa.
In the hospice there is a small kitchen reserved for patients´ relatives. Each day the daughters of the Turkish patient are preparing dinner in this kitchen. Therefore, it is difficult for other relatives to use the kitchen. Thus, the other relatives turn to us, dismayed and complaining that they very often feel unable to use the kitchen, since the Turkish family leaves no room for others.
The Turkish family tells us that they, of course, would take the needs of the other relatives into consideration, “they just have to tell us”, they respond. The other relatives also argue that they do not dare to raise the issue in an open manner towards the Turkish family, because this may bring them into a position where they appear to be “racists”.
Thirdly, the daughter being a medical doctor, is very active in procuring supplementary tests for her father, insisting on providing him with supplementary medical treatment in another hospital, even though as a professional doctor she would know that this treatment is futile at this stage in her father’s illness. We never experienced anything like this before.
Finally, as professionals in a hospice, it is part of our professional work to speak with the patients about dying and advise them about this basic situation. In the case of this patient, we need to communicate through the family due to the patient´s linguistic capacity. This communication mainly involves his wife. She, on her side, is very much afraid of death. She tells us that she never saw a dead body.
Consequently, when one of the other patients in the hospice died, she actually asked the relatives permission to see the dead body in order to experience what a dead body looks like. This was, of course, shocking for a family in mourning – and it was also quite a surprise for us. We never experienced this kind of behaviour, and we certainly had not foreseen it.
1. Identities of the actors in the situation
The narrator works full time in the hospice. She has been working at the hospice for 6 years. Before this, she worked as a nurse in a hospital for 4 years and previously as a district nurse in primary care for 7 years. Furthermore, she originally trained in Sweden as a psychiatric care assistant.
The narrator is a female Swedish-born nurse with long-term experience within the medical field. She works full time in the hospice. She is 60 years old and lives with her husband, now retired. She is the mother of 3 adult sons, all of them living elsewhere. She is also a grandmother to 2 small children. She describes herself as agnostic with a strong humanistic mind. She loves nature and enjoys garden work. Nature is important to her.
The incident involves a family of Turkish origin, staying currently in the hospice due to the terminal illness of the family father. There is no particular information about the illness. What matters is that the man is dying and therefore transferred to hospice, where his family can be present as much as possible. The patient and his wife as well as the daughters are faithful Muslims. They have been in Denmark for about 40 years. They speak Danish, but the patient has, due to his illness, forgotten much of the Danish language.
The Turkish family consists of:
The terminal patient in the hospice, of Turkish origin, 78 years old. The patient is speaking very poor Danish due to his advanced and terminal illness. He is in a state where he can barely get out of bed by himself
The wife of the patient, of Turkish origin, 65 years old. The wife lives as a housewife, and she speaks very good Danish.
The 4 adult daughters of the family, 30-40 years old. It is unknown to the narrator, whether the daughters were born in Denmark or Turkey. However, the parents, the patient and his wife, have been living for about 40 years in Denmark.
One daughter is a housewife.
One daughter is a medical doctor
One daughter is a laboratory technician
One daughter is living in Africa, being though in close touch with the family in Denmark.
The other medical professionals involved in the incident include:
A number of hospice nurses and healthcare assistants from 2 different departments of the hospice. The staff members consist of both female and male nurses.
Other relatives to terminal patients admitted to the hospice:
A number of relatives of other terminal patients. Like the Turkish family the other relatives would generally spend a lot of time with their dying family members, thus also using the facilities provided for relatives and other visitors.
2. Context of the situation
The incident – or rather the parallel incidents – takes place in a hospice in the Copenhagen area.
The hospice is situated in a two-floor building. Each floor functions as a separate unity/department with a permanent staff. The hospice is organised in two units in order to obtain an intimate, quiet and tranquil atmosphere with a restricted number of professionals taking care of a restricted number of terminal patients and their relatives.
Each department of the hospice includes an apartment with living room and a small kitchen to be used by visiting relatives. It often happens that close family members and relatives stay with the dying person around the clock. But this is usually confined to the very last stage and phase of life of the terminal patients.
3. Emotional reaction
The narrator has previous experience with patients from other countries, and thus she feels herself experienced in dealing with cultural differences. She likes the Turkish family and feels respect for the care the wife and daughters show to their loved one, the father.
However, she is surprised, troubled and very much disturbed, when the wearing of religious symbols interferes with the execution of the professional work in a medical institution.
Likewise, she really finds herself in a dilemma when she, along with her colleagues, has to find a way to mediate between the daughters´ constant use of the kitchen and the needs and expectations of the other families. She is also afraid that her instructions about the common use of the kitchen may be perceived as a discriminatory act, due to the daughters´ ethnic-cultural background.
Finally, the narrator is dismayed that the daughter, who is a doctor, is interfering with the medical treatment and even makes arrangements with an outside hospital. She feels that the daughter fails to recognise and respect the professional competences of the hospice staff members.
