Dying the Good Death: Cultural Competence and Variance in Hospice Care

Home , Cultural variation, Death, Death and culture, Transculturation

Tapestries: Interwoven voices of local and global identities

Volume 8 Issue 1 Resisting Borders: Rethinking the Limits Article 9 of American Studies

2019

Lydia Koh-Krienke Macalester College, [email protected]

Keywords: Death, Hospice, Cultural competence, Culturally relevant, Pluralism, Universalism

Follow this and additional works at: https://digitalcommons.macalester.edu/tapestries

Recommended Citation Koh-Krienke, Lydia (2019) "Dying the Good Death: Cultural Competence and Variance in Hospice Care," Tapestries: Interwoven voices of local and global identities: Vol. 8 : Iss. 1 , Article 9. Available at: https://digitalcommons.macalester.edu/tapestries/vol8/iss1/9

This Article is brought to you for free and open access by the American Studies Department at DigitalCommons@Macalester College. It has been accepted for inclusion in Tapestries: Interwoven voices of local and global identities by an authorized editor of DigitalCommons@Macalester College. For more information, please contact [email protected].

Dying the Good Death: Cultural Competence and Variance in Hospice Care Lydia Koh-Krienke nun-chi. While I would still most likely be Introduction dying in my house, it may have a greater What do you want your death to significance to me as an act of “returning look like? home”. In both of these cases, I die a good I am at home, in a familiar bed with death, even though the setting and process may the nostalgic scent of simmering chicken broth differ. wafting up my nose. Four generations of my This paper will interrogate what it family surround me; the throng of means to “die well” by examining the grandchildren, too young to understand, play intersections between death and culture. with toy cars at my feet, and their laughter In America, we often do not engage with and shouts intermingle to create the cacophony the concept of death, and regard it as a that accompanies playtime. My mother and taboo subject. This mindset restricts us father, whom I am convinced will live forever, from having the necessary conversations stroke my forehead, their smiles lost in a sea about the culturally-specific ways in of a thousand wrinkles. I am old, but not so which we want to die. This may result in old that I cannot lift myself up in bed to a death that has little cultural meaning, survey the powerful dynasty of women, men, which we often equate with a life lived in and children I have created. I visualize my vain. Because of this, I claim that we must hard work in creating a more just and analyze culture and death through a equitable world in every single one of their pluralist, culturally relevant pedagogy in faces, and I feel good. I am ready to rest. order to fully understand what constitutes Amidst the chaos of grandchildren playing, a good death for a particular individual story swapping, and tear shedding, I quietly within a cultural group. I refute the slip away, laid to rest by the knowledge that universalist assertion that cultures are my family will continue to grow in number organized into a hierarchy, and and in strength as I watch over them. deconstruct this notion in favor of a If I was brought up in South Korea, pluralist, objective view of culture. I look where my mother’s family originates, I might specifically at a good death from Western visualize my ideal death differently. Rather and Eastern–specifically Korean-American than talking and laughing beside me, my –perspectives in an attempt to better family members might be performing imjong, understand the complexities surrounding and preparing me for my eternal life as an both. ancestor. I may have released the decisions In the second half of this paper, I about my life and death to my children, who argue that it is important to understand a know my preferences inherently through good death in a cultural context in order

to better serve the dying. I evaluate the diaspora from the homeland to the US tools that hospice care provides for a good beginning in 1903 onward, which death in both American and involves the physical crossing of nation Korean-American contexts, and deem our borders made difficult by xenophobic current hospice system to cater primarily legislation and racism. Another layer of to the Western notion of dying well. border crossing occurs out of the process Finally, I conclude that hospice has the of transculturation, or the mixing of two potential to serve as the nexus between different cultures, which gives birth to a cultural variation and death, and propose a unique culture distinct from its two theoretical model that would aid hospice predecessors. Finally, I explore the border clinicians in providing culturally between life and death, and how competent care. This paper will adhere to individuals negotiate this boundary the overarching argument that a good through culturally-specific traditions and death looks different in various cultural values. This analysis of borders is contexts, and that it is a hospice provider’s multilayered and multifaceted; we cross job to understand this. scale as we move through different borders, from a national context to an Methods individual. In this way, we study the The topic of death is not cultural underpinnings of death through traditionally thought of in an American an American Studies lens, and explore Studies context by the academic psyche. how these border crossings relate to our American Studies scholars push the nations, our communities, and ourselves. concept of death off for anthropologists and thanatologists to tackle, in favor of A Note on the Use of “We” more exciting topics. I disagree with this; I Throughout this paper, I use the believe it is essential to frame the death pronoun “we” when commenting on both process by American Studies because it Western American and Korean-American happens to everyone regardless of race, constructions of culture. I mean not to socioeconomic status, sex, or gender. It is hinder the reader’s understanding, but the great unifying factor in a nation–and a instead do so in an attempt to deconstruct world–that is set up to divide. While we the myth of singularity, which American may conceptualize the socioculturally culture often assumes when referring to a “correct” way to die within the context of culture or group. I will discuss this our own culture, we still must recognize concept further in later sections, but I say that death systematically crosses and even this now to bring my own positionality sometimes dissolves borders. into the foreground of my argument. I It is in this way that this project belong to both American and Korean explores borders, both in a literal and cultural attitudes; blood from the East and figurative sense. First, I discuss the Korean from the West flows through my veins,

and I have grown up both revering my culture, even though its importance in Korean ancestors and fearing American modern society cannot be understated. ghosts. My perception of death is colored How is culture created? Is it formed both by Western American and Korean through crossing borders, putting up cultural norms. If my act of claiming both walls, or a mix of the two? Is the defining Western and Eastern cultural characteristic of culture language, constructions as my own confuses you, ethnicity, nationality, or a conglomeration good! It is meant to. I welcome you to my of many factors? Are we a nation of ethnic world of cultural confusion with the hope enclaves, or a unified culture? that if you do belong to a single culture, Through asking these questions, I you can begin to understand the complex explore the different ways in which we processes of cultural blending and conflict. construct culture in American society. I I use “we” as a tool to add an additional give special attention to the formation of layer to my argument, a meta-narrative Korean-American culture and describe that reclaims my dual cultural identity how immigration has facilitated the from those who insist on categorizing me development of a culture that as belonging to one or the other. In simultaneously pulls from both of its writing this paper, I have created a space motherlands while creating unique values, to resist those comments that have traditions, and perceptions. By analyzing emphasized one part of my culture and the roots and migration patterns of reduced the other. I exist because of individuals belonging to a certain culture, cultural amalgamation, cultural conflict, we can better understand how its people and cultural blends: I am living, breathing interact with life and, the focus of this evidence of my argument. paper, death. In order to fully comprehend the Constructing Culture different mechanisms that Eastern and Defining Culture: Universalism and Western cultures use to negotiate death, Pluralism we must understand how cultures from Our increasingly globalized world different nations of origin interact with largely recognizes America as a nation the American psyche. First, I define composed of difference, and our history culture and discuss the two main views of reflects this. The intersections of universalism and pluralism that theorists colonization, immigration, importation, have adhered to from the 18th to 21st forced exile, and diaspora have created the centuries. I argue that universalism is American multicultural society in which inherently discriminatory, and therefore we now live. With this constant flow of describe the creation of a transnational ideas, languages, and Korean-American culture in a pluralist ethnicities, our colorful nation sometimes context. Finally, I expand on the concept struggles with the concept of defining of pluralism to claim that both American

