Cultural Considerations in Palliative Care

Culture is a fundamental determinant of how individuals and families experience serious illness, interpret symptoms, make treatment decisions, and navigate the dying process. In palliative care — where conversations about prognosis, suffering, death, and grief are central — cultural responsiveness is not merely desirable but essential to delivering safe, equitable, and person-centred care.

Australia's population is among the most culturally and linguistically diverse in the world. According to the Australian Bureau of Statistics (ABS), more than 7.6 million people (approximately 30% of the population) were born overseas, originating from over 200 countries and speaking more than 300 languages. The largest overseas-born populations include those from England, India, China, New Zealand, the Philippines, and Vietnam. Additionally, Aboriginal and Torres Strait Islander peoples — Australia's First Nations peoples — comprise approximately 3.8% of the total population (around 984,000 people as of the 2021 Census) and carry a disproportionate burden of chronic disease and early mortality.

Despite this diversity, palliative care access and outcomes remain inequitable. Research consistently demonstrates that:

• CALD patients are less likely to access specialist palliative care services and more likely to die in acute hospital settings rather than at home or in hospice.
• Aboriginal and Torres Strait Islander peoples are referred to palliative care later in the disease trajectory, experience higher rates of uncontrolled symptoms, and are more likely to return to Country (their traditional lands) to die when this is culturally important.
• Language barriers, health literacy gaps, and unfamiliarity with advance care planning processes contribute to lower rates of documented wishes among CALD populations.
• Stigma associated with the word "palliative" in some communities — where it may be perceived as abandonment or as hastening death — can delay engagement with services.

The Australian Institute of Health and Welfare (AIHW) reports that palliative care-related hospitalisations for Aboriginal and Torres Strait Islander peoples are approximately 1.4 times the rate for non-Indigenous Australians, yet access to community-based and specialist palliative care remains significantly lower, particularly in remote and very remote areas.

This article provides a framework for culturally responsive palliative care across the Australian context, addressing care for CALD communities, Aboriginal and Torres Strait Islander peoples, the critical role of interpreters, and accommodation of diverse rituals and decision-making practices.

The term "CALD" encompasses people from diverse cultural, linguistic, religious, and ethnic backgrounds who were born overseas or whose parents were born overseas. In the palliative care setting, CALD patients face unique challenges that, if unaddressed, result in poorer symptom management, delayed care planning, and unmet psychosocial and spiritual needs.

Barriers to Equitable Palliative Care for CALD Patients

Cultural Assessment Framework

Clinicians should undertake a structured cultural assessment early in the palliative care trajectory. The following domains, adapted from the Kleinman explanatory model and the Royal Australasian College of Physicians (RACP) cultural competency framework, provide a practical scaffold:

Practical Strategies for CALD Palliative Care

• Engage professional interpreters for all significant clinical discussions — see the dedicated Interpreters section below.
• Use plain language and check understanding with teach-back, not simply "Do you understand?"
• Explore the patient's preferred level of disclosure before delivering prognostic information. Ask: "Some people want to know everything about their illness. Others prefer their family to know first. What is your preference?"
• Identify and document the patient's nominated decision-maker(s) and the family's preferred decision-making model in the care plan.
• Reframe "palliative care" where needed — terms such as "comfort care," "supportive care," or "holistic care" may reduce stigma and improve engagement.
• Accommodate religious and spiritual practices proactively — prayer mats, dietary provisions (halal, kosher, vegetarian), chaplaincy or spiritual care services, and clergy visitation.
• Partner with ethno-specific community organisations and multicultural health services (e.g., NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors [STARTTS], AMES Australia, Settlement Services International).
• Document cultural preferences prominently in the medical record, including communication preferences, dietary needs, ritual requirements, and bereavement expectations.
• Consider the "double grief" experienced by CALD patients and families — grief related to the illness compounded by loss of homeland, displacement, migration trauma, and social isolation.

Aboriginal and Torres Strait Islander peoples are the First Nations peoples of Australia, comprising hundreds of distinct nations, language groups, and cultural practices. Palliative care for First Nations peoples must be grounded in respect for cultural identity, connection to Country, community, and the holistic concept of health embedded in the National Aboriginal Health Strategy definition: "Health is not just the physical well-being of the individual but the social, emotional, and cultural well-being of the whole community."