4. Representations, values, norms, ideas, prejudice: The frame of references of the person who experienced the shock
Value: medical professionalism is prior to religious preferences and needs
The nurse is trained to help terminally ill patients, often during situations of emergency. In the Danish healthcare system, the performance of this professional practice has high priority and cannot be obstructed by any kind of religious – and in some respects not even private – needs, conditions and expectations. The medical care of patients is supposed to be the responsibility of professionals in the institutionalised welfare system. This also includes the value that the medical professionals have a high status which laity should respect.
Even though the Danish healthcare system and Danish medical professionals are increasingly trained to involve patients and relatives in care functions, the medical care is still a professional field. The professionals in a hospice are very experienced in handling families and relatives, but the relation of families and relatives are subordinated to the professional medical care. The Turkish family is in a way interfering with the professional hierarchy, procedures and expectations.
Firstly, the mother is almost “occupying” the patient, her husband, when staying around the clock from the very beginning of his hospitalsation in order to carry out as many caring functions as possible, thereby almost hindering the professional´s work.
She checks all food (Halal), holds his hand and keeps the room clean and tidy.
Secondly, one of the daughters directly intervenes in the professional treatment by prescribing supplementary treatment. By doing so, the daughter – in the eyes of the narrator and her colleagues – crosses a boundary between being professional and being a lay person. In their eyes, she is first and foremost a lay person who visits the hospice for private reasons, i.e. her father’s terminal illness. But she confuses two roles when she starts to act as a doctor. It is particularly a thorn in the side for the staff members, because she is indirectly questioning their medical assessment.
Value: Gender equality in the professional performance is prioritised above religious preferences and needs
Even though there still exists a more or less visible gender hierarchy in the Danish healthcare system, it is an official and law-based policy that all sexes have equal access to all professional positions. Thus, male nurses should be recognised of both colleagues, patients and relatives as equal to female nurses – and equally skilled.
Nowadays, this is accepted among most professionals and laymen. In the incident, the wife is opposing this basic value by denying the male nurses access to the patient during the nighttime, where she doesn’t wear her veil/headscarf.
Value: Respect to patient and family needs weigh heavily in the professional identity
Despite the high level of gender awareness, it is noteworthy that the staff members seek to meet the needs of the wife – and probably also the patient – when replacing the male nurses with female nurses during nighttime. There is a growing professional awareness that the needs and requirements of patients and their families should be met as far as possible. When it comes to the Turkish family’s needs, the staff is facing a dilemma because the fulfillment of the family´s needs are in conflict with basic professional principles of gender equality, but also the value of giving first rank to professional care rather than religious procedures.
Value: Death is a most private matter
In Danish society, death is generally considered to be a private matter, perhaps with the exception of very famous person with a public status. Death takes place, in a matter of speaking, in the private sphere and is reserved to family, close relatives and close friends. The privacy of death includes the dead body. This privacy and intimacy around the dead body is an expression of respect for the dead person. But it also implies elements of a kind of timid ritual, where the bereaved – usually only the closest family and relatives – have a last moment with their beloved one. Actually, most Danes pass away in their home.
The more public ritual around death is later expressed through the funeral ceremony where the dead body is hidden from the participants.
In the eyes of the professionals and the relatives of the dead patient, the wife in this incident is violating these common values and rituals surrounding death. She is doing so by asking if she can see the dead body in order to become more familiar with death as an existential condition she herself is about to meet and has never experienced. Thus, her practical and pragmatic approach is interfering with the privacy values and ritual approach of the professionals and other relatives. The professionals are also reacting from more private values and emotions in this situation.
Value: Sharing of common facilities prior to individual needs and preferences
It is often said that there is a cultural distinction between Western individualism and non-Western collectivism. Accordingly and generally spoken, Danes would be considered as individualists in ways of thinking and acting. But, at the same time, there are in general very strong values and norms about paying attention to other people´s needs in situations where you have to share common facilities. Although this value is changing with new generations, it is still considered by many people as ill-mannered if one does not share common facilities in a considerate and proper way.
Thus, the daughters exceed this standard for good and considerate behaviour, when they use the shared kitchen every evening, thereby preventing other relatives from cooking.
When the nurses tell the family, that other relatives sometimes feel that they cannot use the kitchen, the Turkish family responds that the other relatives just have to formulate their need, then the family is willing to let them use the kitchen.
From what the narrator tells us there is reason to believe that the Turkish family is actually prepared to make room for others in the shared kitchen. The family just doesn’t realise that other relatives need to use the kitchen, since the others never showed signs of this need. But the dilemma is that the Turkish family does not by themselves demonstrate this attention to the other families´ needs, even though these needs are not explicit. Thereby, Turkish family is unwittingly breaking an unwritten cultural and behavioural rule and value.
