Cultural and religious issues professionals may encounter following a bereavement

Yunus Dudhwala, Barts Health NHS Trust

Support workers and professionals may encounter a variety of cultural and religious issues following a bereavement. Different faiths have varying beliefs surrounding death, and it is important for those caring for and supporting bereaved people to be aware and sensitive of these. This guidance will cover Hinduism, Islam, Judaism and Sikhism, the current four largest religions in the UK behind Christianity.

Practical issues that support workers may face

Cultural and religious issues can have a significant impact following a bereavement, particularly if there is conflict between religious customs and legal and medical requirements. Whilst some religious ceremonies may be similar to Christianity, and some crossover exists in Aramaic religions, major differences also arise. It is important for professionals to be aware that there may also be differences within different religious sects.

Pre-death rituals and last moments

In the immediate moments before death, it may bring members of faith groups and religions comfort to recite prayers, hymns and be with family and relatives or religious figures.

Last rites

Hinduism
During the final stages in life, it may be requested for a Hindu priest to be present to conduct last rites on a body. These can include tying a thread around the neck or wrist around the patient as blessing, and recital of hymns and excerpts from holy books. It may also be possible that a dying Hindu asks to lie on the floor in the moments before death. This custom has dual reasons; both to ease the breathing of an individual, so that the soul can depart easily, and also due to Hindu beliefs that the body is constructed of five elements. Lying on the floor also indicates a closeness to mother earth [1].

Islam
For Muslims that are close to death in a hospital or other environment outside of the family home, it will be greatly appreciated if arrangements can be made for the patient to be turned in a South-Easterly direction. This is so that they are facing the Kaaba, the black cube shaped building in the centre of the Masjid al-Haram, the Sacred Grand Mosque in Mecca. Where it is not feasible to turn the patient, their feet may be pointed in the direction of Mecca [2].

For patients that are conscious, family members and religious figures that are present will encourage them to recite one of the five pillars of Islam, a declaration of faith known as Shahada. This pledge consists of the words: “There is no God except Allah, Muhammad is the messenger of Allah”. A dying Muslim may also recite the last words of the Prophet Muhammad: “Allah, help me through the hardship and agony of death.”

Judaism
There are no specific last rites that are regulated under Jewish law, but there exist a variety of prayers and psalms patients may wish to speak before death. Jewish customs hold that no intervention should be made which could hasten the death of an individual; among more devout and traditional Jews, this may extend to avoiding moving or touching a patient. If an individual is conscious, then they may wish to say the Shema, or Psalm 23, ‘The Lord is my Shepherd’. The ‘Vidui’ prayer is commonly spoken before death, and is used as a confession before death. In Orthodox Jews, it is a mitzvah (good deed), to form a ‘minyan’, a group of ten adult males, to recite the prayer [3].

Sikhism
When a Sikh family sense that a relative is about to die, they will recite the ‘Sukhmani Sahib’, the hymn of peace. The dying individual may then attempt to say the ‘Waheguru’, or other passages or scripture that are suitable from the Guru Granth Sahib, the central Holy Scripture in Sikhism. The Kirtan Sohila, a night-time prayer said by Sikhs before the sleep, is also often recited either in before the moment of death, or immediately following the bereavement [4].

Prior to the funeral and medical issues

Last offices, post-mortem and treatment of the deceased’s body

Procedures that follow a death, such as a post-mortem, can often conflict with cultural and religious requirements. Care after death has a wide range of responsibilities, which include balancing legal obligations with spiritual and cultural customs.

Practically, this can consist of activities that ensure the body has been suitably prepared to be transferred to a mortuary or funeral director, enabling processes required for organ or tissue donation and safeguarding the health and safety of all those that come into contact with the body. Emotional support to the family will also be provided, and personal possessions will be returned to relatives [5].

Some religious groups may object to a post-mortem being undertaken, and have called for less-invasive methods such as MRI and CT scans. In the UK, resistance from Jewish and Muslim community groups was recognised through the 2009 Coroners and Justice Act, which highlighted the demand for a minimally invasive alternative [6].

Attitudes to post-mortem

Hinduism
Whilst post-mortems may be disliked by families and cause distress, there is generally no religious restrictions or objections to post-mortems in Hinduism. It is advised that care should be taken to ensure that the body is well presented following a post-mortem [7].

