Māori, living and dying with Cardiovascular Disease in Aotearoa New Zealand
Kathleen Mason, Frances Toohey, Merryn Gott and Tess Moeke-Maxwell
School of Nursing, Faculty of Medical and Health Sciences, University of Auckland,
Auckland, New Zealand
Correspondence to Kathleen Mason, School of Nursing, Faculty of Medical and Health
Sciences, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. Email:
Purpose of review:
This article provides an informed perspective on cardiovascular disease (CVD) and
palliative care need among Māori New Zealanders. High Māori CVD risk factors will
contribute to a sharp increase in older Māori deaths which has implications for health and
palliative care service provision.
Cardiovascular Disease is New Zealand’s leading cause of premature deaths and
disability among Māori. A projected rise in older Māori deaths within the next 30 years will
require increased palliative care. However, accessing palliative care and obtaining and
understanding information can be challenging for families who are already often
overburdened with high social and economic disadvantages. Meeting the high financial costs
associated with end-of-life care make living with CVD challenging. Engaging with the health
system’s bio- medical approach when holistic care is preferable can be a major barrier.
Māori families provide the bulk of care at end-of-life, but they can become fatigued
with the challenges that accompany long-term progressive illnesses, such as CVD. They are
also burdened by the financial costs associated with end-of-life. It is often difficult for Māori
to access palliative care and to obtain and understand information about the illness and
treatment. Navigating an unfamiliar and complex health system, low health literacy among
Māori and poor relationship building and communication skills of health professionals are
significant barriers. Cultural safety training would help to increase health and cardiovascular
professionals’ cultural understanding of Māori and their holistic end-of-life preferences; this
could go some way to strengthen rapport building and communication skills necessary for
effective engagement and informational exchanges. Increasing the Māori palliative care
workforce and introducing cultural safety training among health professionals could help to
bridge the gap. A current study to gather traditional care customs and present these to whānau
and the health and palliative care sectors in the form of an online resource could contribute to
this decolonising objective.
Key words: Cardiovascular, Cultural safety, End-of-life, Māori Palliative Care
Cardiovascular disease (CVD) is a broad term encompassing diseases affecting the
heart and blood vessels, including congestive heart failure, ischaemic heart disease, stroke,
coronary artery disease and acute coronary syndrome (1**). CVD is a significant Maori
health inequity. However, there is a lack of specific research on Māori CVD and palliative
care. In this review, we reflect on how the health sector could better support Maori whānau
(family, including extended family) and those living with CVD to live and die well. Although
Māori whānau draw on their collective strengths to provide end-of-life care, care is often set
against a backdrop of social and economic disadvantage. There are difficulties with whānau
accessing services and forming trusting relationships with health providers which is critical to
being able to benefit from formal care services. We draw upon the Te Pākeketanga study
findings to highlight barriers bereaved Maori whānau encountered when an older whānau
member with CVD engaged with the health sector at the end-of-life (2*).
Overview of CVD in New Zealand
CVD has a significant global burden and remains the leading cause of premature
death and disability in New Zealand, accounting for around 33% of deaths annually (3). In
New Zealand, socioeconomic and ethnic disparities are evident, with CVD being the leading
cause of mortality and morbidity for the Māori population, with Māori typically presenting at
a much younger age compared to non-Māori (4, 5). In 2010-2012, the mortality rate among
Māori for CVD was more than twice that of non-Māori (3). Additionally, in 2012-2014,
Māori were over 1.5 times more likely to be hospitalised due to CVD when compared to non-
Māori, highlighting clear inequities in the burden of CVD in New Zealand (3). The burden of
CVD falls inequitably on the Māori population and cannot be explained by risk factor
variation alone, indicating differential access to health care as well as the quality of care
received from health services (1**).