and Korean-American cultures do not in the formation of new cultures and the exist as monolithic entities but as a transformation of existing ones. America’s spectrum of values that individuals cultural soil has the potential to be rich belonging to these cultures adhere to in and fertile for new cross-cultural different ways. relationships, even while racism, Like most things, to fully capitalism, and sexism often poison new understand the concept of culture, we growths. The idealism of American must follow its history, both in a linguistic culture, the great nation of difference, and sociopolitical sense. The word exists on the basis of cultural symbiosis; “culture” has its roots in the Latin colere, our singular, unifying culture is our meaning to till, cultivate, or farm. multiculturalism. Originally used in agricultural rhetoric, Not everyone agrees that different culture was adopted by social theorists to cultures existing in mutual harmony is a refer to the cultivation, tilling, or farming good thing. Some scholars, particularly of civilization instead of land (Yudice White European academics living in the 2014). These connotations of growth and 1700s, believed that some cultures had development gave way to our modern more inherent value than others, usage of the word. According to specifically citing a broad European American Studies scholar George Yudice, culture as the ideal to which all other culture is “intellectual, spiritual, and cultures should be measured (Yudice aesthetic development, [and] the way of 2014). This caused a schism in the life of a people, group, or humanity in accepted model of how Western social general” (Yudice 2014). Just as farmers theorists conceptualized cultural tend to their crops differently based on difference, which gave rise to two main their environment and species, so do we theories: the universalist and pluralistic tend to our own traditions, art, religion, views. A universalist is defined as one who and other products of cultural difference. believes in and perpetuates the notion of a Culture is malleable, something that cultural hierarchy in which some cultures humanity manipulates, feeds, and are superior to others. This view of culture transforms. is linked, perhaps inextricably, to the Historically, America has come to imperialism and nationalism (Yudice represent a geopolitical space in which 2014) that arose as an exercise in the different cultures have congregated expansion of European values and claims. through various means of migration – Universalists in the late eighteenth century both forced and willing. This viewed European culture as superior to all conglomeration has created a multicultural others, encapsulating “the best which has landscape within America, spaces where been thought and said in the world” people with different nations of origin (Yudice 2014). The universalist’s interact and create relationships, which aid superiority of traditions and values

invoked a strong sense of U.S. and In contrast, the pluralist view European nationalism; this ideal made rejects the perception of a hierarchy of harmful practices such as forced culture, arguing that “each particular assimilation and colonization permissible culture has its own value that cannot be in the eyes of White Anglo-Americans, measured according to criteria derived driven by overt sentiments of White from another culture” (Yudice 2014). saviorism and 19th century Manifest Instead of using a binary of superiority Destiny doctrines. and inferiority, pluralism analyzes culture Furthermore, the universalist view using a system of objectivity, defined as understood culture with a singular the perspective that views distinct cultural mindset. That is, universalists tended attitudes and practices simply as “either to obliterate difference or to differences. This objective attitude stereotype it through racist and imperialist towards culture is in direct contrast to appropriation” (Yudice 2014). This view universalists’ subjectivity, which allows the assumed that all individuals that fall into a individual’s own culture to fill the role of certain cultural group adhere to the norms the “superior culture” in this hierarchical and expectations of that culture. model. Universalism did not take into account As a reaction to discriminatory subcultures or the individuals that “reject” scholarship produced by universalist certain aspects of their culture simply academics, pluralists such as Franz Boas, a because they adhere to other value German-American scholar well systems. Today, most scholars and indeed, acquainted with the blurred line between most people accept that language, fascism and European imperialism, began ethnicity, race, gender, and a multitude of to confront the racist undertones of other social factors modulate the lens universalism in 1928, exposing this view’s through which an individual perceives the tendency to foster prejudicial imperialism world, and can thereby affect the ways and blanket overgeneralizations (Yudice one interacts within the dominant ideals, 2014). Boas recognized the harm of traditions, and values of a culture (Yudice grouping individuals of a certain ethnicity 2014). Universalists, however, discount or nationality within a singular culture, diversity and maintain the perspective that which glosses over the nuances and all individuals interact in a singular way complexities of human life. As an early with a dominant culture. By painting with pluralist, Boaz equated universalism with this broad of a brush, universalists operate racism in part because of this under the assumption that all people overgeneralization, and also because of the within a culture can be viewed through a violent undercurrents of hierarchy that singular lens, which as we will discuss in gave way to colonization, forced the next section, is not the reality of assimilation, and soon after these, cultural belonging. extermination. By the 1950s, largely due

to Boas’ scholarship, pluralism had made involvement, many American soldiers headway as a socially legitimate married Korean women while stationed examination of culture and difference. there. US legislation such as the The pluralistic view of culture is McCarran-Walter Act and the War Brides valuable not only because of its usefulness Act of 1946 (Chan 1991) eased entry for as an objective tool to measure cultural those Korean wives and children of US difference, but also because it opens the soldiers to assist in the reunification of idea of national culture to include a wide families (this legislation contradicts the variety of interpretations. As Yudice states, current US policy of separating families at “cultures [can] no longer be imagined as the US-Mexico border: America is a circumscribed by national boundaries” backwards State). Finally, we are living in (2014). With this broadened, pluralistic the third major wave of Korean view of culture that rejects immigration. Beginning in 1965 with the overgeneralizations based on nationality passage of the Immigration Act (Chan and ethnicity, we can analyze specific 1991) and continuing to this day, Koreans cultures through new lenses. Next, I will currently make up 3.8% of immigrants to specifically look at the people who belong the United States. The Immigration Act of to Asian-American cultures, and examine 1965 not only removed severe restrictions the process of cultural creation as it relates on immigration, but also lifted to the Korean-American identity. national-origin quotas that allowed more Koreans to cross the border and remain in The Formation of Korean-American Culture the US. This third wave of immigration is The formation of the largest, and is the reason for the Korean-American culture begins with the existence of many Korean-American Korean diaspora to the United States. This families. consisted of three major waves of The flow of culture paralleled the immigration instrumental in establishing movement of people from Korea to the this new facet of American culture. The US. Americans, however, largely adopted first, occurring from 1903-1905, was due the universalist view of these individuals, to male Korean laborers entering Hawaii and have lumped Koreans with all other to work on sugar plantations (Kim & Lee Asian-American cultures. Western 2006). 1951-1964 marked the second, America makes no distinction between the which consisted of Korean wives of US old, storied, and diverse histories of soldiers, war orphans, and students (Kim Chinese, Japanese, Korean, Indian, et al. citing Hurh 1998). Because of the Taiwanese, Vietnamese, and the myriad of Korean war (1950-1953), many immigrants from Asian-origin individuals immigrated during this time backgrounds, all with unique and vibrant period to escape persecution and violence. cultures. Evidence of the American In addition to this, because of US perception of the “Asian collective” in the