Islam
Post-mortems are opposed in Islam, and should not be undertaken unless they are required by law. Any post-mortem that is undertaken without legitimate and compelling legal or medical requirements is seen under Islam as a desecration of the body, although attitudes to organ donation may vary within different groups and sects [8].

Judaism
Attitudes towards post-mortem among Orthodox Jews are similar to those in Islam, and examinations are not permitted. Custom and religious belief holds that the human body is property of God that is leant to the individual during life. Following death, all efforts should be made to ensure that the body is held in as undisturbed a condition as possible. However, in progressive and Reform movements, attitudes to organ donation and autopsies may be more liberal [9].

Sikhism
Whilst Sikhs may prefer for a post-mortem not to be undertaken, there are no religious restrictions on examination taking place. However, it should be noted that Sikh religious custom is for the funeral to take place as soon after death as is possible. Medical staff should seek permission from the next of kin before conducting a post-mortem. Practitioners should also take care to avoid cutting body hair, and ensure that they do not remove the five 5 Ks from the deceased [10].

The 5 Ks (Kakkars):
The 5 Ks are symbols that are worn to identify their membership of the Khalsa, a body of devout Sikhs.

The articles included in the 5 Ks are Kesh, which refers to the practice of uncut hair, Kanga, a small wooden comb, Kacchera, a loose undergarment worn by Sikhs of both gender, Kara, a steel or iron bracelet and the Kirpan, an iron dagger [11].

Alternatives to traditional post-mortem

Virtual autopsy, or ‘Virtopsy’, is a recent development in forensic techniques. This method may be able to provide a long term replacement for invasive physical post-mortems. An extensive study into the effectiveness of the accuracy of this method was conducted in Manchester and Oxford between 2006 and 2008. Researchers examining the results concluded that CT scans produced more accurate results than MRI scans, and that error rates produced by radiologists using these methods were similar to those gained from traditional autopsies.

However, the report also concluded that the accuracy of detecting sudden forms of death, particularly in relation to heart conditions, was often far more limited than in conventional post-mortem procedures [12]. Following legislative changes in 2009, the option of non-invasive post-mortem was introduced to pathologists in late 2013 [13].

Mortuaries and touching the body

Generally, in all four faith groups covered in this guidance, there is no objection to medical staff who are not faith members touching the body. In Sikhism, Hinduism, Islam and Orthodox Judaism, permission to touch the body may only be provided if the hospital staff are of the same gender of the deceased.

Funeral and preparation

In many faiths, it is necessary for a funeral to be undertaken very soon after the death. Medical practitioners and support workers should be aware of the potential for religious requirements to clash with legal and medical procedures, particularly in cases where a bereavement is sudden or traumatic. Issues may also arise if a death occurs out of hours or on a weekend, where access to a registration facility may be more limited. Practice may also vary according to location, and it is important for bereaved families to be provided with support and accurate information.

Hinduism
In the immediate period after the death, hospital staff should ensure that the deceased body’s eyes are left closed and limbs straightened. Families should always be consulted prior to a body being touched. Any jewellery or religious symbols should be left on the body, which then should be covered with a white sheet. Whilst in India many Hindu’s choose to die at home, and funerals generally take place within 24 hours of the death, the more extensive administrative process in the UK often delays this custom [14]. Attempts to release the body as quickly as is possible to allow the family to prepare for cremation will be greatly appreciated.

Islam
As in Hinduism, family members will also wish to close the eyes of the deceased immediately after death. Relatives will also wish to ensure that the lower jaw is bandaged to the head, to prevent the mouth from opening, and turn the body to the right and to the South-East, to the direction of prayer known as the ‘Qibla’. In cases where post-mortem is not required for legal purposes, the family will seek for the body to be released as soon as possible [15]. When comforting a bereaved family, male support workers, police and other professionals should take care not to offer physical signs of comfort, such as hugs, to the opposite gender.

Judaism
Immediate rituals after death are similar to those in Islam. Relatives will ensure that the deceased’s eyes are closed, and mouth closed and tied. The body will be covered in a white sheet. Traditionally, Jewish customs require a funeral to occur within 24 hours of the death. However, burial may be delayed if necessitated through legal delays, or in situations where a body needs to be repatriated or if relatives are travelling to attend the funeral. Burial will also not occur on the Sabbath or other holy days [16].

