â€å“i Read a Book One Day and My Whole Life Was Changed.ã¢â‚¬â – Orhan Pamuk

Ma¯ori have the correct to high-quality, advisable intendance in all health settings. This study aimed to determine the perceptions and preferences of Ma¯ori for end-of-life intendance in a hospice. A Kaupapa Ma¯ori arroyo to research shaped this qualitative airplane pilot  study. Data were collected using semi-structured interviews with five elders fromMa¯ori communities and two focus groups with seven family unit members of Ma¯ori patients who had recently received hospice care. Thematic assay identified (1) that participants perceived hospice equally like a hospital, a place where people died, (ii) what they appreciated and wanted from  ospice, such as family unit-centred endof- life care and respect for Ma¯ori cultural practices, (iii) what they perceived as problems and barriers to receiving hospice care, and (4) their potential solutions to these problems, such equally community data seminars about the breadth of hospice services. These findings have implications for how Aotearoa/New Zealand hospices can ensure appropriate intendance for Ma¯ori patients and their families, as  well every bit for clinicians and other hospice staffwho aim to provide culturally sensitive intendance.

Cardinal words

terminate of life, family carers, hospice,Ma¯ori, New Zealand, palliative care

Introduction

Ma¯ori are indigenous to Aotearoa/New Zealand, and comprise approximately 15% of the country's 4.4 million inhabitants (Statistics New Zealand, 2011). Disparities between Ma¯ori and not-Ma¯ori in morbidity, bloodshed and the quality of healthcare services received are well documented (for example, see Robson and Harris, 2007). Ma¯ori are less probable to admission healthcare services in general, despite having higher levels of need (Robson and Harris, 2007). Findings from a 3-yr chart review (n = 1293) conducted at a hospice based in Wellington, the capital city, showed that between 2006 and 2008 only 6% of patients selfidentified every bit Ma¯ori, fifty-fifty though Ma¯ori represent x% of the population of this region (Majuscule Coast Commune Health Board, undated). Although this chart review indicated that the length of time during which individuals received hospice services and the number of inpatient unit visits did not differ significantly by ethnicity, information technology was establish that Ma¯ori patients were significantly younger and were more probable to dice at dwelling than non- Ma¯ori patients (Taylor et al, 2012).

Many Ma¯ori people limited beliefs and practices with regard to what constitutes health and with regard to the processes of death and dying which appear quite distinct from those from other cultural backgrounds (Cram et al, 2003; Walker et al, 2008; Waldon, 2003). Specific traditional rituals at the time of decease and bereavement are as unique as those from any culture. Indeed, they can vary slightly from ane Ma¯ori tribe to another. Traditionally, for example,manyMa¯ori believe that it is spiritually of import to die and be buried at one's bequeathed habitation. Bodies are typically returned to this location if the deceased did not dice there. Extended family and friends assemble for 3 to five days to mourn the deceased at the local meeting house. Those who mourn talk, and fifty-fifty joke or sing, to the deceased to bring closure to their relationship. Mourners may sleep in the large meeting house where the deceased person is lying. At the terminate of the mourning flow, the deceased person is buried (Schwass, 2005).

Hospices in Aotearoa/New Zealand are striving to respond to the New Zealand Palliative Intendance Strategy (Ministry of Health, 2001) that advocates culturally sensitive palliative care for all. A contempo qualitative study of Auckland surface area indigenous and immigrant clinician, patient, and family perspectives on challenges to hospice services described several barriers to accessing hospice care among Asian, Pacific andMa¯ori people in northern Aotearoa/New Zealand (Frey et al, 2013). These barriers included unfamiliarity with what hospice care involves, perceptions of hospices as a place in which to die that costs a lot of money, language barriers, gatekeeping physicians who assumed that members of these groups would adopt non to use hospice services, and fearfulness of discrimination from the predominantly white hospice clinicians (Frey et al, 2013).

