End of Life Planning for Pakistani Americans

Fifteen years ago, 75-year-old Pakistani American Herma Ali was diagnosed with Stage III Breast Cancer at Stanford Medical Center. The Stanford breast cancer team endowed with the appropriate Pakistani cultural care of assessment and treatment for Herma’s disease. To respect Islamic traditional beliefs, they didn’t use the word “cancer” to elucidate the treatments and diagnoses to Herma. After using chemotherapy and surgery on Herma for one year, her family received the glad tidings of her remission of breast cancer. “Herma is alive and well after never hearing the word ‘cancer’ from the Stanford team,” said her son Abbas. Herma’s family has been grateful for the Stanford team.

Two years later, Herma Ali knew what she wanted for her good death. She was determined to leave the world to make sure others knew she had lived a great Islamic life with a positive contribution to the world. Herma was one of the few Pakistani Americans who utilized advance directives. Advanced directives are essential at the end-of-life care to make the patient’s chosen course of medical care very clear. Before dying, she gently but firmly delivered the shahaadah—the declaration, which means there is no god except Allah. Her family stood next to her and recited a Quranic surah for seeking Allah’s forgiveness in the Hereafter. They also supplicated good words in front of her to make the process of dying easier. Stanford was very respectful of Islamic death rituals. The Stanford nurse, Frances Mert, wore gloves at all times after her death because it was believed her body belonged to Allah. Herma had the same sex nursing staff too; she had good control of her final days for a good death.

Herma’s family made sure that she was ready for burial right after her death because this is mandatory in Islam. Her preparations included being washed and wrapped in sheets of white cloth. Afterwards, the “Imam” performed the funeral prayer for Herma outside of a mosque, along with other Muslims in the community. Then she was buried in a Muslim graveyard.

Herma Ali created a great example of someone who exploited the benefits gained from advance directives. But she was the only one of many Pakistani Americans to do so. For an efficient solution to this problem, I would urge physicians to discuss the advantages of advance directives to this specific ethnic group during their appointments and follow-ups.

Pakistani older adults are a growing population in America. According to the 2010 U.S. Census, there were 2 million individuals who identified themselves as Pakistani. Pakistanis over 65 years old are 80% of the Pakistani population. Many of these Pakistani Americans can also have cultural appropriate care across the nation. The Stanford’s module is available readily for health care professionals, and people providing care of elders from Pakistani backgrounds in America. Active end-of-life planning is an unfamiliar concept to most elderly Pakistani Americans. These older adults might be reluctant to participate for active end-of-life care as they may believe talking about death can make it reality.