Individualism and collectivism in common goods
Thus, the incident reflects how norms and values about individualism and collectivism should not unambiguously be attributed to Western and non-Western cultures and groups of countries. On both a mental and practical level, both values may be found in different cultures, but generally on different societal levels. In the Turkish family, the collectivism is especially strong within the family framework. In the Danish families – and beyond in the Danish society in general – the collectivism is strongly associated to the welfare state concept of equality and the value of equal access. You must share the common goods, and one should not “usurp” the common goods at the expense of others. There is reason to believe that it is exactly this internalised concept of equality that the other families and the staff members enforce (or rather dare not to enforce) to the Turkish family.
Value: Formal acceptance of cultural differences based on political correctness is more important than interpersonal dialogue and exchange
The lack of communication around the kitchen may reflect values around anti-discrimination:
There is – according to the narrator – a certain fear among the other relatives to be accused of discriminatory behaviour if they complain about the family´s “occupation” of the kitchen day after day. This “reverse” discrimination approach is seen in other situations. The value of not criticizing people of other ethnic-cultural background – even if there are objective reasons for the objection – reflects itself in the fact that discrimination is a phenomena taking place in society. Apparently, it is important for both the staff members and the relatives to distance themselves from any suspicion of discrimination. Unfortunately, the result of this reluctance is that the Turkish family is actually exposed to both irritation, frustration and isolation.
Thus, in the wake of the general debates on diversity management, integration and inclusion, many people are reluctant to criticise persons with another ethnic background on concrete issues. The kitchen issue reflects this reluctance as well as the fear to be perceived as xenophobic.
In total, the actual need for equal access to the kitchen is subject to the value that one should not discriminate against people with different ethnicity and cultural backgrounds – resulting, eventually, in a real dissociation and irritation.
It is very important not to be accused of racism.
5. What image emerges from the analysis of point 4 for the other group (neutral slightly negative, very negative, "stigmatized", positive, very positive, real, unreal) etc?
The nurse and the other professionals in the hospice do, indeed, claim that they are fond of the Turkish family. The family members are described to be all very nice, polite and humble. The narrator basically respects the caring attitude of the family. She actually tries to negotiate on their behalf with the other families, concerning the use of the kitchen facilities.
Likewise, she and her colleagues are seeking practical solutions, so as to have only female nurses to attend the patient during nighttime – thereby finding compromises between the adherence to religious and professional practices and values. But even so, she is really shocked by the fact that a religious symbol interferes with the professional duties. To her it is not a sustainable situation.
Despite all the positive feelings, at the same time the narrator is surprised, disorientated, dismayed and even insulted that one of the family members – the doctor – goes against the hospice doctors´ assessment by seeking other alternative treatment for the terminally ill father.
Thus, the image is contradictory and basically ambivalent.
6. Representations, values, norms, prejudice: The frame of references of the person or group that is causing the shock / that caused the shock in the narrator
There is, in general, a close relationship across generations in Turkey. The adult children are supposed to take care of their parents, and they are supposed to respect the older generation.
The man and father is traditionally regarded as the head of family. Even if reforms have changed the position of women in society in many respects, most women are still far from the equality experienced, in general, by Danish women.
The women of this particular family of Turkish origin are prepared to do anything to help, support and take care of their husband/father. One of the daughters uses her professional position as a medical doctor to meet these values and norms, even though she thereby has to “mix” the professional and private identity. In reality, by this action, she is also as a medical professional in the Danish healthcare system violating her professional standards by sending the patient to another hospital for supplementary tests and treatments, knowing that this may be a useless effort towards her terminally ill father.
Thus, her actions in this situation may reflect the dilemma between her professional (Danish) assessments and values – and her traditional commitment to family values which are partly transferred from her parents´ origins in Turkey – and also partly being a part of traditional Danish family values – especially for daughters.
In summary, the women of the family are giving first priority to cultural-based, traditional values and norms, even though they probably are aware of the rules, values and practices in the Danish healthcare system, given especially one daughter´s own professional position.
Furthermore, they have no linguistic challenges or conceptual obstacles. Apparently, the family also gave high priority to education of the daughters. However, a core point may be the missing communicative – and thus probably conceptual – skills of the husband/father. It could be that the husband/father has a stronger attachment to traditional values and gender positions than the female family members.
In total, the family is stretched between different cultural values, norms and practices of both religious, gender-related and societal character. When death is knocking at the door, they tend to turn to the more traditional cultural values, perhaps, by doing so, to meet the strongest needs and expectations of the dying husband/father.
7. Does the situation highlight any problem concerning the professional practice, or in general about the respect of cultural differences in intercultural situations?
Strict adherence to religious beliefs, values and practices may in many cases interfere with the execution of Western professional healthcare functions.
The incident reflects that it is possible to find common solutions and negotiate compromises to a certain degree. But at the same time, it is necessary to deal with situations where those solutions and compromises are no longer possible, due to increasing acuteness of the health condition of the patient. Then the interaction between patients, relatives and professionals has to be taken to a new level of intercultural dialogue and mutual understanding.