Death and dying in Ghana: Implications for palliative and end-of-life care

Abstract

In Ghana, death and dying are not simply biomedical endpoints but are deeply rooted in cultural, spiritual, and communal ideologies. These beliefs shape how individuals and families perceive terminal illness, respond to end-of-life (EoL) trajectories, and interact with palliative care (PC) services. Unlike Western medical models that prioritize institutionalized and medicalized death, the Ghanaian perspective is influenced by communalism, ancestral continuity, and religious doctrines that emphasize divine healing and spiritual deliverance. This commentary examines how Ghanaian cultural norms, particularly the conception of good and bad death, the taboo surrounding discussions of dying, and the centrality of family in care decision-making, create both opportunities and challenges for PC and EoL care delivery. While spiritual beliefs offer coping mechanisms that foster resilience, they may also foster unrealistic expectations and delay the initiation of PC services, thereby undermining symptom management and psychosocial support. At the same time, the family’s pivotal role in caregiving, decision-making, and bereavement provides a strong foundation for culturally sensitive PC models. The paper calls for healthcare providers and policymakers to develop family-centered and culturally congruent care frameworks, invest in community-based education to destigmatize PC, and integrate bereavement care into the continuum of support. Training providers in culturally competent communication and embedding PC into national health policy and curricula are also recommended.

Introduction

As humans, we face numerous uncertainties. Uncertainties about our success, failures, the next meal, and our economic growth, among others. However, one thing is certain: so long as we are born into this world, we will eventually die. Consequently, death and dying have become an integral part of the transitions of life. While death and dying know no exceptions, ¹ it is often a less discussed subject. This is probably due to the emotional rollercoaster that often accompanies discussions of death and dying. This approach to communicating death and dying influences not only individual experiences but also broader healthcare systems, particularly the delivery of palliative care (PC) and end-of-life (EoL) care.

In many Western contexts, death is often medicalized and institutionalized, with increasing efforts to humanize dying through hospice and PC services.^2,3 Conversely, in non-Western settings such as Ghana, death and dying are viewed through the lenses of communalism, spirituality, and ancestral continuity. ⁴ This suggests that in Ghana, death is not regarded as an end but as a transition to another state of being. These deeply rooted sociocultural perspectives present both opportunities and challenges for the practice of PC and EoL care in Ghana. This paper examines death and dying within the Ghanaian context and discusses its implications for PC and EoL care.

Cultural conceptions of death in Ghana

Culturally, Ghanaians view death as a transition to the afterlife. In other words, it marks a phase where the deceased person transitions to become an ancestor in the existential realms. ⁵ This belief is accepted by the dominant religious groups in Ghana (i.e., Christianity, Islam, and traditional African belief). In addition, for many ethnic groups in Ghana, including the Akan, Ewe, and Ga-Adangbe, the concept of “asamando” (meaning, land of the dead) is central to post-death cosmology. ⁶ The Ghanaian culture further posits that to secure a favorable transition to this world, the individual must have a good death. In this context, a good death is described as a death that is peaceful and natural. ⁷ Specifically, it includes dying at home, being surrounded by loved ones at the time of death, receiving the appropriate last rites, and having one’s social obligations fulfilled.^7,8

Individuals who die from unnatural causes (e.g., suicide, accidents, or stigmatized illnesses such as HIV/AIDS) are classified as having a bad death.^7–9 Such persons are often denied full funerary rites. It is also believed that people who die a bad death would not be welcomed to the land of the dead. It is important to acknowledge that this social construction around good and bad death in Ghana creates a subconscious moral framework around dying that shapes how individuals and families respond to terminal illness (e.g., end-stage cancers and AIDS). As stated earlier, these cultural expectations around death are tightly intertwined with religion. As such, many Ghanaians believe that divine will governs life and death, and that miraculous healing is possible through prayer, anointing, or spiritual deliverance. ¹⁰ This reinforces a preference for religious intervention over medical prognosis when dealing with life-limiting conditions, and thus, becomes a potential barrier to early uptake of PC and EoL care.

Attitudes toward dying and EoL discourse

Having established the cultural view of death and dying in Ghana, it is essential to examine attitudes toward these discussions to better understand their impact on PC and EoL care. In traditional Ghanaian culture, it is believed that words carry performative power; this means that what you say is likely to come true. Because of this, talking about death and the dying process is often seen as taboo. ¹¹ Patients, families, and even healthcare providers may avoid directly discussing prognosis, opting for euphemisms or silence. This assertion is supported by a study by Appiah et al., ¹² which found that health professionals’ difficulty in delivering bad news is a major barrier to providing PC services to people with cancer and other health issues in Ghana.

