Trigger Topics: Where Religion & Health Care Intersect MODULE

Evangelical Christian How Many Religions? Hinduism Buddhism Atheism Santeria Shinto Jainism Agnostic Southern Baptist Russian Orthodox Wiccan Shi’a Muslim Baha’i Unitarianism Rastafarianism Lutheran Eastern Orthodox Sikhism Protestant Voudon Jehovah’s Witness Evangelical Christian Pentecostal Taoism Sunni Muslim Orthodox Judaism Zoroastrianism Methodist Presbyterianism Hasidic Conservative Judaism Mormonism Alaska Native Candomble Roman Catholic Paganism Confucianism Reform Judaism Seventh Day Adventist Mahayana American Indian Spiritual

A Practical Approach Given the diversity between and within religious traditions, it is impossible to be knowledgeable about every religion you might encounter. A more practical approach is to learn to identify specific areas within health care where religious concerns might arise for a patient and/or his or her family. Being familiar with these general areas will help you identify the appropriate questions to ask and better prepare you to deal with potential conflicts and challenges as they arise. This presentation will highlight 15 areas within health care where religion often comes up.

Trigger Topics Acceptance of Drugs and Procedures Dietary Requirements Dress & Modesty Hygiene Informed Consent Observance of Holy Days and Rituals Complementary and Alternative Medicine Organ Transplants and Donations Reproductive Health Pregnancy & Birth End of Life Acceptance of Drugs and Procedures Blood and Blood Products Conscience Rules Prayer with Patients Proselytizing

Culture, Belief and Practice CULTURE: the values, norms, and traditions of a particular group. EXAMPLE: a Somali Muslim woman refuses to be seen by a male doctor. BELIEF: conviction of the truth of some statement or the reality of some being or phenomenon. EXAMPLE: a patient refuses treatment, believes God decides time to die. PRACTICE: a repeated or customary action; the usual way of doing something. EXAMPLE: a patient alters medication regimen to fast for Yom Kippur.

Culture, Belief and Practice

Stereotypes: FIXED thinking Generalizations Stereotypes: FIXED thinking Generalizations FLUID starting point to explore the cultural and religious beliefs of the patient Galanti, G. (2008). Caring for patients from different cultures. Philadadelphia, PA: University of Pennsylvania Press.

Dietary Requirements Religiously motivated food restrictions that impact meals and/or medication. FOR EXAMPLE: A Jewish family may be concerned as to whether the infant formula they are using is certified kosher. A Muslim patient may request halal meals during his/her stay at the hospital. The son of an elderly Hindu patient suffering from dementia is distraught when he discovers that his mother has been served (and eaten) a non-vegetarian meal.

Dress & Modesty Religious garb or symbols and specific behavior relating to modesty. FOR EXAMPLE: A Hasidic man declines to shake hands with his wife’s female physician. An Eastern Orthodox patient is distraught when her request to wear her cross necklace into surgery is denied. A Muslim woman refuses to be examined by a male physician.

Hygiene Religious practices related to washing prior to prayers and mealtimes or religious concerns pertaining to grooming needs. FOR EXAMPLE: An Orthodox Jewish patient with OCD washes his hands twenty times a day, fearing that he is not correctly performing the religious ritual of washing his hands before meals and studying the Torah. A Hindu patient in a long-term care facility is distressed because she is no longer physically able to perform her morning ablutions (washing), a task she is required to perform before her morning prayers. Solution: if no shower available, provide a jug of water.

Informed Consent Requirements around consultation and/or obtaining the consent of a family member or religious leader to approve a course of treatment. FOR EXAMPLE: A Catholic patient insists on speaking to a priest before going to a coronary catheterization lab. A Jewish patient refuses to agree to surgery until she has spoken with her rabbi.