Of particular concern is not only the high CVD mortality rates observed for the Māori
population but the impact of CVD on life expectancy (6). In 2013, life expectancy at birth
was 73 years for Māori males and 77.1 years for Māori females, compared to 80.3 years for
non- Māori males and 83.9 years for non-Māori females (7). As Māori are disproportionately
impacted by CVD, this is reflected in the shortened life expectancy observed for Māori
compared to non-Māori (8).
In 2013, Māori accounted for 14.9% (or 598,602) of the total New Zealand population
(9) and it is expected to grow beyond 1 million by 2038 (10). The Māori population is
youthful, however, the proportion of Māori aged under 15 years has decreased and for those
aged 65 years and over it has increased (9). Further, the aging of Māori deaths is also
projected to increase significantly in every age band above 75 (11*). These factors, along
with the inequitable burden of CVD on Māori, highlight the need for appropriate services to
support Māori patients with CVD (12), especially those with a life-limiting diagnosis such as
Heart failure, in particular, shows distinct inequities regarding morbidity and mortality
for Māori. In 2010-2012, heart failure mortality for Māori was more than twice that of non-
Māori (3). Additionally, Māori were more than four times more likely to be hospitalised due
heart failure compared to non-Māori (3). Heart failure is the final common pathway for many
cardiovascular conditions and may occur due to coronary artery disease, myocardial
infarction, hypertension, diabetes or rheumatic heart disease (13). Heart failure is a life-
limiting condition and patients tend to experience symptoms such as shortness of breath, fluid
retention and congestion (13). However, patients with congestive heart failure may not
receive palliative care treatment due to the unpredictable time course of disease progression,
alongside the presence of other comorbidities (14, 15*).
At present, there is no specific policy in New Zealand outlining the palliative care
management of patients with heart failure (16). It is recognised that palliative care services
are often targeted towards patients with life-limiting illnesses such as cancer. However,
patients with heart failure often experience similar symptoms to those with a terminal cancer
diagnosis such as breathlessness, fatigue, limited mobility and reduced quality of life (14,
15*, 17). Additionally, long-term prognosis following hospitalisation for congestive heart
failure is poor in Australia and New Zealand, with less than half of patients surviving for
more than five years (18). Although patients with heart failure have contact with the wider
health care team around the time of diagnosis, the focus tends to be on medical management
of the condition rather than supporting patients throughout their illness and across the end-of-
life trajectory (14). The life- limiting impact of heart failure and associated comorbid
conditions a patient is likely to experience as part of their risk profile demonstrates that these
patients also require access to adequate and timely palliative care services in order to meet
their care specific needs (14).
Māori palliative care
The vision for palliative care in New Zealand is to ensure that “[all] people who are
dying and their family/whānau who could benefit from palliative care have timely access to
quality palliative care services that are culturally appropriate and are provided in a
coordinated way” (19, p.7). Māori, however, face a variety of barriers and challenges that
impact on service uptake (20**). Māori families, like other families, provide the bulk of care
at end-of-life (21, 22*, 23), but, engaging with a Western model of care at end-of-life is
relatively new to Māori (24*). Research has signalled commonalities in the palliative care
preferences of indigenous peoples, including those of Māori (25*). These preferences
comprise of dying at or close to home, family involvement and the inclusion of cultural care
practices (20**). A Western concept of home as a single dwelling does not necessarily fit with
Māori who often have multiple homes, including ancestral homes and homes of other kin
whom they may live with at end-of-life (26).
Māori approach to end-of-life care
Māori are a diverse population group where identity, cultural knowledge, fluency of
the Māori language, connection to whānau and tribal groups, and religious and spiritual
beliefs vary (27). The impact of historic and ongoing colonisation processes have meant that
not all Māori individuals or whānau have been able to retain their cultural capital and
traditional care customs (23, 28). Despite this, many Māori whānau draw on tribal cultural
values and practices to strengthen them when caring for a whānau member living with, and
dying from, a life- limiting illness (23, 29).