Literature also shows that there is a lot of denial with respect to the dying person and their family. One study revealed that belief in supernatural healing or miracles constitutes a fundamental cultural attitude to dying in Ghana. ¹³ Consequently, family caregivers and persons living with terminal conditions refuse to accept the prognosis of their condition. ¹⁴ They invest heavily in visiting prayer camps, fasting, or spiritual deliverance instead of preparing for death or accepting PC services. Nonetheless, the Ghanaian cultural system appreciates the role of the family/social support networks in the dying process. This is epitomized in some of the Akan proverbial sayings. For instance, there is one proverb that states: “Owuo atwedeɛ, baakfoɔ mforo.” To wit: “one person does not climb death’s ladder.” ¹⁵ This proverb embodies the notion that the family is not only a unit of emotional support but also a key decision-making body in health and EoL matters.

Implications for palliative and EoL care

The cultural perceptions about death and dying in Ghana have both positive and negative effects on PC and EoL care. On the negative side, the hesitation to openly discuss death and advance care planning can lead to unrealistic expectations about care. Open communication allows health professionals to share a prognosis with patients and their family caregivers. ¹⁶ It also enables them to engage in honest, person-centered conversations that help families prepare for the inevitable decline of their loved ones. However, when cultural barriers prevent such open dialogue, families and patients may expect curative treatments even when the condition is irreversible. This resonates with Buehler and Obeng’s study, ¹⁷ which identified a lack of consensus among family members about the type and extent of care as a major challenge in delivering PC. Meanwhile, healthcare providers might focus more on symptom management. It is important to recognize that unrealistic expectations can also cause moral distress among providers, who may feel pressured to pursue futile treatments out of fear of being seen as negligent or disrespectful.

Persons living with terminal conditions and their families often prioritize divine health and miracles. ¹⁰ Such actions can be described as a coping mechanism to surmount the psychological distress associated with living with a particular terminal condition. While spiritual optimism can foster resilience, it also carries the unintended consequence of delaying the initiation of PC services. Many families interpret engagement with PC as an admission of defeat or a loss of faith in divine intervention, which may be perceived as spiritually or socially unacceptable. This can be a recipe for delayed initiation of PC services and could exacerbate aggressive EoL care. When PC is initiated late in the disease trajectory, patients are less likely to benefit from anticipatory symptom management, holistic psychosocial support, and advance care planning, which are essential for preserving dignity and optimizing quality of life until death. Consequently, late referrals undermine the very ethos of PC, which emphasizes comfort, personhood, and relational closure over curative outcomes.

On the positive side, the cultural acknowledgment that one does not climb death’s ladder alone reinforces the centrality of the family and communal support networks in navigating illness, dying, and bereavement (see Figure 1). It underscores a need for PC and EoL care service providers to recognize the patients’ families as an integral stakeholder in service provision. Their involvement in the PC and EoL care processes helps people living with terminal conditions to make peace with themselves and their loved ones. ¹⁸ It also helps to effectively prepare the family for the loss of their loved one, and enhance patient-centeredness, dignity, emotional continuity, and social cohesion throughout the dying process and into bereavement.

Figure 1.

Implications of cultural perspectives of death and dying on PC and EoL care.

Conclusion and recommendations

In this paper, I make the argument that death and dying in Ghana go beyond being a biological event to being a way of life that has serious implications on PC and EoL care in a country with limited PC services. Moving forward, PC and EoL service providers should adopt an approach that recognizes the critical role of the family/social support networks. From a policy perspective, this can be achieved by formalizing the role of families in treatment planning, consent processes, and discharge decisions. At the clinical/health facility level, service providers can introduce dedicated family meetings to discuss prognosis, care goals, and symptom management strategies. Evidence suggests that family meetings significantly reduce caregiver distress and enhance caregiver preparedness. ¹⁹ Such meetings must also be characterized by open communication so there is a clear indication of care expectations at every point of the disease trajectory.

Ghana can learn from Australia, where clear guidelines exist for conducting family meetings in PC and EoL settings. ²⁰ Hudson et al.’s ²⁰ guidelines emphasize three main considerations: preparing for the meeting, conducting the meeting, and documentation/follow-ups. In preparation, a designated healthcare professional must coordinate the meeting, ensuring it is well-planned, inclusive, and sensitive to family needs. In addition, Hudson et al. ²⁰ state that the facilitator must obtain the patient’s consent, identify key family members for involvement, and assess family dynamics using tools such as a genogram. During the meeting, the healthcare professional should create a respectful space for open communication, clarify the patient’s understanding of their condition and care goals, and address key concerns from both the patient and family. ²⁰ The Australian guideline also emphasizes the importance of documentation and follow-ups. Specifically, Ghana can adopt this approach by promoting accurate documentation of attendees, decisions, and plans, and sharing a summary with the patient and care team. ²⁰ Follow-up with the main family contact is also essential to evaluate the meeting’s effectiveness and to ensure ongoing communication and support.

Health facilities offering PC and EoL care services must make provisions for structured grief support. Studies have shown that group and individual counseling alleviate grief symptoms, reduce distress, and improve psychological well-being for many bereaved individuals.^21,22 Hence, health facilities providing PC and EoL care in Ghana must implement person-centered bereavement support systems. The Ministry of Health and Ghana Health Service must take a keen interest in continuous professional development for PC and EoL care providers. Special attention must be given to communicating care expectations, disease prognosis, and death.