These issues relating to end-of-life care are non unlike those establish among other indigenous peoples, for case, in Australia, Canada, and the USA. All of these have been described every bit oftentimes having in common the following factors that affect terminate-of-life care (see, for example, O'Brien et al, 2013; Johnston et al, 2013; McGrath and Phillips, 2009; Kelly et al, 2009; Hotson et al, 2004):

• remote homes, resulting in social isolation when the patient is taken to an urban-based palliative care service

• beliefs and customs, such as spiritual connexion with the state of one'south heritage, prompting the desire to die at habitation

• low economic status and distrust of western medical care contributing to delayed entry into a westernised healthcare arrangement

• respect for traditional and spiritual healers and healing modalities

• the vital importance and involvement of an often large, extended family unit

• deference to elders in the community who can provide knowledge pertinent to end-of-life care

• holistic philosophies about how to alive and die, which include a spiritual component.

Given the known health and healthcare disparities between Ma¯ori and non-Ma¯ori in Aotearoa/New Zealand, and the trend among ethnic peoples of the South Pacific and North America, it is plausible thatMa¯ori may not receive the same quality of cease-oflife hospice intendance every bit non-Ma¯ori patients do. However, Ma¯ori have the right to high-quality, appropriate care in all wellness settings (United Nations, 2007).

With the exception of the study by Frey et al (2013) which recruited merely six Ma¯ori patient or family carer participants, in that location is a paucity of documentation about Ma¯ori perceptions and experiences of receiving endof- life intendance from a hospice. A search of half-dozen databases (including CINAHL, PubMed and PsycINFO) revealed no other written report of Ma¯ori patient or family perspectives. Therefore the purpose of this pilot written report was to accost the post-obit questions. How do Ma¯ori perceive hospice care? What cultural practices would be desired if they were receiving care at a hospice? What aspects of hospice support are appreciated? What are the barriers to entering hospice services? What could hospices do to improve care for Ma¯ori patients?

Cultural and philosophical underpinnings

Hospices provide palliative intendance for those with a lifelimiting illness. Palliative intendance aims to ease suffering and maintain quality of life by addressing physical, psychosocial, cultural and spiritual symptoms and needs (Palliative Care Subcommittee, New Zealand Cancer Treatment Working Party, 2007). In Ma¯ori society this care is usually delivered past a multidisciplinary team, and places patient and familywha¯nau at the centre of care. The Ma¯ori te whare tapa wha¯ model of hauora (health) is based on four pillars: wairua (spiritual well-beingness), hinengaro (emotional and mental wellness), tinana (physical well-existence) and wha¯nau (family, including extended family unit, and the wider social arrangement) (Durie, 1985; Ministry of Health, 2012). Co-ordinate to this model, hauora is supported not only by disease prevention and cure but also past health promotion that recognises and builds upon existing assets, such as wha¯nau support.

Both palliative care and theMa¯ori te whare tapa wha¯ model emphasise holistic caring and value the role of wha¯nau. However, this study aimed to determine more precisely which aspects of palliative hospice intendance are appreciated by Ma¯ori people, and what other aspects could exist improved to ensure that Ma¯ori patients receive appropriate intendance.

For an explanation of the te reo Ma¯ori terms that are used in this newspaper, see Table 1.