In addition to overseeing the care of the ill person’s physical and emotional health, a
Māori approach to end-of-life care, as with other indigenous peoples, aims to support their
spirit’s transition to the spiritual realm (25*). Preparing the spirit to cross the ārai (veil
between the physical and metaphysical realms) places a responsibility on whānau to ensure
that the ill person’s mana (authority, status, prestige) is maintained throughout the end-of-life
trajectory (23). Meeting the ill person’s holistic needs within this context requires his or her
cultural customs to be upheld.
Challenges to providing end-of-life care
Māori carers can become fatigued with the challenges that accompany long-term
progressive illnesses, such as CVD, especially when there may only be one or two primary
carers (23). Although collective whānau care systems are effectively utilised by many
families, the reality is that smaller whānau compositions and globalisation mean that fewer
carers are often available to provide care (23, 29). Furthermore, some older Māori individuals
prefer to maintain their self-determination and autonomy and therefore may refuse whānau
support, highlighting the diversity of Māori today (30). However, this stance may also be a
protective mechanism among older Māori who may not wish to burden their families (31*).
Māori are more likely to live in areas of high deprivation (3), and, like other families,
Māori whānau are responsible for meeting the financial costs associated with end-of-life care
(21). These include transportation, parking for appointments and hospital admissions,
clothing, linen, GP visits, medication, alternative therapies and food. Māori whānau may
delay seeking medical help or fail to keep appointments due to high medical fees, lack of
transportation or hospital parking fees (21). Further, financial constraints experienced at end-
of-life care are compounded when whānau members give up paid work to provide care or
transition to a lower income level via government assisted income (21).
Observing obligations involving tikanga (customs) and kawa (protocols) can incur
additional financial costs (23). As such Māori may be unable to observe end-of-life cultural
care obligations (21) unless obtaining additional resourcing (32). Returning to an ancestral
home before death helps to strengthen the dying person’s spiritual connections to their iwi
(tribe) and tūpuna (ancestors), however, the transport costs can be restrictive (26).
Consuming kai rangatira (special foods) and water from special places surpasses the need to
satisfy the taste buds, but sourcing these items can be costly (21). A significant cultural cost
associated with end-of-life and dying for Māori is the practice of hospitality related to
manaakitanga (kindness, generosity and support). Māori hosting responsibilities are evident
in the respect shown to people who visit the ill person before, during and following death.
The cost to feed and home visitors can be very high and usually falls to the immediate family,
as is the case with tangihanga (traditional funerals) which may be held over several days.
Some Māori, however, are opting for cremation because they lack the financial resources to
return a deceased loved one home for tangihanga (23).
Māori experience higher rates of mortality than non-Māori and they are reliant on the
health sector to diagnose and manage CVD (3). It is important that accurate information is
received by the person with CVD and their families to help them prepare for the end-of-life.
Vignette: More information needed for whānau
A daughter reflected on her mother’s (80+) end-of-life, and her subsequent death
from heart and lung failure. Despite her whānau wishing their mother could live at home
for longer, the older woman transitioned to a care home as her health deteriorated and she
required full nursing care. Her daughter stated she felt unprepared for her mother’s slow
and protracted decline in health, the co-morbidities that arrived with the ageing process,
and the impact this had on her. She felt that more information should be given to families
Māori, predominantly rural Māori, are more likely to have a higher CVD risk, be
under diagnosed and under treated than non-Māori (33*). Late diagnosis and late referrals
can impede access to palliative care (34, 35). Therefore Māori with CVD may not fully
benefit from specialist palliative care services. This gap needs to be reduced, particularly as
research evidence suggests Māori families may benefit from engaging with palliative care
services such as hospices (29).
