The Impact of Cultural Diversity on End-of-Life Care

Abstract

Despite the universality of death for humanity, end-of-life care needs and expectations are highly unique and influenced by the individual’s cultural conditioning, values, and beliefs. In the pursuit of quality end-of-life care provision within the increasingly complex and diverse contemporary medical context, it is vital for cultural idiosyncrasies to be taken into consideration in order to attend to the individual patient’s needs and end-of-life goals. Palliative chaplains, as the spiritual care specialists within the multidisciplinary healthcare team, play a crucial role in the support and facilitation of the holistic vision of end-of-life care delivery. However, the capacity of the chaplains to become culturally competent practitioners are often insufficiently addressed in their professional educational pathways, creating additional challenges for them in their practice. Using Hong Kong as a case study, this article examines the impact of cultural diversity on the effectiveness of the chaplains’ delivery of end-of-life spiritual care. Specifically, special attention will be focused on two identified challenges resulting from the lack of integration of local cultural understandings within the religion-cultural practice framework of chaplaincy formation: the cultural taboo of death, and the cultural idiosyncrasies in end-of-life communication. This article hopes to raise awareness of cultural incongruencies within the current chaplaincy professional formation and development, and to initiate further attention and efforts to support chaplains in becoming culturally competent practitioners in the pluralistic healthcare landscape.

1. Introduction

With rising awareness and recognition of the need to provide quality medical care that addresses the multitude of complex needs in life-threatening illnesses, which technical intervention alone cannot meet (McCue 1995), contemporary medicine has increasingly advocated for a holistic vision of healthcare, which incorporates other dimensions of care like religion and spirituality. Within this holistic vision of end-of-life care, which strives to pay equal attention to a patient’s physical, psychological, social and spiritual needs (Savel and Munro 2014), palliative chaplains are the spiritual care specialists responsible (Puchalski et al. 2009), within a multidisciplinary healthcare team, for attending to the spiritual needs of patients and their loved ones in the dying experience, such as life support issues (Carey and Newell 2007) and death anxieties (Cooper 2011, p. 20). Meeting the patient’s spiritual needs is closely correlated with the enhancement of patient (Astrow et al. 2007) and family (Daaleman et al. 2008; Wall et al. 2007) satisfaction with overall care. Most importantly, end-of-life spiritual care is particularly crucial at this acutely vulnerable time of the patient’s illness experience, when physical healing is no longer a possibility and supportive comfort care has become the priority (Billings and Pantilat 2001; Sulmasy 2006). At the final margins of life, when end-of-life treatment plans are shifted towards palliation, the effectiveness and quality of care are highly dependent upon its alignment to the patient’s individual end-of-life goals (Meier et al. 2010), which are shaped by a multitude of factors, including culture and spiritual beliefs (Balboni et al. 2007).

Even though dying is a universal experience for humanity, no one responds to death in the same way, since their interpretation and understanding of suffering, illness and death are culturally impacted (Long 2011). Cultural influence on the difficult decisions faced at the end-of-life is particularly pertinent, as it determines how death and dying are understood by the individual patient and their loved ones (Ludke and Smucker 2007). Cultural idiosyncrasies must therefore be taken into consideration when devising end-of-life care plans, which should be influenced by cultural beliefs, values, and practices (Crawley et al. 2002). In other words, the cultural competency of end-of-life care professionals across the disciplines, including the chaplains, is key to quality care for the diverse patient population being served in a contemporary medical setting (Bullock 2011).

Yet, even with the recognition of the significance of providing culturally congruent care, the effective delivery of culturally competent end-of-life spiritual care is not easily attained in practice (Ho et al. 2018). Many factors contribute to the challenges faced by chaplains and their ability to deliver effective, timely and culturally sensitive end-of-life spiritual care. Such hurdles are plentiful to begin with but become even more difficult to navigate when serving a diverse, multicultural patient population within the acute medical setting. In that situation, the challenges include their need to work under the urgency of time limitation in the end-of-life context at the same time as acquiring knowledge and appreciation of different cultural significance to best minister to their individual care recipients. However, the capacity to meet such demanding and evolving challenges and needs within the chaplain’s role of “brokering diversity” (Pesut et al. 2012) to recipients from a wide spectrum of cultural and religious backgrounds is not always sufficiently developed in chaplaincy formation, where little to no attention is paid to the importance of culturally pertinent interaction in end-of-life care. The lack of formation leaves the practitioners having to face and manage these complex and critical situations alone.