Observance of Holy Days & Rituals Observing certain holy days or performing religious rituals that require accommodations around scheduling of procedures or modifying treatments for fasting. FOR EXAMPLE: A Muslim patient with diabetes wishes to fast for Ramadan. An Orthodox Jewish patient refuses to sign an intake form on a Friday evening, as writing is forbidden on the Sabbath. A Hmong woman in poor health wishes to perform a soul calling ceremony in the operating room where she believes her soul loss occurred. .

Complementary & Alternative Medicine Using religiously or culturally indicated alternative remedies or seeking the assistance of a traditional healer. FOR EXAMPLE: A Pentecostal patient with cancer informs his physician that he has decided to stop chemotherapy. He believes God has healed him. The parents of a young Haitian child diagnosed with psychosis want to have their child exorcised by a Voodon priest. A Hindu patient prefers to use Ayurvedic medicine to manage her pain.

Organ Transplants & Donations Religious beliefs that influence willingness to accept a donor organ or agree to donate an organ. FOR EXAMPLE: The family of a Japanese child who is brain dead is furious when asked if they will agree to organ donation. According to their Shinto beliefs, interfering with a body brings bad luck and injures the relationship between the dead and the bereaved. An African American Protestant family becomes distraught when asked if they would be willing to donate the organs of their loved one, who is brain dead following a car accident. They believe that God could still perform a miracle and accuse the hospital staff of “playing God.”

Reproductive Health Religious views on contraception, abortion, or fertility procedures such as in vitro fertilization or sterilization. FOR EXAMPLE: A Muslim woman is reluctant to see a doctor about irregular periods. She is anxious that a pelvic exam will be required lest this cause further bleeding. (Muslim women are exempt from certain rites such as prayer when menstruating.) A Catholic family is reluctant to consider birth control pills as a treatment option for their teenage daughter who suffers from endometriosis.

Pregnancy & Birth Religion-specific practices associated with labor and birth, such as particular foods, rituals, or traditional remedies. FOR EXAMPLE: A doctor notices that the husband of an Orthodox Jewish woman who is in labor is not touching his wife (holding her hand or rubbing her back). A social worker is called after staff become concerned that a Hindu couple is not bonding with their newborn baby because they refuse to fill in a name on the birth forms.

End of Life Religious beliefs around performing particular rituals before or after death or that dictate particular perspectives on withdrawing care or prolonging life. FOR EXAMPLE: After a Buddhist patient passes away, his family requests that his body not be moved from the hospital bed for the next three days. A Baptist family refuses to allow a DNR order to be placed on the chart of a loved one. They believe that God could still heal the patient and are hoping for a “miracle from God.” Some Jewish families will object to a DNR order for a patient who is brain dead, based on a religious belief that death only occurs when a patient’s heart and breathing have stopped.

Acceptance of Drugs & Procedures Religious objections to specific drugs and procedures due to various religious restrictions such as fasting, preferences to use alternative medicine, or religious dietary objections. FOR EXAMPLE: A Buddhist patient refuses to use pain medication. He believes that having an unclouded state of mind at death influences one’s rebirth. A Muslim family objects to physicians using a porcine skin graft to treat a burn on their daughter’s arm. Pig products are considered haram (forbidden).

Blood & Blood Products Religious beliefs that restrict the use of blood or blood products. FOR EXAMPLE: A young woman who self-identifies as a Jehovah’s Witness refuses a blood transfusion after suffering an internal hemorrhage from delivering twins. The parents of a 6-year-old child in critical condition due to sickle- cell crisis insist that no blood transfusions be performed during surgery due to their religious beliefs as Jehovah’s Witnesses.

Conscience Rules Religious beliefs of the health care provider that conflict with the needs or requests of the patient. FOR EXAMPLE: A Catholic physician objects to prescribing birth control pills. A Sikh physician wears a full beard due to his religious beliefs, which conflicts with hospital policy regarding safety/hygiene. A Jewish physician refuses to withdraw care from a patient on life- support due to his religious beliefs around protecting/prolonging life.