Māori are more likely to live in rural areas where access to local hospitals or specialist
palliative care services are reduced or absent (34). Distrust may prevent some Māori from
seeking help early or engaging with health and palliative services across the end-of-life
trajectory. There is a lack of awareness of hospice services (36) and a dearth of appropriate
information about palliative care and specialist palliative care services (34, 37, 38). Many
whānau do not know what the Government’s statutory providers’ offer, such as financial
support to cover funeral expenses (21). It is often the poor cultural knowledge and
communication skills of health professionals that act as a barrier when conveying information
to whānau about a life-limiting diagnosis; the use of medical jargon, for example, is a
common barrier (35). Poor communication about moving from active treatment to palliative
care can be confusing and distressing for whanau (39**), and a lack of respectful
communication can prevent building relationships with Māori based on trust (34).
as this may have helped her to prepare for the changes that accompanied her mother’s end-
I probably want the doctor to tell it as it is. To be a little more honest. Honesty in
terms of what sort of expectations – I’d really would like to know that. I kind of
expected that Mum would live longer in a Rest Home situation. That sort of
optimism – I would like to have known… My mother nursed Prisoner of War
soldiers, Japanese POW’s. My mum talked about those guys coming back from
South East Asia, the Kiwi guys; jeez they looked awful, just skin and bone. And
Mum was just – it was terrible, She looked like a Chimpanzee. Because she had
quite prominent bone structure - was very prominent in her face… it looked awful –
not nice to look at physically – that appearance. I’m sure if my mother saw herself
in the mirror she wouldn’t have liked that… I had no idea she’d be like that.
Te Pākeketanga Study participant, 2013-2016
Vignette: Poor communication
Morgan (80+) had lived with CVD for over 20 years. His wife and daughter
described his end-of-life as being “quite happy” which they attributed to Morgan living at
home with his “family around him”. As his CVD worsened Morgan required medical
attention, however, he lacked trust in hospitals. His daughter said “The last time we
brought him to the hospital he said ‘Don’t take me there, they’ll kill me off’.” The whānau
felt their cultural norms were breached when health professionals did not adequately
inform them that Morgan was close to dying. Without realising how ill he was, Morgan’s
whānau returned home after a visit. His unexpected death compromised the whānau tribal
tradition to companion their dying. Being at Morgan’s side would have given the whānau
an opportunity to provide him with cultural and spiritual support. Dook recalled:
A holistic paradigm of end-of-life care is undoubtedly preferred by Māori (23).
Despite New Zealand’s palliative care philosophy encompassing care of tinana (physical),
hinengaro (emotional-mental), wairua (spiritual) and whānau (family-bereavement) pillars of
care, the reality is that palliative care continues to be focused mainly on pain management
and symptom control. ‘Whanaungatanga’ requires that time and attention be paid to building
relationships with patients and whānau through developing sincere connections in the context
of the care relationship. Establishing a rapport helps to bolster trust in services and health
professionals. Use of rongoā Māori (traditional plant medicines) may be used effectively
alongside western medicine signalling the need for Western and traditional healing
approaches to work together to benefit indigenous peoples (40). Experiences of racism within
the health system also act as a barrier for Māori at end-of-life and make those who are
already potentially vulnerable feel unsafe (23, 34).
The need for, and access to, palliative care in relation to CVD is not well understood
and requires further research for Māori, and for New Zealand in general. There is also a
critical need for research on Maori whānau experiences of caregiving. Cultural education is
needed to support health professionals to work successfully with indigenous people (37, 40)
particularly where cultural traditions and spirituality are concerned (41, 42). Cultural safety
training would help to increase the sector’s knowledge of the meanings Māori attribute to
their cultural values, beliefs and end-of-life care customs. This would help to strengthen
health providers’ communication skills as respectful (clear, direct) communication (43) is
necessary for effective informational exchanges with whānau. Increasing the Māori palliative
care workforce (36) would support Māori preferences and outcomes at end-of-life.
Māori have a higher risk of, present younger and have poorer outcomes related to CVD.
The Māori population is growing and aging, and it is expected that the age of Māori death
Research indicates that Māori benefit from engaging in palliative care services, such as
Little is known about the CVD need for and access to palliative care in New Zealand for
Māori and non- Māori population groups.