I came to the realization of the need for an emphasis on culturally pertinent interaction in chaplaincy formation from my experience in the practice itself. I was trained in an Anglican theological institution and have been a hospital chaplain in Hong Kong, with a focus on palliative care, for the past five years before and still after completing my doctoral studies in Practical Theology.

In this article, I will investigate the impact of culture on the effectiveness of chaplains’ practice of end-of-life spiritual care. In order to do so, I will focus on the situation in Hong Kong as a case study to examine how the chaplains’ professional formation causes challenges in their practice. More concretely, I will especially pay attention to challenges related to a lack of integration of local cultural understandings into the practice framework learn during the formative years.

In order to examine the intricate and complex relationship between culture and the practice of spiritual care, Hong Kong, with its colonial history and its position as a bridging site between China and the rest of the global world (Postiglione 2006), provides a fitting milieu for such an examination. China’s Special Administrative Region of Hong Kong1 has been described as resembling a “fault line”, torn between competing for Western and Chinese cultures (Purbrick 2020). Even though Hong Kong is inhabited by a multitude of ethnic groups representing a wide array of cultures, languages, and beliefs (Anderson 2021, p. 249) and is known as “a cultural and linguistic melting pot” (Gibbons 1979, p. 113), over 90% of the population is ethnically Chinese. This is partially why, despite the fact that the majority of Hong Kong residents identify more with the West (Purbrick 2020, p. 480), traditional Chinese cultural influence remains a deeply rooted presence in Hong Kong. Thus, the distinctiveness of the local context provides a helpful platform to assess and identify any existing gaps in the current formation and equipping of palliative chaplains to become culturally competent practitioners within the secular and pluralistic medical settings.

2. The Cultural and Religious Background of Hong Kong

Hong Kong evolved from a small fishing village located in the southeast corner of the People’s Republic of China when its sovereignty was ceded to the British Government in 1843 during the First Opium War (Carroll 2007, p. 12) to become the current lively cosmopolitan center it is (Tsang 2003). As one of the world’s reputed international metropolitan cities, Hong Kong exemplifies a sophisticated multicultural hub. In spite of its growing diversity, Hong Kong’s predominant population group is still Chinese (HK Govt Census 2005).2 Examples of other significant foreign resident groups among the 0.58 million from non-Chinese communities include those from the Philippines (31.5%) and Indonesia (26.2%) together with British, American, and Australian nationals (10%), generating the distinctive “hybrid status” (Carroll 2007, p. 169) of Hong Kong local culture. The diverse and heterogeneous regional demographics have also resulted in an eclectic assortment of religions in Hong Kong. Amongst the various religious communities representing dominant faiths such as Christianity (Protestant and Catholic), Islam, Hinduism, Sikhism, and Judaism (Postiglione 2006) is the “diverse and amorphous” Chinese religion in Hong Kong, which is composed of a syncretic blend of Buddhism, Daoism and a range of practices referred to as “popular or folk religion” (Bosco 2015, p. 8). These traditional customs and practices include expressions of reverence for family ancestors through ancestor worship, which is a significant part of Chinese life regardless of religious beliefs (Lakos 2010, p. 69), as well as geomancy or shamanism (Bosco 2015, p. 8). It is easy to miss the prominence and popularity of Hong Kong Chinese religion in the absence of a government-run department in charge of local religious affairs, unlike the more conspicuous and discernible dominant institutional religions (Liu 2003). For example, in the case of Christianity, despite constituting only 10% of Hong Kong’s population, two religious organizations are highly visible: the Anglican Church (Sheng Kung Hui) and Roman Catholic Church (Bosco 2015, p. 14). Even though Chinese religion in Hong Kong is less conspicuous and organized and even though many residents of Hong Kong define themselves as irreligious (Bosco 2015, p. 8) and do not identify with a particular religious tradition (Chan and Lee 1995, p. 85), unofficial cultural and religious practices idiosyncratic to Hong Kong Chinese religion remain a significant influence on the day-to-day life of local residents (Liu 2003). These informal, yet integral practices and cultural customs constitutive of the syncretic nature of Hong Kong Chinese religion (Youngblood 2018, p. 329) guide important life decisions3 and need to be taken into consideration in end-of-life provisions.