US can be found in census records and specific Asian-nation-American identity is testing categories, where these individuals an amalgamation of American and their from starkly different cultures and nations Asian country of origin’s values. The must check a singular box: cross-pollination of these two cultures “Asian-American” (United States 2017). results in the creation of a new distinct Lisa Lowe, professor of American Studies identity and culture. Major streams of at Yale University, studies this erasure of cultural variation, Lisa Lowe argues, serve distinct cultural difference in the to sweep away the facile notion of the Asian-American experience by directly Asian-American culture as a singular confronting universalist perceptions of identity. One distinguishing element from Asian-Americans, such as the one the pluralism toolbox is how exclusion and highlighted above. She disrupts the notion resistance have shaped different Asian of the “Asian-origin collectivity” by experiences in America. Difference in describing factors that contribute to national origin as well as generational cultural schism in individuals of Asian relation to exclusion policies such as the descent. The universalist perception of an 1882 Chinese Exclusion Act, legislation overgeneralized Asian-American culture, prohibiting the immigration of Chinese Lowe writes, is complicated not only by laborers as a reaction to violence and the different nations of origin, but also by loss of American jobs, and its subsequent “intergenerationality, by various degrees repeal through the Magnuson Act of 1949 of identification with and relation to a (Lowe 1996) contribute to the different ‘homeland,’ and by different extents of ways Asian-origin individuals interact assimilation to and distinction from with culture formation. ‘majority culture’ in the United States” In addition to this, mechanisms of (Lowe 1996). In true pluralist fashion, she combating forced assimilation have varied rejects the construction of dominant and across generational gaps, leading to minority positions that cultures occupy, difference in forms of cultural resistance. and argues that difference within the K. Scott Wong, professor of American Asian-American identity–by age, by Studies at Williams College, links Mary country of origin, by the number of Louise Pratt’s definition of transculturation generations one is distant from an Asian to these forms of resistance, referring to homeland experience–forces us to refuse Asian-origin immigrants’ process of superiority politics as well. “select[ing] or invent[ing] from materials In addition to the construction of transmitted to them by a dominant or Asian-America culture as a singular entity, metropolitan culture” (Wong 1999). This we can go one level deeper and discuss the process of transculturation connects back universalism present within a singular to Lisa Lowe’s notion of the formation of nation of origin, such as the an Asian-American identity that is distinct Korean-American identity. For many, a from both an Asian and American

experience. Here, Wong proposes that surrounding our own mortality are often Asian-origin immigrants do not simply dictated by our cultural beliefs or by our assimilate directly into American culture, rejection of them. nor do they live according to an Asian If you are skeptical, take a look at cultural silo in America. Rather, the American popular culture. The hopes and Asian-origin immigrant takes pieces of fears of death most of us feel in American American culture and weaves them along society are reflected in popular culture with threads of their home culture into a such as music, TV shows, and social new cultural identity. media. While these all portray a This also invokes a theme of dramaticized and idealized version of autonomy: the analogy of culture as a death, they reveal what our vision of a farmer cultivating his crops paints an “good death” looks like. Popular culture immigrant assimilating to a culture as a mirrors the yearning many of us keep coerced act. The farmer regulates the locked deep inside of us to die in a growth of his crops through where he particular way, in a particular plants them, how he manipulates the environment, beside particular people. vines, and what branches he chooses to cut This varies from culture to culture, off so that all his crops can grow in especially within the United States. As Lisa harmony. Applied to immigrant Lowe and K. Scott Wong explain, many populations, this analogy suggests that Asian-American cultures do not individuals that have crossed the American completely assimilate to American culture, border need to be clipped, trimmed, and nor do they exist in siloed cultural states trellised to fit the cultural mold of an based on their nation of origin. Rather, American citizen. Lowe’s and Wong’s the Asian-origin immigrant creates a new perspective of an Asian-origin immigrant cultural identity, and with it comes new specifically choosing which cultural formulations and conceptualizations of traditions and values to adapt to and death. In this section, I will discuss the mixing them with their home culture intersections between culture and death pushes back against this notion, and for both Western and Asian-origin returns the power to the immigrant. societies, specifically within the United States and Korea. Intersections of Culture and Death As we discussed in the last section, A Western Perspective our culture shapes our lives as we grow In this section, I identify three and develop, and influences us through main themes in the American death culturally specific norms and traditions. It process that stem from Western cultural is in this very same way that culture shapes values. First, I present the paradox of our our experience of death as well; our simultaneous fear of and addiction to the thoughts, feelings, anxieties, and doubts concept of death in American society. I

then move to a discussion of the way an effective solution to conflict. Our many Americans deny their own spending certainly reinforces this: the US mortality, subconsciously or consciously, defense budget matches the rest of the as a mechanism to subvert their anxiety of world’s military spending put together death. Finally, I examine the factors that (Tierney 2011). cause American society to place such a With war comes the inevitability high value on autonomy and dignity in of death. War steals the lives of soldiers the dying process. Again, I want to echo and civilians alike, and systematically Lisa Lowe and K. Scott Wong by saying operates to annihilate for the simple goal that Western culture is not homogeneous; of power attainment. This begs the many individuals do not adhere to these question: does the American love of war conceptions of death, just as they do not translate to a love of the death of others, adopt all Western norms and values. and even ourselves? America indoctrinates However, I attempt to interrogate broad our soldiers with the lesson that dying for cultural themes that dominate most of one’s country is honorable, puts the fire of America’s notions of death, and eventually nationalism into their eyes, then hands arrive at the larger, overarching question them a gun and nudges them into artillery of cultural accessibility in hospice care. fire. Is this not reflective of a clear-cut love If we look at America purely from of death? an international standpoint, it would This question does not fully appear that America has a love affair with capture the nuances of America’s death. American involvement in war has relationship with death. Again, these dominated our history; we have been at sentiments of America’s apparent war war as a for nation 225 years since 1776, obsessions are rooted in culture. Because and at peace less than 20 years out of 242 we have been a nation at war for so many (Charpentier 2017). Since the nation’s years, we inherently live in a war culture. birth, our continual involvement in Those who are 16 years old and younger wars–many of them not our have not yet seen America at peace in own–comprises 93% of our history, not to their lifetimes (Byron 2017), and have thus mention the previous violence and killing grown up with war as a constant that that accompanied our colonization and shapes and impacts their cultural identity. occupation of Native land (Charpentier In addition to its relationship with death, 2017). Andrew Mitrovica writes that if war amplifies nationalistic sentiments to you were to throw a dart at a globe, their extremes. This refers not only to the “chances are it will land on a country love of one’s country but also to the permanently scarred by America’s long, greater feeling of being part of a greater irresistible compulsion to wage war” whole for which it is heroic to die (Seale (Mitrovica 2017). These statistics suggest 2009). that America values the concept of war as