Palliative care delivery in New Zealand can benefit from improving cultural education and
cultural safety, improving informational exchanges between health professionals and Māori
whānau and increasing the Māori palliative care workforce.
For me, when the doctors indicated about hospice care it didn’t sink in to me how
serious Dad- how close he was to death. It was a bit hard to catch up with the
doctors sometimes… [If we had known] we would have sat by him [or] we would
have taken him home.
Te Pākeketanga Study participant, 2013-2016
Financial support and sponsorship
Conflicts of interest
1. Cram F. Improving Māori access to cardiovascular health care: Literature review [Internet].
Auckland: Koata Ltd; 2014.
** Examines post-2006 literature on interventions to improve access to CVD health care for Māori,
Indigenous peoples, and ethnic minority groups. The review highlights the importance of different levels
of interventions, for example, community, clinical (including investment in a culturally responsive
workforce and implementation of evidence-based tools and guidelines), medication, and health system
drivers (strategy and policy).
2. Gott M, Moeke-Maxwell T, Williams L, Black S, Trussardi G, Wiles J, et al. Te Pakeketanga:
living and dying in advanced age--a study protocol. BMC Palliative Care. 2015;14(74):21.
* A protocol paper for a post-death study examining end-of-life circumstances of Māori and non-Māori
dying >80 years and the experiences of their whanau/families during the end-of-life and bereavement
3. Ministry of Health. Tatau Kahukura: Māori health chart book 2015 (3rd edition) [Internet].
Wellington: Ministry of Health; 2015.
4. Whittaker R, Bramley D, Wells L, Stewart A, Selak V, Furness S, et al. Will a web- based
cardiovascular disease (CVD) risk assessment programme increase the assessment of CVD risk
factors for Māori? The New Zealand Medical Journal. 2006;119(1238):u2077.
5. Earle N, Poppe K, Doughty R, Rolleston A, Kerr A, Legget M. Clinical characteristics and
burden of risk factors among patients with early onset acute coronary syndromes: The
ANZACS-QI New Zealand cohort (ANZACS-QI 17). Heart, Lung and Circulation.
6. Rolleston A, Doughty R, Poppe K. The effect of a 12-week exercise and lifestyle management
programme on cardiac risk reduction: A pilot using a kaupapa Māori philosophy. International
Journal of Indigenous Health. 2017;12(1):116-30.
7. Statistics New Zealand. New Zealand period life tables: 2012-2014. Wellington: Statistics New
8. Wells L, Broad J, Jackson R. Estimated prevalence of cardiovascular disease and distribution of
cardiovascular risk in New Zealand: data for health care planners, funders and providers. The
New Zealand Medical Journal. 2006;119(1232):75-82.
9. Statistics New Zealand. 2013 census quick stats about Māori [Internet]. Wellington: Statistics
New Zealand; 2013 [cited 2 October 2018]. Available from: www.stats.govt.nz
10. Statistics New Zealand. Ethnic populations projected to grow across New Zealand: Statistics
New Zealand; 2017 [cited 2018 2 October 2018]. Available from:
11. McLeod H. The need for palliative care in New Zealand: Technical report prepared by Heather
McLeod for the Ministry of Health. Hamner Springs: Heather McLeod & Associates 2016.
* A technical report examining patterns of deaths by age, gender, ethnicity and deprivation in New
Zealand, registered in the calendar years 2000 to 2013.
12. Cameron V, Faatoese A, Gillies M, Robertson P, Huria T, Doughty R, et al. A cohort study
comparing cardiovascular risk factors in rural Māori, urban Māori and non-Māori communities
in New Zealand. BMJ. 2012;2(3):e000799.
13. Curtis E, Harwood M, Ridell T. Cardiovascular disease. In: Robson B, Harris R, editors.
Hauora, Māori standards of health IV: A study of the years 200-2005. Wellington: Te Rōpu
Rangahau Hauora a Eru Pōmare; 2007.