Besides the religious diversity present in Hong Kong, the classical Chinese philosophy of Confucianism must also be taken into account in delivering effective and culturally-congruent end-of-life care to recipients of the Hong Kong Chinese population, as it permeates Hong Kong’s religious and cultural background and continues to play a key role in shaping the Chinese people, especially in relation to death and dying (Hsu et al. 2009, p. 153). Confucianism was an expression originally coined in the sixteenth century by Jesuit missionaries in China to refer to the all-embracing Chinese cultural and philosophical-religious thought based on Confucius (551–479 BC) (Hsu et al. 2009, p. 158). Although Confucianism is not commonly categorized as a form of religion, its embeddedness within the Chinese culture remains visible in many aspects of Chinese life (Jacobs et al. 1995, p. 29). The philosophical school of Confucianism, with its ethical emphasis on attaining the harmony of the human world through the cultivation of areas such as morality and social behavior, has had a prominent shaping influence on Chinese thought throughout history (Hue 2007, p. 40). With respect to the end-of-life context, traditional Chinese philosophical and religious thought stemming from Daoism, Buddhism, and Confucianism significantly shapes the perception and understanding of what constitutes a good death, with considerable implications for effective end-of-life care (Chan et al. 2006, p. 127). As an example, despite the wide overlap between Hong Kong’s understanding of spirituality and the Western concept of spirituality associated with the relationship and connectedness of self, others and the divine, as well as attaining meaning and hope (Lin and Bauer-Wu 2003, p. 71), two additional, unique aspects in end-of-life spirituality are discernable in the cultural context of Hong Kong: the fulfillment of personal responsibilities and the acceptance of death as a life process (Mok et al. 2010, p. 368). These two distinctive facets of end-of-life spirituality reflect the cultural emphasis on an individual’s social responsibility toward the collective good of others and are a distinguishing feature of Confucianism (Mok et al. 2010, p. 367). The contextual idiosyncrasies derived from the “secular orientation” (Leung and Chan 2010, p. 160) of Hong Kong’s framework of spirituality, with its emphasis on the value of self-knowledge and maintaining harmonious interpersonal relations profoundly impact the cultural comprehension of a good death (Lee et al. 2018, p. 2). These nuanced dissimilarities of Hong Kong culture’s understanding of the end-of-life from the Western model become more discernible in the formulation and implementation of palliative practice and profoundly affect the goal of attaining culturally congruent end-of-life care. The pertinence of culture-specific understanding is further enhanced and becomes visible when approached from the perspective of a practice framework that has omitted cultural idiosyncrasies in its design. The unforeseen hurdles emerging from an approach that has insufficiently factored in the intricate complexities of cultural idiosyncrasy will be examined and illustrated in the following sections.

3. Formation of Chaplains

Chaplaincy formation is crucial in developing the hospital chaplain’s understanding and ability to fulfill their role in delivering quality spiritual care. To become a hospital chaplain, a person must first attain a bachelor’s or master’s degree in theology from a seminary or another recognized theological institution. Secondly, a process of practical formation is required to be undertaken with the objective to learn how to work effectively in the complex institutional dynamics of the contemporary healthcare setting. The specific model of this supplementary training may differ depending on the geographical location, but it always involves a period of supervised chaplaincy placement. For example, hospital chaplains in the UK are required to have completed a minimum of six months’ chaplaincy placement in addition to postgraduate certificate training.4 In other parts of the world, such as the United States, Canada, Australia, and Hong Kong, this postgraduate professional development takes place in the form of a chaplaincy accreditation program called Clinical Pastoral Education (CPE).