In reference to our own personal increase, especially for males in college deaths, not our killing of others, we (Lehto & Stein 2009). idolize dying for the “cause” our culture Death anxiety can stem from imposes on us, even though dying in the multiple sources; first and foremost it is an name of America may not, in reality, adaptive survival technique. In the human make much difference. This extreme form brain, the amygdala region in the of nationalism gives our death purpose, temporal lobe houses implicit or which is part of our conceptualization of a unconscious feelings of fear, while the “good death,” a concept I will explain in hippocampus regulates explicit fear the next section. American culture’s memories (Lehto & Stein 2009). In other emphasis on nationalism is inextricably words, the chemicals in our brain regulate intertwined with our culture of war, our anxiety of death. The way we which affects our perceptions surrounding generate death anxiety is therefore death. Therefore, a satisfactory answer to relatively constant throughout humanity. the question posed above would be that It is the ways in which we deal with our because our culture has been shaped by fears of our own mortality that are our constant state of war, we glorify our culturally regulated. American society own deaths if they serve a nationalistic recognizes death as an interruption or an purpose. incompatibility with life (Seale 2009). We Our apparent addiction to war and largely perceive the process of death as an its relationship to the idea of dying in the ending, as a force that takes away our name of nationalism sets up a future plans. As we perceive ourselves to contradiction in modern culture. While approach closer and closer to our own we commit acts of war often, which deaths, a concept many refer to as death always results in American deaths, we salience (Tomer & Eliason 1996), our level foster a simultaneous cultural fear of our of death anxiety changes. As death own mortality. Scholars in the field of becomes more salient, we begin to thanatology, or death studies, refer to this inventory our lives, and take stock of how as death anxiety, most often characterized much–or how little–we have as the “negative emotional reaction accomplished. This either increases or provoked by the anticipation of a state in decreases the amount of death anxiety we which self does not exist” (Tomer & feel, depending on our exposure to and Eliason 1996). Most of us, not just in relationship with death. This process of American society but in the world at death anxiety, of course, varies widely large, experience death anxiety. In fact, a across individuals and is developmental theory of death anxiety context-dependent, but is a prevalent suggests that there are certain periods in theme in American perceptions of dying. life where death anxiety is expected to While the literature shows the causes of death anxiety are mostly

biologically and socially constructed, the denial of our own mortality in the United ways we negotiate and perpetuate this States. This stems from the American anxiety are largely cultural. For instance, cultural dichotomy of the veneration of referring back to the American love of youth and the complete disregard for the war, we mediate our fear of our own elderly. Once again, we can turn to mortality by ensuring our own survival at popular culture to find evidence of this all costs. In a somewhat gruesome claim, phenomenon: advertisements for Clive Seale states that in Western culture, wrinkle-remover, hormone injections, we bizarrely equate killing others as our and cosmetic surgery pervade the media. own immunization over death (Seale We market almost exclusively to young 2009). people, and if an older population is the Our war culture perpetuates the targeted consumer, the product is usually assumption that the more individuals we in some way to remove all signs of age kill, or the more deaths of others we from the body. The anti-aging industry is observe, the less salient our death booming because we as a culture have no becomes. We distance ourselves from our place for the elderly. In a society that own mortality through the same process places such a high value on efficiency and of “othering” that universalists use to productivity, we do not have time to slow separate entire cultures from one another. down for those whose bodies cannot Although we are in close proximity to function as fast. As soon as a population death—in the case of war, we may even be becomes elderly we value them less the ones doing the killing—we have because, according to American culture, developed the distinct cultural ability to they no longer have the capacity to put up false barriers between us and the produce, and thus becomes useless (Peters dying. Therefore, our culture of war has et al. 2013). We shuttle them off to inverted our sense of death salience: even nursing homes, where they can live out though we are so close to death, our the rest of their days hidden from the personal mortality is far removed. public eye. American culture has become so saturated This only perpetuates our denial of with images of death and violence that we our own death: if we do not interact with have become desensitized. Our death the deaths of the hidden elderly and the anxiety, in this case, has decreased because evidence of our own mortality, it becomes of death salience, a phenomenon that our less salient to us, and we no longer have to war culture has produced. This serves as engage with our own death anxiety. In evidence to support my claim that death their study of nurses caring for the dying, anxiety, in response to our proximity to Peters et al. found that the level of death death, is culturally regulated. anxiety among nurses was mediated by A second way we negotiate death older age and length of practice (2013). anxiety in a cultural sense is our systematic Nurses with more exposure to death had

less death anxiety, presumably due to their Oken et al. found in a study of doctors acceptance of death as a natural part of life. treating terminally ill patients that 88% of Again, we see a shift in death anxiety due them would not inform their patients of to death salience; just like in war culture, the imminence of their death (1961). This nurses’ proximity to death decreases their underlines an important motif in fear of it. This is mirrored by society’s understanding American culture’s need to removal from and consequent heightened always reorient individuals’ thoughts from fear of death due to our treatment of the the possibility of death towards the elderly. Our mechanism of ignoring our confirmation of life. fear in order to cope with death anxiety The final way I discuss Americans’ remains the prevalent attitude in America, systematic denial of our own mortality is even though evidence (Peters et al. 2013) the way we treat the already dead. For supports that increased exposure to death many Americans, the funerary will likely decrease fear. tradition—an interesting topic in itself, Westernized cultures tend to which is for another paper—represents a construct the idea that life is always space to process, engage with, and mourn preferable to death (Seale 2009). the death of a loved one. However, once Therefore, we tend to steer individuals we have properly packaged someone’s away from things that remind us about death through the bereavement process, mortality, including those who are close which takes varying lengths of time for to death, labeling these thoughts as different people, then “little by little the morbid, grotesque, or socially dead cease to exist” (Seale 2009). We may unacceptable. We “conceal the sick and construct monuments such as grave sites the elderly from view for the protection of or urns filled with the dead’s ashes, but [society’s] members from death these function in remembering an awareness” (Seale 2009). In doing this, we individual’s actions in life, not death. not only perpetuate our culture’s denial of Indeed, for many Americans the death, but we also may be inflicting harm individuals that die exist exclusively in the on those for whom death is particularly past, while their present state is one of salient. This includes the medicalization nonexistence. and institutionalization of dying people; The one caveat to this is our because of our cultural need to preserve treatment of ghosts in the United States. life at all costs, we are often unable to Often invoked in horror movies and accept the reality that every human will depicted as frightening beings, ghosts are eventually die. Even amidst terminal the one personification of the dead that illness, many dying people still search for a secular America accepts (along with cure with their doctors egging them on, zombies and undead). Originating in even if they do not believe in their Christian and pagan beliefs that sinners patient’s chances of survival. In 1961, would return from hell as ghosts to

admonish and threaten their family derived from sociocultural ideas that members if they did not adhere to God’s Western society has grown to value and rule (Seale 2009), the modern American cherish. Many individuals belonging to conceptualization of ghosts exists this cultural group deviate from this idea, primarily to serve as a source of especially if we take religion into account. entertainment. We construct ghosts as I present this simply as a manifestation of violent harbingers of horror and murder, the dominant ways in which America but in reality brush them off as simply converts death into a series of acceptable fantasy. In this way, we give the dead in processes that are culturally palatable. modern secular American society little to The first, and perhaps the most no power to impact the lives of those still critical prerequisite Americans need in living (Seale 2009). This, along with the order to die a good death is autonomy. other elements of death anxiety and denial We set up an unrealistic negotiation with of death, varies by culture, which we will death that if we are all eventually going to explore in sections to come. die, we at least reserve the right to choose how it happens to us. Our defense against The Good Death: A Western Construction our fear of death is control. If we can Now that we have discussed the regulate the ways and the rate at which popular American cultural values death affects us, then we can somehow surrounding mortality, we can begin to tame the wild and unruly processes of construct the Western idea of what death. This sentiment reaches back to the processes constitute a “good death”. The early 1400s, with the publication of Ars Institute of Medicine characterizes a good moriendi (the art of dying). An ancient death as one that is “free from avoidable Christian prescriptive protocol detailing distress and suffering for patients, families, the processes necessary for dying well, the and caregivers, [and] in general accord Ars moriendi were crucial in the creation with patients’ and families’ wishes” of the “tame death”, in which death (Emanuel & Emanuel 1998). What is operated with “indifference, resignation, missing from this definition, however, is familiarity” (Barrett 3). The docile and the cultural aspect; just like different even compliant nature of this kind of societies’ perceptions of death vary death allowed individuals to get their depending on culture, so too do the affairs in order, say goodbye to their notions of what a good death looks like. family members, and “die happily ever Here, I discuss the three themes of after” (Barrett). Especially in our current autonomy, dignity, and relief from political climate of mass shootings, hate suffering that, according to the literature, crimes, and hot-headed presidents, we fulfill the American social requirements crave autonomy over our own mortality. for dying a good death. Again, it is Current events increase our death salience important to recognize that these are and anxiety, and we clutch at the idea of a

