African cultural concept of death and the idea of advance care directives
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0973-1075.191741
Source of Support: None, Conflict of Interest: None
An advance care directive is a person's oral or written instructions about his or her future medical care, if he or she becomes unable to communicate. It may be in written or oral form. Africans ordinarily do not encourage the contemplation of death or any discussion about their own or their loved ones' death. According to the African belief system, life does not end with death, but continues in another realm. Becoming an ancestor after death is a desirable goal of every individual, a feat which cannot be achieved if an individual asks for an unnatural death by attempting to utilize advance care directives. Advance care directives are considered to be too individualistic for communitarian societies such as Africa. Coupled with the communitarian nature of African societies are issues such as lack of awareness of advance directives, fear of death and grief, and the African cultural belief system, which are potential barriers to the utilization of advance care directives in the African setting. Hence, the need for culture sensitivity which makes it imperative that patient's family and loved ones are carried along as far as possible, without compromising the autonomy of the patient in question when utilizing advance care directives.
Keywords: Advance care directive, African, Cultural, Family
An advance care directive is a person's oral or written instructions about his or her future medical care, if he or she becomes unable to communicate. It may be in written or oral form. It may also contain the names of persons to make decisions on a person's behalf, on what kind of treatment would be desirable, in situations that the person concerned may be incapable of making such decisions personally. This affords individuals the opportunity to exercise their rights regarding their medical care in advance. 
Dancy and Davis  assert that death is a "universal, natural, persistent, inescapable, unavoidable, and undeniable fact of life." When death occurs, there is usually an impact on the family and friends of the deceased, the magnitude often depends on whether death was expected or unexpected. Even the dying person goes through periods of fear, anger, and grief, once the inevitability of death becomes apparent. However, according to the great philosopher Epicurus, the human soul perishes with the body at death, bringing to an end all sensation and conscious existence.  Thus, death according to the proponents of Epicurian ethics, being merely the cessation of sensations, is nothing to be afraid of.
The processes of unexpected (sudden) death and expected death (dying) are quite different. In the case of expected death, that is dying, the individual goes through a process of gradual termination before death occurs whereas in unexpected (sudden) death, this process is either absent or is relatively short. In both cases, the loved ones are left behind to go through the grieving process albeit differently. Whereas the grieving process begins before death occurs in the case of a dying person, the process begins after death if the death occurred suddenly or unexpectedly. In the case of dying, there is anticipation that death will ultimately result, hence the loved ones have time to prepare both emotionally and cognitively for death when it eventually occurs. Coping after death is thus relatively easier for the survivors, and the dying person has time to take care of unfinished business such as preparing a will. In the case of unexpected (sudden) death, however, such emotional and cognitive preparation as seen in the case of a dying person is absent, coping by loved ones is difficult, and the deceased person may not have the time to take care of unfinished business such as preparing a will, if he or she had not prepared one before. ,
In most cases, death is often looked at from both religious and cultural perspectives in Africa. Religion is said to help provide meaning and answers to the problems of uncertainty, powerlessness, and scarcity that death creates.  Funeral rituals have thus evolved to acknowledge this, incorporating religious value in the rituals and enabling bereaved persons to find meaning for an event that for most people is inexplicable. For example, why should a 5-year-old die instead of a 50-year-old? It does not make logical sense except, perhaps, from a religious perspective.
The American Academy of Family Physicians in one of its guidelines emphasizes the need to recognize and address cultural issues, among others, on end-of-life care.  This becomes imperative particularly when one understands the fact that culture is the "worldview, values, norms, and behavior patterns shared by a group of individuals, and profoundly impacts behavior and the family; it shapes how persons make meanings out of illness, suffering, and dying."  It is against this backdrop that this review focuses on the social-cultural concepts, beliefs, and practices concerning death, which are of significant relevance to Africa in general, and how failure of an attending health professional to acknowledge and respect these concepts, beliefs, and practices can result in misunderstanding and conflict with the family members of the dying patient.  It would also examine how these factors are likely to influence the utilization of advance care directives in this part of the world, and provide suggestions on how to overcome these factors or mitigate their influence on the utilization of advance care directives.
According to Eyetsemitan, the traditional African belief system is also referred to as ancestor worship and is based on an understanding that the life course is cyclical and not linear. Based on this system of belief, those who are dead are alive in a different world and can reincarnate (and return to this world) in new births.  Death is considered a rite of passage for those who die at an acceptable (old) age.  When death occurs in Africa, divination as to the cause of death is sought from dead ancestors, with death causes usually attributed to spiritual elements (witchcraft, offending one's ancestors, or Gods) rather than medical or physical reasons.  Furthermore, it is an African cultural belief that to be in the world of the dead confers supernatural powers over those in the world of the living, such as the ability to bless or to curse, and to give life or to take life among others.
After death, an individual lives in a spirit world, receiving a new body which is identical to the earthly body, but with the capacity to move about as an ancestor. Becoming an ancestor after death is thus a desirable goal of every individual and it is believed that this cannot be achieved if an individual did not live a meaningful life, or had his or her life cut short say through an accident or by an unnatural death.  An African individual would, therefore, prefer a slow and lingering death that comes naturally, as they would not only be able to tidy up many issues such as making peace and saying farewell to relatives, but also they would also be admitted in the spirit world.  Death in any group apart from the very old is considered unnatural and premature. 