3.1. Theological Formation

Currently, Hong Kong hospital chaplains are primarily “devout practitioners from conservative Christian traditions” (Youngblood 2019, p. 329). Although there is no available data on the denominational demographics of Hong Kong Christian chaplains, a brief survey of the membership of the Association of Hong Kong Hospital Christian Chaplaincy Ministry suggests that the majority of the registered chaplains are from Evangelical Protestant faith communities.5 This differs slightly from the case in North America, where there is a comparatively higher proportion of chaplains from Mainline Protestant backgrounds (White et al. 2021, p. 13). Until recently, the Hong Kong chaplain community was constituted of members from the Christian faith (Protestant and Catholic). It was not until 2011 that the Buddhist chaplaincy service came into the scene under the oversight of the Centre for Spiritual Progress to Great Awakening (SPGA) to provide Buddhist spiritual care to fourteen public hospitals in Hong Kong.6 However, the majority of healthcare chaplains remain a cohort of Christian chaplains. These “Christian faith-based clergy” (Luk 2019) complete theological training in seminary as a foundational step before pursuing additional, more practical, training: CPE. The name ‘seminary’ is derived from the image of a protective nursery for nurturing growing young plants into maturity and has its historical roots in the sixteen-century Council of Trent (Oakely 2017, p. 223). Traditionally, through the process of seminary education, candidates are prepared for the ordained priesthood (Keating 2012, p. 309) or for serving in “other ‘credentialed’ lay ministries” (Reisz 2003, p. 29). Concerning chaplaincy formation, seminary formation serves to root the candidates in the Christian faith through a curriculum comprising historical, biblical, theological, and ethical courses (Calian 2002, p. 12), guiding them to align, clarify, and solidify their vocational calling and identity to serve outside of the Church as hospital chaplains. Seminary formation thus affirms and trains chaplains to embrace the historical vision and role of hospital chaplaincy, to represent and serve on behalf of the church (Pesut et al. 2012, p. 826). The theological formation in Hong Kong seminaries reflects a similar traditional vision to equip chaplains in their vocational calling working in the hospital setting. Amongst the subjects taught in seminaries, courses such as pastoral theology, counseling and family ministries within the core curriculum or offered as electives contribute to nurturing the chaplains for the necessary skillsets in their role to deliver spiritual care to the diverse patient population in their practice. However, in spite of the seminary’s long history of instructing future ministers through Christian theological education and priestly formation, the content of the curriculum taught mostly emphasizes scriptural knowledge which has been critiqued as limited and “perfunctory in its spiritual depth and practical value” (Jeynes 2012, p. 70). This lack of practicality and the ensuing need to extend ministers’ training beyond seminary theological education became the impetus from which the dual training model emerged, incorporating additional supplementary formation to deepen ministers’ practical skills and knowledge in order to serve outside of the church.

3.2. CPE

In Hong Kong, hospital chaplaincy began in 1984 with the first Christian chaplain providing spiritual care as a volunteer within a public hospital (Chow 2015, p. 49). Since then, and with the growing presence of chaplains in Hong Kong, the need to supplement future chaplains’ formation has been attained through the training program of CPE. CPE is a methodology that originated in the United States of America in the early part of the twentieth century and which has since become an interfaith professional education program for ministers working in different contexts, including hospital chaplains (Clevenger et al. 2021, p. 223). The rapid expansion of CPE from its inception was part of a larger movement that responded to the perceived insufficiency of theological education at the time with its predominant focus on attaining scriptural knowledge while neglecting learning from human experience, thus neglecting to develop the relevant practical skillsets for ministers serving in the real world (Hall 1992, p. 282). The two founding fathers of CPE, Anton T. Boisen and Richard Cabot, were particularly concerned with the discrepancies of academic seminary education in preparing ministers to serve in the healthcare context, which prompted them to advocate for theological students to have supervised experiences in clinical settings as part of their ministry training (Jernigan 2002, p. 381). Through CPE’s traditional action-reflection-action model of learning, students are led through supervision and the practice of self-reflection in their experience of patient engagements with the aim of growing in self-awareness and professional competency (Pohly 2016, pp. 78–79; O’Connor 2006, pp. 90–93). CPE is conducted in units, with each unit consisting of four hundred hours of supervised clinical experience within an approved training center.7 This program aims to further clarify chaplains’ vocational identity, a task initiated in seminary, as well as to enable theologically-trained practitioners to be equipped with practical training to apply their knowledge into relevant and effective ministry (Little 2010, p. 2). In Hong Kong, the predominant training and accreditation model used is patterned from the American Association for Clinical Pastoral Education (ACPE). Within the program, the pastoral competence of the students is strengthened to prepare them for the better navigation of the demanding healthcare landscape as spiritual care specialists. The curriculum includes subjects pertaining to pastoral practices, ministerial ethics, interfaith connections, and effective communication skills such as listening, to name a few.8 Practicing chaplains are required to have completed at least one unit of CPE.9 CPE in Hong Kong is carried out in a very similarly operated model to the Western contexts, where the program originated, which is not purely secular but is motivated to attend to the pluralistic and religiously diverse needs of the care recipient by focusing more on the inter-religious dynamics within spiritual care encounters.