Tabular array 1 :Explanation of te reo Maori terminology

Methodology

Projection blueprint

This airplane pilot written report was shaped by the Kaupapa Ma¯ori inquiry paradigm. The Treaty of Waitangi, the founding document of Aotearoa/New Zealand, sets out the principles of partnership, self-determination, equity, and protection for Ma¯ori (www.nzaot.com/downloads/ contribute/TheTreatyofWaitangiAFrameworkfor MaoriHealth.pdf). Kaupapa Ma¯ori applies these principles in a enquiry setting for the benefit of Ma¯ori people, particularly the community in which the research takes place. KaupapaMa¯ori is oriented towards restoring justice, reclaiming resources and recovering histories (Smith, 1999). The Health Inquiry Council of New Zealand mandates that any research involving Ma¯ori people must involve consultation with Ma¯ori and, in item, Ma¯ori in the community in which the research volition have an impact (Health Research Council of New Zealand, 2008). Thus Kaupapa Ma¯ori research is characterised as research byMa¯ori, forMa¯ori and with Ma¯ori (Wellness Research Council of New Zealand, 2008). Although the principal investigator of this pilot written report (EJT) did not identify as Ma¯ori, the coinvestigators included a university-based wellness researcher (SS), the Chief Executive of a hospice (RE), and a Ma¯ori Liaison from the aforementioned hospice (PT), all of whom identified equally Ma¯ori. This projection was initiated by the Ma¯ori chief executive, who requested the hospice's non-Ma¯oriResearchDirector to directly information technology. Te PouTautoko (pregnant the key post supporting a meeting house), the hospice's Ma¯ori advisory group, was consulted throughout the design and implementation of the study. This group provided affidavit for the design, suggestions almost how to collect data, and recommendations about who to interview. The Ma¯ori researchers led and guided all advice and consultation with the Ma¯ori report participants and Ma¯ori community. They besides ensured that appropriate protocol was adhered to at meetings and interviews.

The hospice

This study was conducted at Mary Potter Hospice (MPH), a charitable trust that serves the Wellington region of Aotearoa/New Zealand. This hospice offers free multidisciplinary palliative care, primarily in the dwelling but besides in day units and an eighteen-bed inpatient unit. Although there was a sense amid the MPH staff that Ma¯ori hospice apply was increasing, no empirical information to substantiate this ascertainment existed.

Participants and recruitment

Participants were recruited in 2010 from two groups, namely whanau and kauma¯tua.

Wha¯nau

Wha¯nau are family members of Ma¯ori patients who had utilised the hospice service and who had died during the half dozen- to 18-calendar month period prior to the written report. Once they had been identified (past a calculator search of hospice patient records), individuals were sent a letter of the alphabet of invitation and then contacted by telephone by the Ma¯ori Liaison to discuss participation. Confront-toface or personal contact is preferable in Kaupapa Ma¯ori research (Smith, 1999). Given the salient role of wha¯nau support, the researchers chose to allow multiple members of one wha¯nau to participate. Opening the invitation to the wider wha¯nau was considered congruent with Ma¯ori civilisation.

Kauma¯ tua

Kauma¯tua were invited to take part in interviews. Kauma¯tua are male or female person elders who are selected by their community for their knowledge of Ma¯ori community and their power to instill this cognition in the younger generations (Barlow, 1994). Kauma¯tua may be called upon to settle disputes or to correspond the community to those outside it.These elders arehonoured and shown considerable respect. The kauma¯tua, who were identified past the Ma¯ori advisory group or Ma¯ori Liaison, were approached past either the Primary Executive or the Ma¯ori Liaison. Kauma¯tua were selected not only because they could provide wisdom informed by a deep knowledge of Ma¯ori culture, but also because they could represent their communities at large. Kauma¯tua from diverse iwi (tribes) were selected. Although this was not planned, all v of them had had relatives who had received hospice care.

Ideals

The Central Regional Health and Disability Ideals Committee granted approval for the report. All of the participants (focus group members and kauma¯tua) gave their written consent after receiving information well-nigh the study. The consent document advised participants that if their participation acquired distress, the hospice's spiritual carers and counsellors would be bachelor to them.

Methods

Research based on Kaupapa Ma¯ori tends to favour qualitative methods, as these are based on social interaction. Two methods were selected:

i Wha¯nau participants were invited to take part in one of 2 focus groups, both of which took identify in a Ma¯ori health clinic adjacent to a meeting hall (marae). These focus groups were conducted in accordance with accepted practice, with limited grouping size, a pre-set up structure for questions and the meeting, guided past a trained facilitator, with a secondary researcher in a supportive role (Ruff et al, 2005).