14. Barclay S, Momen N, Case-Upton S, Kuhn I, Smith E. End-of-life conversations with heart
failure patients: a systematice luterature review and narrative synthesis. Br J Gen Pract.
15. McIlvennan C, Allen L. Palliative care in patients with heart failure. BMJ. 2016;353.
* A review summarising literature on the developing role of palliative care in patients with heart failure
and the opportunities and challenges for integrating it as part of routine care.
16. Waterworth S, Gott M. Involvement of the practice nurse in supporting older people with heart
failure: GP perspectives. Progress in Palliative Care. 2012;20(1):12-7.
17. Afshar K, Geiger K, Muller-Mundt G, Bleidorn J, Schneider N. Generalist palliative care for
non-cancer patients. Der Schmerz. 2016:1-11.
18. Hariharaputhiran S, Horton D, Hossain S, Labrosciano C, Nadlacki B, Adams R, et al. Long-
Term mortality following hospitalisation for heart failure in Australia and New Zealand: a
population-wide study. Heart, Lung and Circulation. 2018;27:s55-6.
19. Ministry of Health. The New Zealand Palliative Care Strategy [Internet]. Wellington, New
Zealand: Author; 2001.
20. Shahid S, Taylor E, Cheetham S, Woods J, Aoun S, Thompson S. Key features of palliative care
service delivery to Indigenouse peoples in Australia, New Zealand, Canada and the United
States: a comprehensive review. (Report). BMC Palliative Care. 2018;17(1).
** A review of articles published from 2000 onwards regarding palliative care service delivery to
Indigenous populations. The review noted commonalities in palliative care preferences for Indigenous
people, barriers to service utilisation and the models developed to address gaps. The review provides an
overview of practices found effective in delivering palliative care to Indigenous populations.
21. Gott M, Allen R, Moeke-Maxwell T, Gardiner C, Robinson J. 'No matter what the cost': A
qualitative study of the financial costs faced by family and whānau caregivers within a
palliative care context. Palliative Medicine. 2015;29(6):518-28.
22. Gott M, Wiles J, Moeke-Maxwell T, Black S, Williams L, Kerse N, et al. What is the role of
community at the end of life for people dying in advanced age? A qualitative study with
bereaved family carers. Palliative Medicine. 2018;32(1):268-75.
* A study exploring the role of the community at end-of-life for people dying in advanced age from the
perspective of their bereaved family caregivers.
23. Moeke-Maxwell T, Nikora LW, Te Awekotuku N. End-of-life care and Māori Whānau
Resilience. Mai Journal. 2014;3(2):140-52.
24. Moeke-Maxwell T, Mason K, Toohey F, Dudley J. Pou aroha: An indigenous perspective of
Māori palliative care, Aotearoa New Zealand. In: Textbook of palliative care [Internet]; 2018.
* Describes important caregiving strengths of New Zealand Māori whānau, the facilitators and barriers
related to providing end-of-life care, and the cultural care values that protect and strengthen Māori
25. Duggleby W, Kuchera S, McLeod R, Holyoke P, Scott T, Holtslander L, et al. Indigenous
people's experiences at the end of life. Palliative & Supportive Care. 2015;13:1721-33.
* A metasynthesis of qualitative research findings regarding end-of-life experiences of Indigenous
26. Moeke-Maxwell T, Nikora LW, Te Awekotuku N. Homedeathscapes: Māori end-of- life
decision-making processes. In: Kepa M, McPherson M, Manu'atu L, editors. Home: Here to
stay. Wellington, NZ: Huia; 2015.
27. Durie M. Whaiora : Māori health development. 2nd ed. Auckland, N.Z.: Oxford University
28. Reid P. Contemporary perspectives. In: Schwass M, editor. Last words: Approaches to death in
New Zealand's cultures and faiths. Wellington: Bridgett Williams Books with the Funeral
Directors Association of New Zealand; 2005. p. 41-9.