However, despite the efforts of CPE, there is an increased expression of concern in recent years regarding CPE’s efficacy in developing effective professional hospital chaplains with the necessary skills to cope with the evolving demands of institutional dynamics, including the ability to broker diversities in contemporary healthcare (Cadge 2012, p. 83; Fitchett et al. 2015; Massey 2014; Ragsdale 2018; Tartaglia 2015). In the following section, I will proceed to explore this concern regarding the efficacy of chaplaincy formation using the concrete example of Hong Kong. I will focus on how the dual-track formation of Hong Kong chaplains, with their vocational identity founded on deeply rooted Christian values on the one hand and the “non-sectarian, interfaith model of chaplaincy” (Youngblood 2018, p. 331) comprising CPE on the other, reveals unexpected complications unforeseen in the original design of CPE training.

4. From Formation to Practice: The Challenges of Chaplaincy in Hong Kong’s Cultural Milieu

In keeping with the rest of the global world, Hong Kong has been striving towards the ideal of a holistic end-of-life care provision in the past few decades, guided by the vision of “being patient-centred, family-orientated, dignity-conserving and culturally-competent.”10 Hong Kong chaplains, akin to chaplains in Western contexts, are trained to become spiritual care specialists working with the multidisciplinary healthcare team to address the multitude of end-of-life care needs underpinned by the said vision. However, unlike some of their Western counterparts, hospital chaplains are not under the direct employment of the hospital institutions but are funded by the church or other Christian organizations and are granted access to work in the hospital by means of an assigned honorary title. Having overcome this unusual first hurdle to have gained access to work within the hospitals, Hong Kong chaplains face other challenges as they seek to apply the skills and knowledge acquired through their dual-track formation in practice.

A general challenge in this transition may not be specific to Hong Kong but could be an experience shared by Christian chaplains in other contexts: the incompatibility of the two modes in chaplaincy formation, theological education and CPE. The conflicting orientations underpinning the two distinctive sources of chaplaincy foundational knowledge—religiously rooted theological education and the more generic and humanistic approach of CPE—become problematic in practice as Christian chaplains are left to reconcile the differences between divergent understandings on their own. One such conflict is related to the chaplains’ foundational understanding of commonly encountered issues in the end-of-life context, which has been indelibly shaped by theological formation, yet does not fully align with the secular orientation endorsed by their supplementary training in CPE. For instance, the orientation of the Christian pastoral approach informing end-of-life care is drawn heavily from the Scriptures, modeled after Jesus’ dying and underpinned by Christian virtues such as patience, compassion and eternal hope (Vogt 2004, p. 135). Each dying person being cared for is seen not as an isolated individual but a member of the body of Christ, the Church, and is guided and supported towards surrender of the self to God as the vision of dying faithfully (Levering 2018, p. 117). Contrasting with that Christian pastoral directive, CPE’s secular, humanistic approach to palliative care emphasizes the “singular existence” (Wu and Volker 2012, p. 477) of each person and the facilitation of personal growth, self-worth, and self-transcendence to reduce death-related distress (Wu and Volker 2012, p. 474). These fundamental dissimilarities in the departure points and orientations underlying the chaplains’ dual formation remain unnoticed and unaddressed in both educational pathways but inevitably become perceptible and problematic in practice when chaplains must resolve these unforeseen hurdles on their own in the reality of their critical and urgent circumstances, as will be shown in the sections below.

In addition to this general difficulty, Christian chaplains in Hong Kong encounter further complications as they are compelled to resolve incongruencies arising from the direct application of CPE to the idiosyncratic cultural context of Hong Kong. The Western design of CPE is a baseline flaw in this application, as the framework of CPE was created for contexts with vastly different socio-cultural backgrounds and religious demographics from Hong Kong such as those of the United States, Canada, Australia and New Zealand (Puchalski et al. 2012, p. 417). As mentioned, Hong Kong’s predominant religious landscape is of a syncretic and heterogeneous nature which vastly diverges from contexts with the more prominent presence of a particular monotheistic tradition such as Judaism, Christianity, or Islam (Youngblood 2018, p. 333). The disparity which comes from the direct implementation of the CPE model, undergirded by culturally divergent pastoral assumptions and orientations in approaching spiritual needs and care, becomes problematic for chaplains who have been formed and trained with this model. Some of these additional obstacles stemming from cultural disparity in formation faced by Hong Kong chaplains are the taboo of death, and the related challenges concerning end-of-life communication.