2 Kauma¯tua were interviewed privately in their homes.

Both the focus groups and interviews followed Ma¯ori protocol relating to mihi (introductions), and were led by the Ma¯ori researcher, with the non-Ma¯ori chief investigator taking a secondary role. The Ma¯ori linguistic communication, te reo, was encouraged if participants chose to speak it. Each participant used a number of Ma¯ori words and idioms, and one elderberry chose to conduct most of the interview in te reo Ma¯ori. (Translation of the occasional word or phrase was done by a Ma¯ori member of the research squad afterwards the transcription. The interview in te reo was transcribed by the Ma¯ori research team member who had conducted the interview, and was so translated by a professional language translation service.) Following each focus group, wha¯nau participants were acknowledged with kai (food), which is key to Ma¯ori gatherings, and kauma¯tua were thanked with a souvenir voucher for NZ$30.

The focus groups and interviews ranged from one to 2 hours in length and addressed the same topics (run across Box 1). If the participants agreed, interviews and focus groups were audio-recorded. Ane kauma¯tua requested that his vox should not be recorded, just agreed that notes could be taken. The recorded focus groups and interviews were all transcribed past either a professional person service or a hospice employee.

Various strategies were used to ensure the trustworthiness of the findings (Lincoln and Guba, 1985). These included prolonged in-depth appointment with participants for at least 1 hr, creating an inspect trail (audio recordings or notes of information nerveless and documentation about the analysis procedure), peer debriefing with project team members during regular meetings, and obtaining validation for the findings from a nonresearch squad member who was an good in Ma¯ori perspectives on hospice care.

Analysis

An anterior thematic analysis (Patton, 2002) was completed by the 2 researchers who conducted the interviews. This assay involved extracting from the transcriptions the data that were relevant to the study questions. These data were then condensed into themes, keeping with them pertinent illustrative data. The themes were clustered mostly around how hospice care was perceived, what was appreciated or desired at a hospice, possible barriers to using hospice services, and miscellaneous observations near how the Ma¯ori participants related to decease and dying. Although the findings were written by the not-Ma¯ori project team leader (EJT), they were reflective of separate analyses performed by both herself and theMa¯ori co-researcher (SS). During this final stage of the assay, these researchers discussed their respective perspectives on the information to ensure reliability and cultural sensitivity; this discussion revealed only minor discrepancies.

Findings

A total of 35 wha¯nau were identified as eligible to take part in the study. However, when the Ma¯ori Liaison attempted to contact them it was institute that either they were either no longer contactable past the phone number listed in the deceased patient's chart, they were not Ma¯ori themselves, they did not have transport, they did not have a family member to back-trail them, they were afraid to participate, or they declined to participate for an unstated reason. The Ma¯ori Liaison perceived that this was prove of a fear of talking about death. Finally, seven wha¯nau (i human being and six women, anile 34–74 years) agreed to accept role in the focus groups. They were the husband, daughter, mother and wives of the deceased persons. Each private brought a relative who likewise participated, sharing their own stories of living with a loved i who had received hospice intendance. These whanau, who represented the experiences of three hospice patients, all became study participants (n = 7). Five kauma¯tua (4 women and one human, aged 62–79 years) were approached, all of whom granted interviews. They were the spouses or parents of the deceased persons.

Theme 1: How do Ma¯ ori people perceive hospice care?

Although some of the participants described receiving a hospice nurse'south care for their loved one at home, they all equated hospice care with the inpatient unit (IPU). A few referred to information technology as being similar a hospital, a place where 'they have their rules ... [and] they are in charge', and consequently 'you don't have the freedom you practice at dwelling house ... y'all are a invitee there ... it isn't your space' (kauma¯tua participant). Several participants were aware of the hospice every bit a identify of treat those with cancer and also for elderly people, inferring that younger people or those with final nonmalignant diseases may receive care elsewhere.