controlled death in the midst of chaos. above all else. These are the pillars of our While other cultures certainly feel the economy, as well as how we measure desire to choose a particular method of success. We fetishize the “self-made man,” dying, the strength to which we value and often condemn those who rely on the individualism makes the way we adhere to support of the government or their the notion of control distinctly American. communities as lazy. Furthermore, we Intrinsically linked to autonomy is often understand a loss of dignity as a loss the concept of dignity. The renown of self. This plays into the death anxiety philosopher Immanuel Kant said that “all that is ubiquitous in American society; the human beings have dignity in virtue of thought of losing our control over our their humanity, that is, their capacity for own consciousness is so paralyzing autonomous action” (Gentzler 2003). because of the high value we put on Americans, by extension, conclude that if autonomy and free-will. We reconcile this we lose our ability to act autonomously, fear through claiming control over our our lives no longer have dignity. This is deaths, which reaffirms our autonomy as the operating principle behind the well as our level of dignity. Oregon Death With Dignity Act of 1997. Finally, we determine the quality This piece of legislature, beyond the of our deaths through the context of legalization of physician-assisted death, suffering. In secular America, we equate ushered in a new era of autonomy in the suffering with pain, and brand it as dying process (Gentzler 2003). Patients something to be avoided at all cost. A now had the legal authority to make the major component of the Death with decision to end their own lives Dignity movement, as mentioned in the prematurely, which allows an individual last paragraph, is not only to preserve not only to control when they die, but autonomy, but to alleviate unbearable and how they die. needless suffering. This offers somewhat The Death With Dignity Act as of a “narrow medicalized view of well as Kant’s theory of innate autonomy suffering, solely defined as physical highlight the perception that death discomfort, [and] ignores or minimizes without autonomy is undignified, and [its] broader significance” (Charmaz therefore is constructed as “bad” according 1983). The broader significance of to American cultural standards. This view suffering, as Charmaz describes, is a loss of stems from the European concept of self-identity that she argues is critical to individualism, or the right to one’s the dying process. Suffering is not only a God-given freedom as an autonomous presence of pain, she argues, but also the being to act according to free-will and absence of a form of self, the notion that desire (Rodriguez-Pratt 2016). one has a place and purpose in the world. As a culture, we believe in the To lose one’s self is to categorically blend power of self-efficacy and independence into a collective sea of consciousness,

which is undesirable for us as Americans. traditions not necessarily as a product of Again, because of the traditional American assimilation, but rather as a function of K. emphasis on autonomy and independence Scott Wong’s concept of (Charmaz 1983), we do not want to let go transculturalization that occurs when two of the aspects that make us unique cultures come into contact. In this section, individuals, and separate us from the I will first lay out traditional Korean collective. A death with suffering, perceptions of death as they exist in South therefore, can be characterized as “bad”, Korea. Then, I will construct the idea of a not just because of the physical discomfort good death in the Korean-American that accompanies pain, but also because of context, to underline how Western the loss of identity that suffering influences have impacted the engenders. This leads us to characterize a conceptualization of a good death. Here, I good death as one with as little suffering place the conceptualization of a good as possible, in order to keep our autonomy Western death into conversation with a intact even through the death process. good Eastern death according to Korean cultural traditions, because this is how An Eastern Perspective they exist in America: not as siloed I have focused, up to this point, on microcosms with ethnic boundaries, but as the intersections between Western culture living, breathing cultures that interact, and and the death process primarily for sometimes clash, with one another. Americans. As noted previously, this The first, and perhaps most population is not a correct representation prominent, theme in the Korean of the racial and cultural amalgamation consciousness surrounding death is filial that is America. As immigrants flood from piety. Defined as the “moral obligation of different parts of the world to this global an adult child to respect and obey one’s nexus we call our nation, it is important to parents and provide support for them in recognize that different cultures place old age,” (Kwak & Salmon 2007), this value on different traditions and ideas, cultural belief sets up power hierarchies especially when it comes to the dying within the family, and ensures that the process. I will demonstrate this through an elderly are not forgotten by those analysis of the cultural products belonging to the younger generations. surrounding death that Korean-origin Even in adulthood, children are expected individuals create, and contrast the to obey their parents as a form of respect Western beliefs I have laid out with the and reverence. Adherence to this cultural Eastern. While many of these traditions norm results in extended families all living originate in the motherland of South together under one roof, which allows for Korea and have been maintained intergenerational relationships and throughout the immigration process, some “reciprocal caregiving”, where the role of have also been adopted from Western caregiver is reversed from parent to child,

sometimes at multiple points during one’s ceased carrying out life processes (Horlyck lifespan (Kim et al. 2006). This principal & Pettid 2014). in Korean culture fundamentally While Korean folklore does contradicts the Western practice of include evil spirits such as the ghosts that isolating the elderly from mainstream life murder and frighten us like in Western in order to deny the reality of death. culture, the dead largely function as Koreans venerate the aged not only benevolent ancestors that continue to because we feel a moral obligation to do regulate the conditions of life for those so, but also because we value the wisdom that they love. In exchange, post-death and familial bond that we share with our ancestor veneration remains a critical elders. This does not necessarily mean that piece of Korean culture. Celebrations such Koreans are less afraid of death; death as 추석 (chuseok), a three-day cleaning and anxiety crosses cultural barriers, national honoring of the ancestral shrine, and daily borders, and is felt nearly universally in prayer permeate Korean culture in return our world (Kwon 2006). The difference is for the gifts and blessings that our that Eastern and Western cultures face this ancestors rain down upon us. Ancient fear in different ways. While Americans Korean culture took this to the extreme, attempt to ignore death, Koreans confront when people would live beside their our anxieties through caring for those deceased parent or spouse in a cramped who raised us, in a sense paying back the hut for as long as four years, mourning years of filial debt we owe to our elders. and paying their respects (Horlyck & This practice of the veneration of Pettid 2014). This symbiotic relationship elders extends to the way we negotiate between ancestor and living relative with death once it has taken those we creates a “dependence and connection love. In secular Western culture, death is between the living and the dead... In this an event in the past tense; our loved one sense, for Koreans, we can say that the died, we planned the funeral, and now we living and the dead live together in this cope with feelings of loss. However, world” (Kwon 2006). Eastern belief constructs death as a simple Finally, I would like to introduce cut and paste mechanism, a removal from three core indigenous concepts that are the present context to another realm. important when considering death and Death does not represent a separation of dying from a Korean perspective. 한 (han), the tangible world and the afterlife, but it 정 (jeong), and 눈치 (nun-chi) all shape the exists merely as an extension of the world way Koreans act in relationship to others we currently live in (Kwon 2006). This within the context of the dying process, cultural belief stems from the notion that yet I will focus on the latter in this section; the dead continue to influence this world, a more in-depth analysis of the former even after their physical bodies have two will be beneficial in our discussion of hospice care specifically. The descriptions