Sikhism
Sikhs also require for the eyes of the deceased to be shut, mouth closed and limbs straightened and then covered with a plain white sheet. Customs ensure that a quick funeral is essential, and efforts to provide a death certificate as quickly as is possible will be greatly appreciated by the bereaved family.

Repatriation

Some faith groups may desire for the body of a relative to be repatriated to the country of the family’s origin. Transporting a body overseas can be an expensive exercise, and costs are in the region of £1,200, but vary on location[17]. For families that wish to repatriate a body, there are several specialist agencies that exist and may be able to assist with this process. If a death occurred overseas and transfer of the body to the United Kingdom is requested by the family, the Foreign and Commonwealth Office may be able to offer advice and liaise with officials abroad.

The funeral

Funeral customs range greatly between the religions covered in this guidance, and may also vary in different sects among belief groups. Whereas Orthodox Jews are completely opposed to cremation, it is permitted in some more liberal groups. It is important for those involved with the process of the funeral to be aware of contrasting attitudes to expressions of grief, the attendance of women and attendance of non-faith members.

Expressions of grief at the funeral

• Hinduism. The expression of grief is usually open, and wailing and crying are not discouraged.
• Islam. Weeping at a funeral is accepted, but loud crying and wailing are frowned upon.
• Judaism. Weeping, wailing and crying are not discouraged and emotional expression is encouraged.
• Sikhism. Mourning attendees at the funeral are expected not to cry and wail, and to keep their emotions controlled.

Attendance of non-faith members and women

• Hinduism. Non-faith members are free to attend a funeral, and women are also able to attend a funeral. However, custom holds that women must stand behind men at the crematorium.
• Islam. Funerals are often private and not open to non-faith members. It is advisable to contact the family to enquire if the attendance of women will be allowed.
• Judaism. In Judaism, any faith member will be free to attend a funeral. However, the role of women at funerals may vary between Orthodox and progressive sects of Jews.
• Sikhism. Any faith member is free to attend a Sikh funeral, and women are also permitted to attend the funeral.

Cremation or burial

• Hinduism. Traditionally, cremation is associated with a Hindu funeral. However, some sects may prefer burial, although this is less common. Children aged under 5 years old will be buried, not cremated.
• Islam. Cremation is strictly prohibited in Islam, due to the same customs that prohibit autopsies to be undertaken [18]. Muslims believe that the deceased body should be given the same respect as a living body, although cremation is permitted in very limited cases where it may prevent the further spread of contagious diseases.
• Judaism. Attitudes to cremation are similar to Islam among Orthodox Jews. However, there are diversities among Liberal and Reform Jews, and cremations have become increasingly popular in some sects, despite tradition favouring burial.
• Sikhism. Sikh funerals generally involve cremation, although burial may be permitted in circumstances where cremation is not possible.

Following the funeral

Mourning periods are very different in the four religions covered. Whilst some may immediately follow the death, other religions may not begin rituals and customs associated with grieving until after the funeral has occurred.

Hinduism
Due to Hindu belief in reincarnation, excessive mourning is not permitted. The mourning period immediately follows the cremation and funeral, and lasts thirteen days. Festive occasions, including weddings and festivals, will be avoided by the family in this period, and in some groups, for a year after the bereavement [19].

Islam
The mourning period in Islam is shorter than that in Hinduism, and traditionally lasts for 3 days after the funeral. However, a bereaved widow will be expected to grieve for a longer period, known as ‘Iddah’ or ‘Iddat’, the stage of waiting, which lasts for four months and ten days. During this time, a woman is not allowed to remarry.

Judaism
The initial period of mourning in Judaism is known as ‘Shiva’, and lasts for seven days. Traditionally, the bereaved will gather in the family home, and receive visitors who will offer support. A ‘Yahrzeit candle’ will be lit in the family home on return from the funeral, and will also be lit on each subsequent anniversary of the death. A separate ceremony will generally also be held to unveil the tombstone at the graveyard.

Sikhism
Sikh mourning is also shaped by the religion’s belief in reincarnation. For ten days after the funeral, bereaved relatives will traditionally remain in the family home and will read the entirety of the Sikh Holy Scripture, the Guru Granth Sahib. The process of reading this book is known as the ‘Sidharan paath’, and once this has been completed the period of formal mourning will end.

References