The hospice was most ofttimes perceived as a place that 'you lot don't get out alive.' Information technology is where one dies: 'the last ride out', 'the cease, doom and gloom!' (kauma¯tua participant and wha¯nau participant, respectively). The participants stated that most Ma¯ori people whom they knew shared this perception. However, they added that their personal experiences did non support this perception, and that they now recognised the hospice as a place for respite care and symptom management. A wha¯nau participant described how she came to realise that hospice care for her loved one meant that 'it wasn't just the end ... at that place was more that could be done.' I kauma¯tua participant went further than this, stating that hospice intendance could prolong life 'at least a few days as its eases pain and suffering.' This elder posited that wha¯nau who do non take their suffering, dying loved one to a hospice 'are selfish to themselves and not caring about the ill.'

What aspects of hospice care do Ma¯ ori appreciate?

The participants' views provide insights into what Ma¯ori people value. Those who had witnessed respite intendance for a loved one found it an extremely positive experience: 'for my children and family if I'm at Mary Potter, get out me in that location. [Be]crusade I exercise know the strain on the family' (wha¯nau participant). Others perceived benefits of hospice care included the quietness in the IPU, which immune the 'spirit to settle' (wha¯nau participant), patient care equipment for employ at domicile, data about how to intendance for the patient and what was happening, counselling and 'someone to talk to' (wha¯nau participant), follow-upward bereavement care, the presence of spiritual carers (clergy) and the availability of a chapel, a non-denominational memorial service, and the availability of and feeling comfy with request staff for help. One kauma¯tua participant described a visit to back up someone at their death with karakia (prayer), and experienced the nurses equally culturally ignorant and disrespectful. However, all of the other participants enthused about the compassion that they experienced from hospice staff. For at to the lowest degree 1 individual, the hospice IPU could create a comforting sense of community: 'At that place is a sense of everybody knowing ... it'due south like nosotros're all wha¯nau even though you are all strangers. ... I was able to go there, not just to be with [my hubby], merely with the people that are effectually, that are only sitting there, just to be part of ... if they wanted ... have a talk ... I like it in there' (kauma¯tua participant).

What aspects of Ma¯ ori culture are desired in hospice care?

Wha¯nau-centred care was of vital importance to the participants. They appreciated existence immune to visit and stay at any time, beingness 'costless to come and get' (wha¯nau participant). Wha¯nau carers wanted staff support so that they could continue to provide intendance such as bathing, and wished that staff would ask their permission to provide intendance for their loved ane. Wha¯nau too emphasised the importance of letting their loved ones spend their final days at home. Elders in particular preferred to die at dwelling house. The reasons for wanting to get home for the final days of life were varied, and included the following: 'Ma¯ori accept care of their own ... it's better, more flexible, they prefer their own space' (kauma¯tua participant); '[my mum] didn't desire to die in somebody else'south bed' (wha¯nau participant); 'their own home is their roots, it's everything— tu¯rangawaewae [a place where one has the right to observe one'southward ain protocols for behaviour, and freedom to express ane's emotions and opinions; this place is linked to kinship and genealogy]' (wha¯nau participant). The importance attached to dying at home could create internal conflict when the wha¯nau carers became exhausted. The hospice's respite service was welcomed both every bit an option when this occurred, and for those patients who did not take local wha¯nau support: 'Information technology takes people in to give the family unit a pause' (kauma¯tua participant).

What caring practices practice Ma¯ ori people use?

The participants identified a range of tikanga Ma¯ori (cultural practices) (see Box 2). Speaking te reo Ma¯ori (Ma¯ori linguistic communication) to those who spoke te reo 'got through' and 'settled' them (wha¯nau participant). Te reo 'linguistic communication is important ... it's much nicer and much softer in your own language' (kauma¯tua participant). This same participant recommended that nurses learn some te reo, especially greetings and farewells, and the everyday terms such every bit the words for eating, toileting and bathing.