I provide are over-simplified only because how death because in doing so, they the English language does not contain the might appear as if they lack nun-chi (눈치 words to correctly capture the nuances of 없는 사람). Therefore, many Koreans will these emotions. refrain from telling their children their The first of these beliefs, han, refers personal preferences on life-extending to a deeply felt anger or grief that boils medical care and advanced directives inside due to repressed emotion. Most simply because they assume their children overt signs of emotion are discouraged by already know without explicit Korean culture (Kim et al. 2006), so han is communication. In Kwak & Salmon’s experienced by many, especially in the transcripts of interviews from terminally ill death of a loved one. Jeong describes a or dying patients, one individual deeply felt inter-personal relationship commented that her preferences would be similar to the English word love. It is not “know[n] through noon-chi. My children romantic or sexualized, nor is it a familial already know what I want, so why talk connection, but a deep bond of trust and about it and cause [emotional] troubles?” empathy between two people that (Kwak & Salmon 2007). This stabilizes relationships. Authors Kim, Kim, demonstrates the cultural preference & Kelly provide a table summarizing the Koreans have for implicit, subtle, and differences between jeong and love, which nonverbal communication as opposed to attempts to capture the complexity of this the Western value of explicit, direct emotion (2006). Lastly, nun-chi is the communication. The concept of nun-chi, intuitive capacity to size-up another along with filial piety and veneration of person without verbal communication. ancestors play into the Korean-American While it may not be immediately obvious, perception of a “good death”, which I will nun-chi plays a large role in the mediation describe next. of death preferences for the elderly and their children. The Good Death: A Korean-American Literally translating to “measuring Construction with the eyes” (Kim et al. 2006), nun-chi is Most of the study on the attitudes seen as an important cultural skill in the of the dying has been conducted within Korean tradition. If one does not develop the Western cultural context. However, [an] awareness of, and sensitivity to, the small wealth of literature describing another person’s nonverbal cue” (Kwak & Korean-American views of death note a Salmon 2007), then they are seen as “good death” as one of the eight blessings tactless and without common sense. throughout the Korean life (Kim & Lee Nun-chi is important to consider in the 2003). Many older Korean women steeped context of the death of a beloved parent or in ancient Buddhist tradition consider elder. Many children will not engage in death to be “the end of suffering in life direct discussion with their parents about and a turning point to move to the next

life” (Kim & Lee 2003). While Buddhist communities is that our elderly individuals and Shamanistic ritual heavily influence are released from decisions concerning what Koreans consider a “good death”, their medical care, and the responsibility core American values such as comfort, falls on the family. The expectation for freedom of pain, and alertness also appear end-of-life care is that the family will in personal interviews and scholars’ make the final decisions, so that the dying analysis of Korean cultural views (Kim & individual has the appropriate amount of Lee 2003). While it is unclear if these time for life-reflection and review. similarities in what a good death looks like According to another interview are products of Koreans’ adherence to conducted by Kwak and Salmon, “even if Western cultural norms, or if they are I had completed an advance directive and simply universal constructions, we cannot left it with my children, they will be the ignore the cultural transformation Lisa one who will make the decision through Lowe and K. Scott Wong analyze as a family discussion” (2007). This is a result of cross-cultural contact. In this fundamental distinction between Western section, I focus again on the differing and Eastern cultures; while the former worths Eastern and Western cultures place places a higher value on independence and on autonomy and institutionalization, but individual choice in the dying process, also explore the influences American Korean-American elders release their values have had on Korean-origin individual autonomy to their children in populations. The creation of a new unique good faith that we know what is best for Korean-American identity results in a set them through nun-chi and filial piety. This of core values and traditions surrounding notion of surrendering one’s autonomy to death from both American and Korean family members has different implications cultures that has been warped by for end of life care, which I will propose transculturation. later. The first factor Korean-Americans In addition to filial piety and perceive to be important in dying well nun-chi-driven implicit communications relates back to our discussion of filial piety. about death preferences, death within the According to this cultural belief, adult home is a value that is integral to many children have a moral obligation to care Korean-American communities. This is and provide for our elderly parents in largely due to the comfort and familiarity order to fulfill our filial duty and pay back being at home permits, as well as the our owed debt through reciprocal nostalgic attitudes that encourage positive caregiving. This is directly correlated to life-review. In addition to this, many the dying individual’s desire for the lack of individuals cite the physician as a autonomy, which turns the Eurocentric disruptive presence in the death process. value of individualism on its head. The In the context of a hospital, death is often widely held notion in Korean-American seen as a failure, a negative outcome that

occurs when medical providers do not Doctors are often treating the dying right adequately do their jobs, even though up until the moment they take their last death is a reality for us all. One doctor breath, which does not align with Eastern cited the difficulty in “step[ping] out of core values. Korean-Americans prefer to the role of preventer and into the role of die at home to maintain comfort and comforter” (Kwon 2006) and how for familiarity as well as cultural traditions. many medical providers this is a difficult Home death, filial piety, and the release of skill to grasp. Therefore, many autonomy are critical procedures in a Korean-American families elect to “good death” for Korean-Americans. circumvent this, and surround the dying with a familiar environment, family and Hospice Care loved ones. The History of Hospice In the home of the dying, an Hospice care as an institution has important ritual the adult children the potential to exist as an intersection perform is imjong, which involves between culture and death, in ways I will watching and sitting vigil at the deathbed. explain in this section. Hospice, from the Some families that adhere more to ancient latin hospes meaning host or guest, has its cultural traditions may perform the kobok, roots in European culture. Originally which constitutes a family member referring to a place of refuge for ill or climbing onto the roof with a white shirt weary travelers on long journeys, hospice and repeating the Korean word bok is built upon the assumption that death (return) three times (Kwon 2006). This should be a meaningful experience not functions in calling back the spirit of the just for the dying but also for the family dead to join the other benevolent (Goldsteen 2006). Dame Cicely Saunders, ancestors, which can serve as a an Anglican nurse, founded the first bereavement mechanism in order to cope hospice (named St. Christopher’s) in with the grief that accompanies losing a Sydenham, England in 1967 (Emanuel & loved one. Emanuel 1998). In addition to hospice in This value placed on dying in the the UK, Dame Saunders planted her idea home contrasts the reality that most of caring for the dying into the mind of Americans face of an institutionalized Florence Wald, the dean of the Yale death; 60% of Americans die in acute care University School of Nursing in 1963. settings such as hospitals, while 20% die in This idea took root and, seven years after nursing homes (NHPCO 2016). Many St. Christopher’s was born, the first US Americans would prefer to die in a hospice was founded in Connecticut comfortable and familiar context, yet the (NHPCO 2016). cultural value of always pushing for a cure The hospice model focuses on and “fighting until the end” (Seale 2009) maximizing comfort and minimizing pain does not allow space for this to happen. and suffering through the dying process.