Key Concepts for Clinicians

Barriers to Palliative Care Access

Best-Practice Approaches

• Partner with ACCHOs: Aboriginal Community Controlled Health Organisations (such as those affiliated with the National Aboriginal Community Controlled Health Organisation [NACCHO]) are the preferred providers for many communities. Collaborative models of care between ACCHOs and specialist palliative services improve access and cultural safety.
• Employ Yarning: Yarning is a culturally embedded communication style that involves storytelling, listening, and shared understanding. Clinical yarning (health yarning) integrates clinical questions within a relational, conversational framework. It is more effective than direct questioning for eliciting concerns, goals, and preferences.
• Support return to Country: Where a patient wishes to die on Country, facilitate this with appropriate symptom management, equipment, and support. This may require coordination with the Royal Flying Doctor Service (RFDS), remote area nurses, and local Aboriginal health workers.
• Respect Sorry Business protocols: Avoid using the deceased person's name (ask the family for the preferred approach); accommodate smoking ceremonies; allow communal grieving; do not rush burial timelines. Refer to the local community's specific protocols, as these vary between nations.
• Engage Aboriginal health workers and liaison officers: Aboriginal and Torres Strait Islander health workers bridge clinical and cultural worlds. They facilitate communication, explain clinical processes in culturally appropriate ways, and advocate for the patient and family.
• Use visual and culturally appropriate resources: The "Dying to Talk" discussion starter developed by Palliative Care Australia includes culturally tailored resources. The "My Story" and "Yarning About Dying" resources developed by ACCHOs are valuable tools.
• Address systemic racism: Ensure staff training in cultural safety (beyond cultural awareness or cultural competence); implement organisational policies for zero tolerance of racism; audit health outcomes by Indigenous status.

Effective communication is the foundation of quality palliative care. When a patient's preferred language is not English — or when the patient uses Aboriginal or Torres Strait Islander languages — professional interpreter services are not optional but ethically and legally mandated for all significant clinical conversations.

When to Engage an Interpreter

• Breaking bad news and prognostic discussions
• Advance care planning conversations
• Goals-of-care meetings and family conferences
• Informed consent for procedures (e.g., PEG insertion, thoracentesis)
• Discharge planning and transition-of-care discussions
• Medication counselling (particularly opioid initiation, syringe driver use)
• Assessment of symptoms, pain, and psychosocial distress
• Bereavement support and follow-up

Types of Interpreter Services in Australia

Best Practices for Working with Interpreters in Palliative Care

• Pre-brief the interpreter: Before the session, brief the interpreter on the clinical context, the sensitive nature of the discussion, and any specific cultural considerations. Allow the interpreter to flag if they have a personal connection to the patient or family that may compromise neutrality.
• Position the interpreter appropriately: Seat the interpreter next to or slightly behind the patient, facing the clinician. The interpreter should be visible to both parties but not dominating the interaction.
• Speak directly to the patient, not the interpreter: Use first-person address — "How are you feeling?" not "Can you ask her how she is feeling?" This preserves the patient-clinician relationship.
• Use short sentences and pause frequently: Allow the interpreter to convey complete thoughts. Avoid jargon, idioms, and metaphors (e.g., "fighting the battle," "passing away") that may not translate well.
• Allow for cultural brokering: Skilled interpreters do more than translate words — they bridge cultural gaps. Allow the interpreter to flag cultural misunderstandings or suggest culturally appropriate phrasing, with the patient's consent.
• Document interpreter use: Record the interpreter's name, the language used, and the mode (on-site, video, telephone) in the clinical record for every encounter.
• Debrief the interpreter: After emotionally challenging sessions (breaking bad news, discussing withdrawal of treatment, death notification), check in with the interpreter. Interpreters experience vicarious trauma and may need support.

Funding and Access

The Translating and Interpreting Service (TIS National), funded by the Australian Government Department of Home Affairs, provides free interpreting for private medical practitioners and public health services through specific access points. Medicare does not directly fund interpreter services, but TIS National is available at no cost to medical practitioners, pharmacists, and allied health professionals in private practice when seeing patients with limited English proficiency. Aboriginal Interpreter Services are funded through state and territory governments and the Commonwealth. Clinicians should familiarise themselves with their local service access arrangements and maintain a list of frequently used language services.

Cultural and religious rituals surrounding dying, death, and bereavement are deeply meaningful and serve important psychological, spiritual, and social functions for patients and families. Accommodating these rituals — or failing to do them — has a direct impact on the patient's dignity, the family's grief trajectory, and their experience of care.