Other tikanga reflected Ma¯ori behavior about people, places and atmospheric condition being either tapu (sacred or restricted) or noa (unrestricted or ordinary). For example, when a person died, the room and the body of the deceased became tapu. Sprinkling water provided spiritual cleansing, and karakia [prayer] was used to mark the transition of the person from one country to the other. When visitors arrived to view the deceased person, they washed their hands when entering and leaving the room. Karakia and sprinkling of water in the hospice room after the deceased person had been removed was regarded as essential before that room could be used once again. Other examples concerned the use of linen, care of personal valuables, disposal of body tissue, and types of food and drinkable. One family unit was displeased with the lack of privacy afforded them when they accompanied their deceased loved one from the IPU room to the undertaker's room, which is regarded every bit a very sacred moment.

Several kauma¯tua recognised the requisite of institutional support of tikanga Ma¯ori practices if they were to occur. Policies supporting tikanga Ma¯ori, staff cultural training, and the employment of Ma¯ori staff who are respected and in leadership positions were seen as contributing to positive hospice experiences for Ma¯ori people. The lack of staff knowledge was axiomatic in one poignant negative experience: 'We did our karakia [in this example sung] and we were stiff, but the nurses were just a nuisance with their applauding and wandering around. They didn't realise that tikanga Ma¯ori was taking place' (kauma¯tua participant).

What are the barriers to accessing or receiving hospice care?

Many of the issues that the participants encountered with hospice care were too considered to exist reasons that discouragedMa¯ori people from accessing hospice services. The near frequent and salient response to queries about these barriers was the perception of hospice care equally the 'end of the line' (wha¯nau participant). One kauma¯tua participant believed that the denial of death prevented people from learning about and using hospice care. The other major reason thought to prevent Ma¯ori people from using hospice care was the cultural imperative around 'caring for our own' (wha¯nau participant). There is a perception among many Ma¯ori that 'there are no options given to wha¯nau who want to look after their ain' (kauma¯tua participant). Elders in particular do non want to leave their own space, and the grandchildren they may accept raised, in order to enter an institution likened to a hospital. The struggle to intendance for i's ain was sometimes intensified past this imperative. Those who accepted respite care in the IPU for their loved ane recognised that they 'just couldn't do any more', and stated that receiving respite care at the hospice was 'a release' (wha¯nau participant).

Other problems or barriers to receiving hospice intendance included difficulties with transportation and parking, and wishing that the hospice was closer to the pa¯ (Ma¯ori settlement), particularly if one was 'the merely brown face' (kauma¯tua participant), every bit the presence of other Ma¯ori people immune i to feel more comfortable and understood. Medical jargon and the lack of open communication were not helpful: 'I got really bellyaching about [the staff] giving people false promise when the truth is they're going to die' (wha¯nau participant). An additional effect was the lack of privacy: 'We went in at that place and there were two or three [patients] in the room. ... Hither we were going to wait at my nephew, to weep for him, and to say 'The fourth dimension has come up for you to exit, only your path is clear earlier you lot.' How could we weep? How could nosotros evidence our grief in that room when others were there?' (kauma¯tua participant).

These factors led participants to offer the following specific suggestions about how to counteract these challenges:

• offering better support for tikanga, such as providing a place for kauma¯tua to carry out cultural practices, and training staff about tikanga

• offering better support for whanau, such as providing facilities for kai grooming, childcare for visiting immature children, a laundry service, encouraging the family to appoint a spokesperson to interface on their behalf with clinicians, and addressing transportation and parking limitations

• improving the environment, moving closer to the pa¯, and making the hospice more like a marae [Ma¯ori meeting house]

• counteracting misperceptions of hospice care by providing information seminars within the Ma¯ori community and advertisements about hospice care, encouraging Ma¯ori patients and wha¯nau to share their positive stories of receiving hospice intendance, and changing the term 'hospice.'