4.1. The Cultural Taboo of Death

The topic of death is widely accepted as one of the most prominent taboos for Chinese people, who generally would avoid talking about death whenever possible (Zhang 2020, p. 1061) so as to elude attracting evil spirits, bad luck or even premature death (Chan and Chow 2006, p. 1). This distinctive sociocultural phenomenon remains a prevalent influence not only for those living in China but also for Chinese-ethnic residents living in other parts of the world (Hsu et al. 2009, p. 154). As observed by Mark Berkson, the prominent presence of the death taboo in Chinese culture is both reflected in and related to the historical silence of Chinese texts concerning matters of death or the nature of the afterlife (Berkson 2019, p. 35). This silence in classical literary attention toward death extends to and continues to impact contemporary Chinese attitudes through the relative absence of modern research on the ontological nature of death, thus perpetuating the cultural fear of death and the socially sanctioned consensus on the avoidance of the topic, including impacts on the development and delivery of end-of-life care in China (Lei et al. 2022, p. 58).

Moreover, the Chinese death taboo is further influenced by Confucianism and Daoism, two of their prominent native religious and philosophical traditions, which share a common trait in their scarce engagement with mortality and the afterlife but prefer to focus on living well as a way to cope with and find meaning in human finitude (Berkson 2019, p. 12). Confucianism’s relative lack of concern for matters of death and its clear focus on seeking ways to live well as a moral being is famously captured in one retort from Confucius when asked about death by one of his disciples saying, “You do not understand even life. How can you understand death?” (Confucius 2000).

A similarly asymmetrical commitment and attention granted towards life, especially the nourishment, prolongation and protection of life, is seen in the teachings of Daoism, which “understands the Dao as pertaining to life but not death” (Lai 2006, p. 83). Collectively, these deeply rooted socio-cultural influences contribute to the ongoing cultural aversion to topics surrounding death and directly impact end-of-life communication and important decisions central to end-of-life care (Thomas 2001, p. 42). Specific to the chaplains’ delivery of end-of-life care, the professional training taught in CPE understands the significance of end-of-life communication to be pivotal and can be facilitated by chaplains to attain a form of closure,11 connection, meaning-making and understanding of self, loved ones, and of death itself (McQuellon and Cowan 2000). However, the entrenched cultural prohibition of attending to topics surrounding death, and the perception that violation of this social norm is “sacrilegious, blasphemous, and disrespectful” (Cheng et al. 2019, p. 760) inevitably complicate the chaplains’ delivery of end-of-life spiritual care as guided by their professional formation. For example, due to the cultural taboo of death, it is common practice for clinicians and families to withhold full disclosure of terminal prognosis from the patients even at the critical end stage of their illness (Zheng et al. 2015, p. 294; Tse et al. 2003, p. 339). Truth telling, a preference valued in other Western contexts such as North America (Hinshaw 2022, p. 45), is perceived as a violation of the principle of nonmaleficence causing harm rather than an opportunity for accessing supportive end-of-life care (Blackhall et al. 1995, p. 824; Caine et al. 2018, p. 1412). Practicing under the constraints and complications of the death taboo, Hong Kong chaplains face additional challenges unaddressed in their professional development to deliver effective and timely end-of-life spiritual care for their Chinese care recipients.

4.2. Cultural Idiosyncrasies in End-of-Life Care Communication

Closely related to the cultural taboo of death is the hurdle impeding Hong Kong chaplains’ facilitation of emotionally charged end-of-life conversations, a practice in end-of-life spiritual care valued and emphasized in their professional training. The series of conversations between patients, their families and the healthcare professionals are understood to be critical for quality provision of care where discussions related to end-of-life goals, life-closure issues and anticipatory grief can be addressed (Rando 2000). However, even though these crucial dialogues are widely recognized as key components of holistic palliative care, successful implementation remains an ongoing challenge with many barriers identified such as the clinicians’ self-perceived incompetence in breaking bad news, or resistance from patients and families in their denial of the unfavorable prognosis (Larson and Tobin 2000, p. 1573). The difficulties resulting from these barriers to end-of-life conversations are not only shared by Hong Kong chaplains, but the resistance is amplified and made more challenging under the backdrop of death taboo.

