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

Round 1

Reviewer 1 Report

This article presents an important argument for the training of chaplains in the context of Hong Kong and I think can be  useful in other cultural contexts to support the ways chaplains everywhere much tend to the cultural needs of the dying. That said, there are several clarifying points that should be added in order to strengthen your paper/argument and clarify the theological and educational particularities of your context or, put another way, to acknowledge the differences between the Hong Kong context and other theological contexts of training. I list these below followed by a few additional remarks.

1) CPE in the western and South Korean context is not purely secular, though it does tend to the inter religious dynamics of spiritual care in the hospital (or other) settings. If CPE is strictly secular in Hong Kong, please state that is particular to this context.

2) Protestant theological training (seminary, divinity school) in the U.S., Europe, South Korea, Australia, and elsewhere include practical theology, including pastoral theology and care which tends to issues issues of death and dying among others, in their curriculum as an elective if not a required course. Many denominations require pastoral care courses (in addition to CPE) for ordination. If (Anglican??) theological training in Hong Kong does not offer these courses at all it is unique among other theological institutions. If they are offered and not utilized that is an additional matter to address. Your paper would be more accurate to state as such. This is particularly important considering the international readership of this journal.

3) It would be helpful for you to state the theological tradition from which you write in order to provide a context for the end of life theological claims you are making (i.e locate yourself theologically). While you have pointed to foundational beliefs of Christianity, the interpretation of these tenets and how to represent them at the end of life vary widely from denomination to denomination.

4)Your article makes the distinction that palliative chaplains are responsible for end of life care. Healthcare chaplains in general, those not working with palliative care teams, in many other countries are equally responsible for end of life care. Please clarify and state what is specific to how end of life care is address  in the Hong Kong context. Are all dying patients tended to only by palliative care teams and those chaplains? Do non palliative chaplains ever offer end of life care. Are there non palliative chaplains? Again, consider your international audience.

5) (Line 321) concerning  the role of the chaplain in facilitating communication that attains "closure" - this is a grand claim for a process, if it exists at all, is a long part of the grief process. Please reconsider this idea. A helpful resource would be The Myth of Closure: Ambiguous Loss in a time of Pandemic and Change by Pauline Boss.

6) Line 329/330 - the use of a resource from 1979 is  not appropriate to support and argument about what is valued in North America in 2022. Similarly, line 380/381 a resource from 1988 is used to support an argument for "contemporary Chinese culture". Please update your resources here.

7) There is a surprising lack of reference to generational difference of belief of which there is usually at least some tension. How do generational beliefs or tensions shape end of life care or the challenges to this care.

Best Regards

Author Response

Thank you  for your insightful comments to improve on the manuscript.

1. I have expanded on CPE in Hong Kong and its similarity with CPE in other contexts in attending to the inter-religious dynamics of spiritual care in line 273.
2. I have expanded on describing theological training in Hong Kong in line 220.
3. I have located myself theologically in line 70.
4. I have added a section to describe Hong Kong chaplaincy further in section 3.1 (line 190)
5. Thank you  for directing me to the helpful resource on closure. I have clarified the point in the added footnote #11. (line 377).
6. I have updated the use of my resources on lines 386 +388.
7. Thank you  for pointing out the need to address generational difference of beliefs and the tension which that may bring to end of life care needs. I have brought that point into the discussion (line 531) to suggest this important aspect be further explored in  future research. 

Reviewer 2 Report

Review of “The Impact of Cultural Diversity on End of Life Care” by Anonymous Author

The author contends that evangelical Christians in Hong Kong  who are chaplains in palliative care units  are insufficiently trained in the Chinese cultural attitudes to death. These chaplains have been trained through clinical pastoral education (CPE) that has been borrowed from the North American context which is a different culture from Hong Kong. The Chinese culture in Hong Kong has different attitudes and practices  towards death than the Western culture in North America. Certainly this is an important topic not only for chaplains in palliative care but all chaplains who encounter many different cultures in their work of spiritual care. This article has much to offer. The references are valuable. The discussion of Chinese death taboos and also the need for harmony and stability within the Chinese family are important points.  The author also emphasizes the need for more cultural training of chaplains which implies a cultural humility. points out the need for more education and training in terms of cultural awareness and humility

The article could be improved through a number of revisions:

1.     Being more specific. The author tends to lapse in generalities that can be contested. For example, chaplains in Hong Kong are described as from the evangelical Protestant tradition. Questions arise around this: how many units of CPE do these chaplains have. There is quite a difference between a chaplain with one unit of CPE and one with four. Are there any Buddhist chaplains or chaplains from other faith groups in Hong Kong? Within the Canadian Association o9f Spiritual Care which uses CPE as its training modality, there are a number of cultural competencies that require cultural knowledge and humility. In the CPE training of these Hong Kong Chaplains, which cultural competencies in CPE are inadequate and/or are the chaplains breaking? There is no reference to the cultural competencies in CPE.

2.     A short case scenario illustrating the authors point would help making it more specific.

3.     The description of CPE fails to acknowledge the competencies on psychological theory, ethics, developing cultural competence and humility and focuses instead on Christian scriptural formation. The author needs to expand the description of CPE and include some of the competencies from CASC or APC.

4.     In the discussion, there could be a suggestion for some empirical research on the topic. Are patients and their families complaining about cultural insensitivity? If so, how many complaints? Interviewing family members through a qualitative research paradigm might help. The paper is dominated by the opinion of the author without empirical data.

We advocate that this paper be accepted with revisions addressing some of the concerns noted above.

Author Response

Thank you for your insightful comments to improve on the manuscript.

1. I have expanded more on the specificities of Hong Kong chaplaincy in section 3.1 (lines 190-207, lines 220-225) and in section 3.2 (lines 267-277).
2. I agree that a case scenario here would be useful, but only if it was an actual experience from a patient or a chaplain, which would require methodological protocols (participant choice, consent forms, interviews, analysis, interpretation, etc) which are out of the scope of this article.
3. I have expanded on the description of CPE in Hong Kong in  section 3.2 as mentioned above (lines 267-277).
4. Thank you for your insightful suggestions. I have included that point in the discussion to suggest for future qualitative research on the perceived gaps in cultural congruencies from the perspective of care recipients to further deepen the understanding of cultural impacts on end of life care.