These suggestions were offered in the hope that other Ma¯ori people would similarly come to do good from hospice care.

The participants all recognised that their culture was changing in terms of how information technology perceived end-of-life care should be. It was acknowledged that some individuals, especially older people, were more observant of tikangaMa¯ori, while others were less aware of their culture's beliefs and practices with regard to terminate-oflife care. For instance, some might want rongoa¯, mirimiri or karakia, while others might not.

Discussion

This small report presents the perceptions held by some Ma¯ori wha¯nau about hospice care. The findings demonstrate how the holistic Ma¯ori framework for well being is compatible with the perceptions of and preferences for stop-of-life treat Ma¯ori patients and wha¯nau (Ministry of Health, 2012). The physical and mental health of the individual, their spiritual well-being and spiritual realities were all of concern to Ma¯ori people. Fundamental to the quest for hauora is wha¯nau ora, family well-existence, and support for and by members of the wider family unit. Encompassing these perspectives is tikanga Ma¯ori (Ma¯ori cultural practices). Indeed, these findings demonstrate how many practices, such equally te reoMa¯ori, mihi, waiata and uses of kai, proceed to exist highly valued in the culture and are therefore vital to culturally sensitive care at the end of life (Barlow, 1994).

All of the participants identified various barriers that could preclude Ma¯ori people from using hospice services, and these were similar to the findings of Frey et al (2013) and Bray and Goodyear-Smith (2013). Notwithstanding, positive personal encounters with the hospice changed their perceptions. Patients could enter and leave the IPU, which meant that more than could be washed to help. Respite care allowed families to have a pause merely nonetheless remain as involved as they wished. Hospice clinicians by and large showed them compassion and respect. These factors, taken together, led almost of the participants to endorse hospice care.

Hospices could provide better back up with end-oflife care for Ma¯ori people. Marketing hospices every bit resource that back up wha¯nau as they intendance for their loved 1 with a terminal illness at home or within the hospice would help to address negative perceptions of hospice intendance (Bray and Goodyear-Smith, 2013). There was besides a need to annul misperceptions of hospice intendance as shortening life, and to brand it articulate that hospice care could ease unnecessary distress, and potentially prolong life (Temel et al, 2010).

The participants recognised that their culture was changing and that therewas a diversity ofMa¯ori beliefs and practices. Given the extraordinarily dynamic nature of Ma¯ori culture, it is important to continue to report how best to support Ma¯ori people at the finish of life, and to exercise flexibility. Clinicians must be prepared to cater for diverse expressions and experiences of Ma¯ori civilization and incorporate tikanga Ma¯ori practices with sensitivity.

Study limitations

This study has some limitations that will affect the extent to which the findings can be generalised. Information technology was a very minor study, with only 12 participants from the Wellington region, so it cannot be assumed that the perceptions held past these participants are cogitating of all Maori patients and wha¯nau. The perspectives of Ma¯ori people from the south end of the N Island or other regions of the state were non included. In addition, the study focused on those who had experienced hospice care at one particular hospice, and the results are therefore inevitably specific to this particular service.

Conclusion

This exploration of the perspectives of Ma¯ori people about end-of-life care in a hospice shows how ane indigenous people's knowledge and praxis in this regard interfaces with a Eurocentric arroyo to care. Although the concept of hospice care reflects a western epitome, these findings suggest that at that place are aspects of holistic hospice care that could be readily aligned with the Ma¯ori hauora framework and used by palliative care professionals to provide culturally safe care.

ACKNOWLEDGEMENTS

The authors are grateful to the New Zealand Health Inquiry Council for funding this Ma¯ori Seeding Grant, too as Mary Potter Hospice'southward Maori advisory group Te Pou Tautoko, the wha¯nau and kauma¯tua who shared their personal knowledge for this study, and Katherine Reweti-Russell, Projection Facilitator, Ma¯ori Health Development Group, Capital and Coast Commune Health Board, Wellington, New Zealand.

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