In the case of Hong Kong chaplains’ practice, an additional obstacle, besides the above-mentioned denial of and reluctance in disclosing poor prognosis with patients, lies in the Chinese cultural aversion to expressing intense emotions. Even though there is an established universality in the physiological patterns of response to emotion-eliciting events, cultural characteristics play a role in the experience and expressions of these emotions (Bond 1993, p. 245). This resistance to emotional expressions is fueled by two cultural idiosyncrasies: the cultural significance of emotional stability, as well as the influence of Confucianism in preserving relational harmony at all times, including end of life.

4.2.1. The Cultural Value of Emotional Stability

Not only are Hong Kong palliative chaplains stumped at the outset with taboo-related obstacles in their role due to the cultural aversion to addressing death, chaplains are further encumbered by the Chinese cultural constraint to express the range and intensity of emotions frequently encountered in tumultuous end-of-life communications.

As chaplains attend to the multitude of complex issues within end-of-life encounters, they are often required to take up the role of a mediator within the triadic communicative process between the care recipients, their families and the healthcare professionals (Ellis 2000). This mediatory role of the chaplains is especially important in the absence of an existing accessible language for conveying the hard-to-verbalize spiritual needs in the illness and dying experience, which when left unattended will likely lead to spiritual pain (McGrath 2002). The necessity of the chaplain’s bridging role is made more urgent in the Chinese context of Hong Kong where the death taboo has cultivated general repression of open dialogue around the crucial, yet sensitive and difficult, issues in facing death. This resistance to the chaplains’ facilitation of the sort of end-of-life communication that identifies and attends to care recipients’ end-of-life goals, a component valued in their training, is compounded by the contextual idiosyncrasies of taboo which actively avoids “talk that meddles with death” (Chan 2009, p. 191) and by the cultural expectation which exalts self-discipline to steer away from extreme expressions (Lin et al. 1981, p. 240) to “follow the middle way” (Man and Chen 1972, p. 390). Under the abiding influence of these components from traditional customs that reinforce moderation in all things, emotional restraint in contemporary Chinese living (and dying) remains widely advocated (Bond 1988, p. 1009), creating the cultural norm where “[f]eelings are not to be spoken but to be sensed and discerned” (Gao and Ting-Toomey 1998, p. 26). In fact, according to Traditional Chinese Medicine (TCM), extreme emotions are pathogenic and detrimental to health, and thus to be eschewed (Bond 1993). These cultural constraints persuading against the expression of extreme sentiment and the lack of a linguistic template for articulating it, which have remained overlooked or inadequately addressed in chaplaincy formation, become problematic in the emotionally volatile end-of-life context, creating further obstacles for effective palliative care.

4.2.2. Cultural Importance of Maintaining Social Harmony

Moreover, this challenge in the effective facilitation of end-of-life communications faced by Hong Kong chaplains is further complexified by another layer of cultural resistance which acts to fortify the Chinese care recipients’ reluctance to enter emotionally turbulent, uncertainty-inducing and intimate end-of-life conversations (Bond 1993). Other than linguistic limitation and social aversion to expressing intense emotions, emotional suppression is also an embedded cultural characteristic that needs to be taken into consideration in practice.

Under the abiding Confucian influence, social harmony is traditionally valued in the Chinese ethos (Hsiung and Ferrans 2007), requiring individuals to fulfill their prescribed roles within the socially sanctioned relational hierarchy to avoid direct confrontations and disharmony (Quek et al. 2010, p. 360). In Chinese culture, the expression and conceptualization of the self are not understood as an autonomous unit with distinctly marked boundaries but are realized in the larger social group where each person fulfills an individual role to maintain collective harmony (Sun 1991, p. 20). The Chinese cultivation of self is thus highly dependent on the fulfillment of social roles, and this has a significant impact on how individuals express emotion. In other words, under the engrained cultural expectation to always preserve accordance, Chinese care recipients may feel the need to suppress or neutralize their emotional display so as to conceal their emotional needs for the sake of preventing disruption of harmony within the relational network (Krone and Morgan 2000, p. 85).