Decision-Making Models Across Cultures

Western bioethics is grounded in the principle of individual autonomy — the patient has the right to receive information and make independent decisions. However, many cultural frameworks operate on different models:

Common Rituals and Practices at End of Life

The following table summarises common (but not universal) end-of-life practices. Always confirm the individual patient's and family's specific preferences rather than assuming adherence to general cultural or religious norms.

After-Death Care and Cultural Accommodation

After-death care is a critical opportunity to honour cultural and religious practices. Clinical teams should:

• Ask the family about their wishes for after-death care before washing or positioning the body. In some traditions, the family (or specific community members) must perform the washing; in others, the body should not be moved or touched for a defined period.
• Allow time with the body. There is rarely a clinical reason to rush the transfer of the body to the morgue. Accommodate extended bedside visitation, prayer, chanting, singing, or vigiling.
• Respect cultural burial timelines. Islamic and Jewish traditions require burial within 24 hours. Facilitate this through prompt death certification, coronial clearance (where applicable), and liaison with funeral directors who are familiar with cultural requirements.
• Accommodate return of the body to Country or overseas. For Aboriginal and Torres Strait Islander patients, repatriation of the body to Country may be requested. For CALD patients, repatriation to the country of origin for burial may be desired. Funeral directors specialising in international repatriation can assist with documentation, embalming requirements, and transport logistics.
• Support organ and tissue donation conversations sensitively. Some cultural and religious traditions support donation; others do not. Explore the patient's and family's views non-judgementally and involve DonateLife staff where appropriate.

Advance Care Planning in a Cross-Cultural Context

Advance care planning (ACP) is promoted in Australian healthcare as a means of ensuring care aligns with the patient's values and preferences. However, ACP processes were designed within a Western autonomy framework and may not translate directly to all cultural contexts. Clinicians should:

• Adapt ACP conversations to the patient's communication style and decision-making model — do not force individualistic ACP onto a patient who prefers family-led decisions.
• Explore whether the patient wishes to discuss end-of-life preferences at all, and at what pace.
• Use culturally appropriate language — avoid terms like "Do Not Resuscitate" and instead frame discussions around "What is most important to you?" and "How can we make sure your care reflects your values?"
• Recognise that for some patients, spiritual and faith-based frameworks (e.g., "It is in God's hands") are not avoidance but a legitimate decision-making framework that should be respected.
• Document cultural preferences in ACP documents and ensure they are accessible across care settings (hospital, community, residential aged care).

Cultural considerations intersect with other dimensions of diversity and vulnerability. The following special populations require additional attention:

Culturally responsive palliative care cannot be achieved by individual clinicians alone. Health service organisations must embed cultural responsiveness into policy, practice, and governance:

• Cultural safety training: Mandatory, ongoing training for all staff — not one-off cultural awareness workshops, but reflective practice that examines power, privilege, unconscious bias, and systemic racism. Training should be co-designed and co-delivered by Aboriginal and Torres Strait Islander educators and CALD community representatives.
• Interpreter service policies: Institutional policies mandating the use of professional interpreters, with easy access to booking systems (e.g., TIS National integration into clinical workflows, interpreter phones on wards).
• Diverse workforce: Actively recruit and retain staff from CALD and Aboriginal and Torres Strait Islander backgrounds at all levels, including leadership and governance roles.
• Cultural liaison roles: Fund dedicated Aboriginal health liaison officers, multicultural health liaison officers, and spiritual care practitioners as part of the palliative care multidisciplinary team.
• Physical environment: Create culturally safe spaces within hospitals and hospices — prayer rooms, family gathering spaces, access to outdoor areas, culturally appropriate food options, and displays of cultural artwork and signage.
• Community engagement: Establish formal partnerships with ethno-specific organisations, ACCHOs, religious institutions, and community leaders. Involve community members in the design, delivery, and evaluation of palliative care services.
• Data collection: Routinely collect and report on cultural and linguistic diversity data, Indigenous status, interpreter use, and patient experience by cultural group to identify and address disparities.
• Policy alignment: Ensure organisational policies align with the National Palliative Care Standards (Palliative Care Australia, 4th edition), the NSQHS Standards, the Closing the Gap targets, and relevant state and territory multicultural health policies.

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