Spiritual and cultural issues, characteristics, and needs are often intertwined and difficult to separate. In other cases, they may have little connection with one another and sometimes one is of greater importance than the other (Kemp & Rasbridge, 2004).

The incorporation of these concepts into the complex matrix of care for a person who is dying and her or his family enhances the opportunity for a good death—however one might define “good death.” The question then becomes, how does one incorporate these concepts into the care or, how does one perform such care? There are no universals in being able to provide the care. Unlike the use of opioid and adjuvant medications to treat pain, clear guidelines in providing culturally and spiritually competent care are difficult to establish on the shifting sands of individual differences in patients and caregivers, cultural and language barriers, religious and spiritual variables, changes in physical condition, and the myriad other factors affecting the patient and family.

As with the treatment of physical symptoms, failure also occurs in providing spiritual care and/or cross-cultural care. In postmodern society, radically different spiritual and cultural realities exist, and their intersection in, for example, the palliative care setting, is not always a success story. Spiritual care based on one faith (or on spirituality without a specific religious foundation) may not connect in any way with a person of a nonsyncretic faith such as evangelical Christianity or Islam (Narayanasamy, 2004a). Likewise, failure may accompany attempts to reach across the cultural chasm between a postmodern, high-tech culture and a traditional culture of the developing world. A myriad of individual, familial, systemic, gender, cultural, and other reasons for failure exist. Regardless of success or failure, working toward rapport and manifesting respect for all aspects of the patient’s life and being are essential qualities of health care.

There are, however, care-enhancing factors that have at least the potential to enhance the opportunity for a good death. For the sake of clarity these are considered separately here, but as with Yalom’s “curative factors” for group psychotherapy, they are intricately interdependent, part of a dynamic process, and of varying value in various situations and at various stages of the process (Yalom, 1995). The most straightforward way to use these care-enhancing factors is to operationalize them one by one or several at a time over time in providing palliative care. For example, clinical competence in physical care would be operational from the beginning of a particular care situation, as would nonjudgmental acceptance of the person receiving care. However, at the outset of care, the advanced practice nurse (APN) may lack cultural or spiritual care competence specific to the patient. This factor would be operationalized as the APN gains specific cultural competence or competence related to the patient’s religion. The term “over time” recognizes that the APN may require time to acquire or implement some factors and that the patient may not immediately (or ever) recognize that a factor is present, that the APN is accepting of the patient’s past, religion, or other aspects of the self.