With the belief that the goal of life is to become an ancestor after death, a person is given a proper burial after death as failure to do this may result in the individual becoming a wandering ghost, unable to live properly after death, and constituting a danger to those who are still alive.  Lending credence to the African concept of death, Dancy and Davis assert that death indicates the physical separation of the individual from other humans. Funeral rites and ceremonies serve to draw attention to this permanent separation, and particular attention is paid to the funeral rites to avoid undue offense to the dead. 
Death rituals and the mourning practices of Africans are varied because of the existence of so many religious and cultural practices.  African societies are communalistic and do not acknowledge advance care directives which according to many Africans encourage "atomistic individualism."  Atomistic individualism refers to the idea that the isolated individual is the only fundamental reality and that the individual is the natural atom in artificial social composite. 
In Africa, individuals are brought up from childhood with a sense of belonging and relatedness with others. Individuals, thus, have a sense of obligation to a larger set of other individuals. This is one of the reasons why African tradition does not recognize the roles that advance care directives play in end-of-life decision-making for an incompetent patient. Instead, decision-making at the end-of-life period is left to the members of the family of the person concerned,  an act which introduces unhealthy disagreement as events unfold.
Africans do not like facing the reality of death and often do not encourage the contemplation of death, be it their own death or the death of their loved ones.  It is somewhat a taboo to think of or discuss one's death. Hence, people do not write their living wills or set aside money for their funeral while still alive, contrary to the practice in the western world. Death is also considered an enemy of life and Africans believe life should be preserved by all means even if the case is a hopeless one. The average African is not likely to discontinue life-sustaining treatment once it has commenced, and also do not favor any artificial termination of life. 
The above-painted picture is contrary to how African-Americans experience death and dying. Sullivan  described some principles of African philosophy that provide relevant background as to how (African-American) families understand and experience death and dying. First is the principle of dual unity. According to this principle, polarities are opposites. For example, day and night, dead and living are viewed as having reciprocal and unifying functions, rather than dichotomous ones. Dual unity means that although death represents the soul leaving the body, it is still inherently related to life, as opposed to representing the opposite of life. The second principle asserts that spirit and matter cannot be separated. By implication, it means that the body and mind cannot be separated. The third principle explains that the family is also a key to understanding African culture. Africans include a larger circle of individuals in their family membership compared with families of European origin. Hence, departed relatives remain in the family circle as the living dead. The living dead remain "alive" in the memories of individuals in their family membership compared with families of European origin. It is this last principle that explains the connectedness and sense of responsibility of an individual to his family or community. In this sense, what happens to the individual happens to the entire group, and whatever happens to the whole group happens to the individual. According to Mbiti, the individual can only say, "I am, because we are; and since we are, therefore I am." 
In the African culture, therefore, the elderly or aged may give verbal instructions to their children concerning their care at the end of their lives. Such instructions may include avoiding prolonged hospital stay, allowing them to die on their own beds and in their children's arms at home, how to conduct the burial ceremony, where they are to be buried. Cultural and spiritual beliefs tend to make individuals, especially the middle-aged ones, avoid making end-of-life decisions while still alive and young. In addition, the practice of paternalistic medicine and its attendant effects on individuals after encountering physicians make such individuals even more resolute not to discuss pertinent personal issues with their doctors. This is because a paternalistic approach by the physician portrays a lack of empathy among others and this invariably diminishes any iota of trust the patient might have had for the physician.
An important point for consideration for medical practice is that for the family physician who usually treats patients in the context of the family, how feasible is it to adapt advance care directives in practice, since it is considered too individualistic? How will the family physician marry the wishes of his patient, who is an autonomous being, with those of the patient's family members who are also considered very important in the management of the patient?
Advance care directives have been criticized as being too individualistic for communitarian societies such as Africa.  The African culture of communal living, lack of awareness of advance care directives, fear of death and grief, physician lack of initiative, and the African belief system are potential barriers to the utilization of advance care directives in the African setting. As a way of encouraging the making and utilization of advance care directives, there is a need for both physicians and other health-care providers to be culture-sensitive. This will give room for inter-cultural conversations and the opportunity to listen to, understand, and benefit from the viewpoints of persons from cultures different from ours.  Other recommendations include discussing the topic whenever the opportunity arises for this will facilitate a structured discussion, raising the awareness of people on the utilization of advance care directives by providing relevant information, completing a statement and providing copies to the individual, the proxy any other relevant party periodically reviewing the statement, and most importantly, implementing the plan at the appropriate time.  However, all these recommendations will be effective only if people realize the important roles that advance care directives play in resolving the conflict between the physician and family members of a dying patient.
Considering all the issues discussed above, it would be offensive to other family members if one of them decides to write an advance care directive without considering the opinion of other family members. It is, thus, very important for the family physician and other physicians to be culture-sensitive and this extends to managing end-of-life issues within the context of the family and their culture, thereby carrying other members of a patient's family along while at the same time encouraging an individual to utilize an advance care directive.
The attending physician should ensure that the patient's family and loved ones are carried along as far as possible,  without compromising the autonomy of the patient in question, while at the same time acknowledging and respecting the communal nature of existence of African families. If some Africans write wills to take care of issues, especially about inheritance after their death, why would they not consider preparing advance care directives to take care of issues at their end-of-life period?
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