Usually only available to those with a “Asian” (NHPCO 2016). What is the prognosis of six months or fewer, hospice reason for this discrepancy? care provides a “team-oriented approach While access and knowledge about to expert medical care, pain management, available hospice resources cannot be and emotional and spiritual support” discounted as large barriers to throughout the individual’s dying process Korean-American communities’ use of (NHPCO 2016). The care team, hospice services, the main issue, I argue, is consisting of nurses, physicians, social the lack of cultural competence in hospice workers, clergy, and music or pet care. If the hospice staff is not familiar therapists, helps provide holistic support with cultural differences surrounding that caters to an individual’s desires, as death that deviate from Western values, well as prepare the family for then they will ultimately fail in their goal bereavement. This type of care aligns with of providing the climate the patient needs hospice’s core focus on “caring, not in order to die a good death. In this next curing” (NHPCO 2016), which is in section, I will briefly outline the barriers direct contrast to the typical aggressive, the Korean-American community faces to cure-based treatments at hospitals. Instead adopting hospice care. Then, I will of pursuing alternative drugs and cures provide a recently-proposed model that that may sustain life, hospice accepts death reimagines hospice care not as culturally as an inevitability and works instead to stagnant, but as a vibrant junction that make the patient comfortable. In addition brings cultural difference and death to this, the majority of hospice care is together in a singular implementation of provided in the context of the home, care. which allows patients to die in a familiar environment. This allows hospice Barriers to Hospice providers to include family members, One argument that many hospice home furnishings, and objects that evoke providers cite as a factor that restricts nostalgic memories as aids in their support Korean-Americans’ adoption of hospice of the dying person. care is the level of knowledge and access While it is true that hospice care that permeates these communities. If has been influential in transforming Korean-Americans are not aware of the end-of-life care in America, we must potential services hospice can provide for critically analyze it through a cultural lens the dying, then the chances that they will in order to unearth its true value. reach out and take advantage of the According to the National Hospice and benefits of hospice care of through their Palliative Care Organization’s 2016 report, own volition and research are small. One 86.5% of hospice patients were Caucasian, explanation for this lack of knowledge while 1.2% were categorized broadly as could simply be the geographic relation to areas with a high concentration of hospice

providers. At their inception, hospices hospice. Jung Kwak highlights the fact were concentrated in predominantly that many Korean-Americans confuse White, upper-class, Christian hospice care with euthanasia, or communities such as Connecticut and physician-assisted suicide. Instead of Rhode Island (Doorenbos & Schim 2004). hastening death, hospice works to ensure Koreans flocked to urban centers during the patient is comfortable and pain-free the three waves of immigration discussed during the dying process. earlier, primarily residing in New York Additionally, rather than hospice Los Angeles, and Chicago (Chan 1991). existing as an avenue through which the This geographic distance from states with patient “gives up” on life, it instead larger concentrations of hospice services functions as a way to give death meaning may account for the historic trend of low in a personal context. This apparent Korean-American involvement in miseducation based on false perceptions of hospice. The effectiveness of this hospice care, while not unique to argument, however, is slightly dampened Korean-Americans, is detrimental to the by the statistic that 95% of Americans use of hospice services in these have access to local hospice care through communities. both the rapid spread of hospice providers Finally, the factor most relevant to as well as Medicare covering hospice the arguments laid out in this paper that services in 1983 (Emanuel & Emanuel could account for the low rate of 1998). Korean-American hospice patients is a Even if geographic proximity and lack of cultural recognition. With its focus access is increasing for Korean-Americans on comfort, pain management, and with the spread of local hospices, autonomy in the dying process, hospice awareness of the services and overall care attempts to provide a good death to message of hospice may still be restricted its patients. However, as the first portion in these communities. For instance, of this paper discusses, these values are not Professor Jung Kwak, fellow at the shared by everyone in the US. The space Gerontological Society of America, states for cultural variation is not afforded by all that “many [Korean-Americans] still hospices, which mostly adhere to a assume hospice is another way of speeding Western model of a good death death. Although hospice and palliative (Doorenbos & Schim 2004). For example, care try to ease the pain of the patient, hospice emphasizes explicit many see it as giving up” (Kwak & communication and autonomous Salmon 2007). This quote exhibits the lack decision-making, which conflicts with of education Korean-Americans have Korean-American values of nun-chi and been exposed to, which generates false filial piety. beliefs and generalizations that may In the next section, I will outline a prevent this population from using potential hospice model that, when

adopted, would allow for cultural initiative that seeks to provide a variation while still maintaining the culturally-distinct intersection between original structure and values on which culture and death for Korean-Americans, hospice was founded. I argue that while as well as facilitate a good death that aligns historically this has not been the case, the with the Korean-American values and hospice system has the potential to serve as traditions outlined previously. a nexus between culture and death in a The Campinha-Bacote model, first way that provides a good death for all published by Dr. Josepha individuals. Campinha-Bacote in 1999, provides a framework through which healthcare Cultural Competency: A Model of Hospice providers can interact and build successful Care relationships with their patients Cultural competency has become (Campinha-Bacote 1999). This the focus of a movement to make the framework focuses on five major modern healthcare system more accessible constructs that shape many cultural to those who do not ascribe to Western competence trainings for healthcare medical forms of treatment. This is professionals: cultural awareness, especially prevalent, as our nation knowledge, skill, encounters, and desire. continues to become more and more Cultural awareness and knowledge, diverse through globalization and according to Dr. Campinha-Bacote, refer transculturation. With this increased focus to an appreciation and sensitivity toward on cultural difference comes multiple different values, practices, and variations, models developed by bioethicists, both biological and societal, in different clinicians, and sociologists alike that cultures. Cultural skill and encounter outline what culturally competent involve cultural assessment in which the healthcare looks like. practitioner collects cultural data from the Although the larger medical system patient, as well as an increase in is moving in this direction, hospice has interaction with a culturally-diverse not yet caught up; cultural competency population. Finally, cultural desire is the models in hospice care remain, for most motivation practitioners feel to learn about hospices, lofty goals that have been and respect the complexities of their theorized in the academic world, but not patient’s culture without forcing them to yet put into practice. In this section, I will adhere to their own cultural norms. The take the 1999 Campinha-Bacote model, a model suggests that if these five tools are useful framework for many hospitals in employed in the context of a health care implementing a cultural competency setting, then a practitioner will begin the program, and apply it specifically to the life-long process of becoming culturally Korean-American population in hospice competent. care. This will serve as a potential

The Campinha-Bacote model can hospice provider in understanding the be readily applied to create a system of family’s needs during the bereavement culturally competent hospice care for process. Finally, an appreciation for Korean-Americans. Formulating a model nun-chi would prevent the hospice of care that is specifically tailored to the provider from violating the unwritten unique cultural values and traditions of Korean rule of implicit communication by Korean-Americans allows hospice speaking explicitly about the dying providers to better serve this population process and risking offending the patient and may even ameliorate the racial and family. disparities in hospice care throughout the When applied in a hospice setting, US. The five major constructs laid out by cultural skill and encounter do not just this model can aid hospice providers in refer to treating more Korean-American more effectively developing culturally patients. While this will inevitably lead to competent care. an increased knowledge of cultural The first two constructs, cultural traditions and values, the hospice provider awareness and knowledge, can be applied must also view the cultures of their in terms of understanding the currents of patients through a pluralist lens. Instead of Korean diaspora, and the process of overgeneralizing all Korean-American culture formation outlined in the first patients into a singular cultural entity, section of this paper. This will facilitate a cultural skill and encounter imply a broader understanding of the unique conscious effort on the part of the hospice construction of the Korean-American provider to learn what values and identity, which will help the hospice team traditions the family adheres to and rejects provide nuanced, culturally-specific care. within their culture. For instance, Additionally, hospice providers must be assuming that all Korean-American well-versed in the three indigenous beliefs patients experience jeong, haan, and nun-chi of haan, jeong, and nun-chi. The practice of does not allow for those that do not “cultivating jeong, practicing nun-chi, and observe traditional Korean values as appropriately acknowledging the presence strictly. This accounts for the multiplicity of haan are three ways in which clinicians of identities and subcultures that exist may increase their cultural competence within the Korean-American identity. In with Korean immigrant clients” (Kim et addition to this, cultural skill and al. 2006). Understanding the concept of encounter inherently reject the jeong and implementing it in hospice universalist definition of culture; this practice would allow the provider to build model views cultural difference in an trust with the patient and family. objective manner that does not impose Acknowledging haan, or the unexpressed paternalistic hierarchy on cultures. For anger or grief that accompany societal instance, hospice providers must not norms of repressing emotions, can aid the consider their own culture to be superior