29. Johnston Taylor E, Simmonds S, Earp R, Tibble P. Māori perspectives on hospice care.
Diversity and Equity in Health Care. 2014;11:61-71.
30. Oetzel J, Simpson M, Berryman K, Iti T, Reddy R. Manaing communication tensions and
challenged during the end-of-life journey: Perspectives of Māori kaumātua and their whānau.
Health Communication. 2015;30(4):350-60.
31. Gott M, Frey R, Wiles J, Rolleston A, Teh R, Moeke-Maxwell T, et al. End of life care
preferences among people of advanced age: LiLACS NZ. BMC Palliative Care. 2017;16(1):19.
* A study exploring the end of life preferences of Māori (>80 years) and non-Māori (>85 years) of
advanced age and identifying correlations between preferences and key socio-demographic influences.
32. Angelo J, Wilson L. Exploring occupational roles of hospice family caregivers from Māori,
Chinese and Tongan ethnic backgrounds living in New Zealand. Occupational Therapy
33. Whalley G, Pitama S, Troughton R, Doughty R, Gamble G, Gillies T, et al. Higher prevalence
of left ventricular hypertrophy in two Māori cohorts: findings from the Hauora
Manawa/Community Heart study. Aust NZ J Public Health. 2015;39(1):26-31.
* Reports on the prevalence of structural changes in the heart, comparing data collected from rural
Māori, urban Māori and urban non-Māori.
34. Penney L, Fieldhouse W, Kerr S. Te Hononga a Te Hekenga o Te Rā: Connections at the going
down of the sun:Improving Māori access to palliative care/tapuhi hunga roku in Te Tai
Tokerau. . Kerikeri, NZ: Kiwikiwi Research and Evaluation; 2009.
35. Koti DM. Te Tatau o te Pō: Perceptions and experiences of palliative care and hospice - a Māori
perspective: Massey University; 2013.
36. Frey R, Gott M, Raphael D, Black S, Teleo-Hope L, Lee H, et al. 'Where do I go from here'? A
cultural perspective on challenges to the use of hospice services. Health & Social Care in the
37. Kara E. Stocktake of palliative care education and support needs for Māori providers within
Waikato DHB District. Waikato, New Zealand: Waikato DHB; 2008.
38. Kidd J, Reid S, Collins N, Gibbons V, Black S, Blundell R, et al. Kia mau te kahu whakamaru:
Health literacy in palliative care. Wellington: Ministry of Health; 2014.
39. Kidd J, Black S, Blundell R, Peni T. Cultural health literacy: the experiences of Māori in
palliative care. Global health promotion. 2018;1:1757975918764111.
** This study explores the palliative care experiences of patients, whānau (families) and health
professionals in relation to health literacy. The study found that several factors impacted participants’
ability to access, understand and use information in palliative care settings, and that patients and whānau
developed complex health literacy practices to work around cultural and communication obstacles.
40. Hampton M, Baydala A, Bourassa C, McKay-McNabb K, Placsko C, Goodwill K, et al.
Completing the circle: elders speak about end-of-life care with aboriginal families in Canada.
Journal of Palliative Care. 2010;26(1):6-14.
41. McGrath P, Holewa H. The living model: A resource manual for Indigenous palliative care
service delivery. Toowong, Queensland: Researchman; 2006.
42. O'Brien AP, Bloomer MJ, McGrath P, Clark K, Martin T, Lock M, et al. Considering Aboriginal
palliative care models: the challenges for mainstream services. Rural & Remote Health.
43. Kelly L, Linkewich B, Cromarty H, St Pierre-Hansen N, Antone I, Giles C. Palliative care of
First Nations people: a qualitative study of bereaved family members.[Erratum appears in Can
Fam Physician. 2009 Jun;55(6):590 Note: Gilles, Chris [corrected to Giles, Chris]]. Canadian
Family Physician. 2009;55(4):394-5.