Taken together, these culture-related forms of resistance to end-of-life communications have inevitably created additional barriers for Chinese care recipients to overcome in order to access and receive the chaplains’ offer of spiritual care. Hong Kong chaplains, inadequately prepared by a flawed training model, are frequently compelled to navigate unforeseen difficulties as they strive to implement their acquired specialist knowledge and skillsets into their practice, acutely impacting the outcome of effective and timely delivery of quality end-of-life care to those in dire need.

5. Discussion

In order to move towards the attainment of the widely embraced holistic vision of palliative care in the increasingly complex and diverse contemporary healthcare landscape, it is vital for cultural idiosyncrasies to be taken into consideration, especially in the end-of-life care context. Successful delivery of this vision is crucially dependent on the cultural competence of the palliative chaplains to effectively navigate the individual needs and expectations of their care recipients who, in the case of Hong Kong, as in many other global contexts, come from a pluralistic background. However, as exemplified in this article, which has used Hong Kong as an example, there remains a gap in the chaplaincy formational pathways: sufficiently integrating the competence to understand and work with cultural idiosyncrasies into existing training modes. This neglect of adequate attention to the significance of the fundamental cultural differences, visible in the diverging worldviews and unspoken assumptions, inevitably creates additional challenges and unforeseen barriers for the chaplains in their practice. Some of these complications arise from the unaudited application of the Western CPE model in the socio-cultural and religiously divergent context of Hong Kong. Especially perceptible are the impact of the Chinese death taboo on the provision of end-of-life care, as well as the emotional constraints and the preservation of relational harmony which also impact the practice.

A key mismatch stems from the individualistic departure point of the humanist, interfaith training approach of CPE when it conflicts with the relational interdependence and collectivist understanding of personhood, foundational to Chinese culture. This fundamental divergence becomes discernibly problematic in practice as chaplains strive to implement the skillsets acquired in a model which prioritizes end-of-life communication to a patient population that is culturally less receptive to this approach when coping with their death and dying needs.

The chaplains encounter additional difficulties that could be a result of the deficiencies of their seminary training, which fails to account for practicing in multicultural contexts. The deeply rooted Christocentric worldview underlying the theological formation of the chaplains diverges fundamentally from the philosophical, existential, and ethical orientation encompassed in the syncretic blend of Hong Kong Chinese religion. The clashing disparities between the two dissimilar religious orientations profoundly impact end-of-life care needs and expectations including the ultimate understanding of a good death which the chaplains are motivated to help their care recipients to attain in their practice. In the absence of sufficient efforts to acknowledge, integrate, and reconcile these distinct cultural incongruencies within the chaplains’ professional formation, the chaplains are left inadequately prepared for the jarring difficulties encountered in their practice and are further hindered in delivering effective and timely end-of-life spiritual care to those in critical need. Palliative chaplains play an integral role within the holistic vision of modern healthcare, especially in their contribution to spiritual wellbeing for those in the final margins of life. In order for them to fully provide the necessary specialist support, ongoing reflection and identification of challenging areas in their practice may be a way forward to sustain the chaplains in their role within the contemporary medical setting.

Even though the complexities of cultural diversity highlighted in this research have presented additional hurdles for end-of-life care provisions, this review of those challenges may also be productively embraced as a fruitful resource for ongoing theological reflections on the current Christian practice of chaplaincy. The opening for discussion on the topic of culture and end-of-life care could be a step forwards in helping to transform and enhance the practitioner’s ability to fulfill their vocational calling in their participation with God’s ongoing redemptive work in, to, and for the world. For instance, future research may on one hand turn to explore how different aspects of Chinese culture bear upon and enrich theological reflection and the existing pastoral directives in end-of-life care. On the other hand, it may be an equally fruitful endeavor to focus on the impacts of the religious–cultural framework of CPE on the cultural conditioning of Chinese Christian chaplains, and the potentiality in opening up unanticipated dimensions for fresh insights in end-of-life care delivery by and large. Moreover, other areas for research may include qualitative studies on the perceived gaps in cultural-congruencies from the perspective of care recipients, or how cultural impacts on end-of-life care needs vary with generational differences in their attitudes towards death taboo and the understanding of the collective self. I thus hope that this article will help ongoing discussions to refine and expand on the professional education pathways that support chaplains in becoming culturally competent practitioners to serve end-of-life care recipients in the increasingly complex and pluralistic healthcare landscape.