to their patient’s, but instead recognize traditions. I have crossed scale to describe variation merely as difference. Eastern and Western interactions with The final component of the national, cultural, and individual borders. Campinha-Bacote model is cultural desire; The purpose of border crossing, in in order to promote culturally competent the context of death and dying, is to care, hospice providers must be motivated understand a concept that is part of a to learn about and engage with their larger whole, something that is greater patients’ cultural belief system. In the than ourselves. To cross national and context of Korean-American patients, the cultural borders is to actively resist the hospice provider must harbor a genuine universalist view of culture: that no desire to understand indigenous beliefs culture is superior to another, and that in and implicit communication that are order to coexist in this world, we must central to the good Korean-American accept cultural variance not as a defect, but death, instead of passively allowing simply as a difference. We can push back patients to practice their own cultural against universalism further when we traditions. This process of passionate cultivate the cultural desire put forth by engagement can not only bridge cultural the Campinha-Bacote model, and actively difference and form the all-too-important celebrate cultural difference. patient-caregiver bond, but also can foster By crossing national and cultural an environment of inclusion, community, borders, we automatically shift scale and and compassion that facilitate a good evaluate the borders between life and death, no matter the culture. Cultural death as they relate to ourselves. This desire, along with the four other aspects of allows us precious reflection time to the Camphina-Bacote model, can facilitate critically analyze our own cultural values the development of hospice as a place and traditions, and determine whether or where cultural variance is accepted and not we adhere to them. My hope is that celebrated in the dying process. this paper has given you the tools to engage in these types of reflections, so that Conclusion when your time comes, you will be able Throughout this paper, I have to conceptualize your personal idea of a explored the themes of cultural formation, good death. Perhaps when I ask you competence, and variation, all in relation again, you will now know to the answer to the dying process. I have argued that to the question: the pluralist view of culture is sufficient to What do you want your death to look understand the nuances of cultural like? deviation, and that when applied to a hospice setting, can facilitate culturally competent care that aids a good death consistent with cultural values and

References Barrett, R. (In Press). In Singer, M. and P. Erickson, A Companion to Medical Anthropology. Malden: Wiley Blackwell. Battin, M. P. (1983). The Least Worst Death. The Hastings Center Report, 13(2), 13-16. Byron, J. (2017). We Have Been At War a Long Time. Proceedings Magazine, 143(8). Campinha-Bacote, J. (1999). A Model and Instrument for Addressing Cultural Competence in Health Care. Journal of Nursing Education, 38(5), 203-207. Chan, S. (1991). Asian Americans: An interpretive history. Boston: Twayne. Charmaz, K. (1983). Loss of self: a fundamental form of suffering in the chronically ill. Sociology of Health and Illness, 5(2), 168-195. Charpentier, A. (2017). The U.S. Has Been At War 222 Out Of 239 Years. Freakonometrics , Retrieved from https://freakonometrics.hypotheses.org. Doorenbos, A. Z., & Schim, S. M. (2004). Cultural Competence in Hospice. American Journal of Hospice and Palliative Care, 21(1), 28-32. Emanuel, E. J., & Emanuel, L. L. (1998). The Promise of a Good Death. The Lancet, 351, 21-29. Gentzler, J. (2003). What is a Death With Dignity? Journal of Medicine and Psychology, 28 (4), 461-487. Goldsteen, M. (2006). What is a good death? Terminally ill patients dealing with normative expectations around death and dying. Patient Education and Counseling, 64, 378-386. Horlyck, C., & Pettid, M. J. (2014). Death, Mourning, and the Afterlife in Korea: Ancient to Contemporary Times. Honolulu, HI: University of Hawai’i Press. Hurh, W.M. (1998). The Korean Americans. Westport, CT: Greenwood Press. Kim, I. J., Kim, L. I.C., & Kelly, J. G. (2006). Developing Cultural Competence in Working with Korean Immigrant Families. Journal of Community Psychology, 34(2), 149-165. Kim, S., & Lee, Y. (2003). Korean Nurses’ Attitudes To Good and Bad Death, Life-Sustaining Treatment and Advance Directives. Nursing Ethics, 10(6), 624-637. Klessig, J. (1992). The effect of values and culture on life-support decisions. Cross-cultural Medicine-A Decade Later, 157, 316-322. Kwak, J., & Salmon, J. (2007). Attitudes and Preferences of Korean-American Older Adults and Caregivers on End-of-Life Care. American Geriatrics Society, 55 (11), 1867-1872. Kwon, S. (2006) Grief Ministry as Homecoming: Framing Death from a Korean-American Perspective. Pastoral Psychology, 54(4), 313-324. Lehto, R. H., & Stein, K. F. (2009). Death Anxiety: An Analysis of an Evolving Concept. Research and Theory for Nursing Practice: An International Journal, 23(1), 23-41. Lowe, L. (1996). Immigrant Acts: On Asian American Cultural Politics. Durham, NC: Duke University Press. Mitrovica, A. (2017). America’s Addiction to War. Aljazeera, Retrieved from https://www.aljazeera.com. National Hospice and Palliative Care Organization (NHPCO). (2016). History of Hospice Care, Retrieved from https://www.nhpco.org. Peters, L., et al. (2013). How Death Anxiety Impacts Nurses’ Caring for Patients at the End of Life: A Review of the Literature. The Open Nursing Journal, 7, 14-21.

Rodriguez-Prat, et al. (2016). Patient Perspectives of Dignity, Autonomy and Control at the End of Life: Systematic Review and MetaEthnography. PLoS ONE, 11(3), 1-18. Seale, C. (2009). Constructing Death: The Sociology of Dying and Bereavement. Cambridge, UK: Cambridge University Press. Tierney, D. (2011). Do Americans Love War? The Atlantic, Retrieved from https://theatlantic.com Tomer, A., & Eliason, G. (1996). Toward a comprehensive model of death anxiety. Death Studies, 20(4), 343-365 U.S. Census Bureau (2017). American Community Survey (ACS) Reports. Retrieved from https://www.factfinder.census.gov. Wong, S. K. (1999). The Transformation of Culture: Three Chinese Views of America. In Maddox, L., Locating American Studies: The Evolution of a Discipline, (408-443). Baltimore, MD: Johns Hopkins University Press. Yudice, G. (2014). Culture. In Burgett, B., & Hendler, G., Keywords for American Cultural Studies 2nd Edition, (69-72). New York, NY: NYU Press.