Proselytizing In a health care setting proselytizing can be broadly defined as “inappropriate religious expression.” FOR EXAMPLE: A phlebotomist, while he is drawing blood, asks a patient what he thinks about Jesus. A member of the hospital housekeeping staff prays over the bed of a patient without his consent. A doctor offers to pray with a patient. A patient undergoing routine surgery requests that a priest be called should anything go wrong. The surgeon dismisses the request as unnecessary.

Prayer with Patients The patient and/or family of the patient request that a member of their health care team pray with them. DOs DON’Ts Follow the patient’s lead – if comfortable doing so. Initiate prayer. Abstain from the prayer itself but remain in the room. Impose your own beliefs. Refer to pastoral care. Make up an excuse and leave the room.

Barriers to Asking About Religion My job is medicine! I don’t want to look ignorant for asking. I don’t want to offend. Religion This topic makes me uncomfortable. I know this already. That’s their problem. Patients will bring it up if they need to. I’ve got enough on my plate. It’s none of my business.

Spiritual Screen/History/Assessment ADMISSION: basic questions to determine patient’s faith affiliation and religious needs. Spiritual Screen CLINICIAN: Ongoing questions to identify religious concerns that impact medical care. Spiritual History CHAPLAIN: In-depth look at a patient’s spiritual makeup to provide support/guidance. Spiritual Assessment Koenig, H.G. (2007). Spirituality in Patient Care: Why, how, when, and what. West Conschohocken, PA: Templeton Press.

Spiritual History: Initial Questions to Ask Are you a member of a faith community? Is your faith an important part of your life? Are there any religious/spiritual concerns you have related to your health that you would like me to know about? Do you have any religious beliefs/practices that would impact your daily activities while you’re here at the hospital? Koenig, H.G. (2007). Spirituality in Patient Care: Why, how, when, and what. West Conschohocken, PA: Templeton Press.

Spiritual History: Continuing the Conversation Ascertaining patients’ main concerns about their illness Conducting an examination Discussing a patient’s diagnosis Determining a treatment plan Understanding any objections to suggested treatment Determining if patient needs spiritual support/guidance Discussing treatment management and follow-up

How Should I Ask? Admission: Are there any religious/spiritual needs or concerns you have related to your health that you would like for me to know about? Concerns: What concerns you most about your condition? Examination: Is there any way I can help make you more comfortable while I examine you? Diagnosis: Have you tried any kinds of medicines, vitamins, herbs, or teas, or sought help from a healer or other type of doctor to cure this illness? Treatment: Do you have any religious beliefs or practices that would be important for us to consider regarding the treatment options I just explained to you?

Objections: I’m understanding that you have certain religious objections to this treatment and I respect that. Can you tell me a little more about your objection? I want to understand your concerns better. Support: Would it be helpful to you speak to your spiritual leader about what we’ve discussed? Management: Do you have any religious practices or religious holidays coming up that we need to consider in managing your care? For example, do you fast as a part of your religious practice? How Should I Ask?

Let’s Discuss! The Case A 43-year-old Chinese woman is an inpatient on day 14 of a high- dose, time-sequential induction regimen for Acute Myeloid Leukemia. Her nurse reports that the patient seemed unable to sleep at all the previous night, but had insisted that she was fine and not in any pain. When her physician examines her, he sees evidence of early mucositis, a very painful inflammation and ulceration of the mucous membranes lining the digestive tract. When he asks her how she is doing, she seems reluctant to discuss her discomfort and rates her pain at only a 4 or 5 out of 10. He suggests oral or IV pain medication as needed to ease her pain, but the patient refuses despite what appears to be considerable discomfort. Her doctor cautions her against rejecting pain medication, explaining the harmful effects that unrelieved pain can have on her mood and her functional status. The patient thanks him politely but reiterates that she is fine and doesn’t need pain medication. University of Maryland Palliative Care Initiative. Basic Cancer Pain Management: Case Studies for Medical Students, Medical Residents, and Hematology/Oncology Fellows.

Think About... Questions Identify what specific pieces of information you need to obtain from the patient to determine appropriate next steps to manage this situation. Compose corresponding questions to draw out this information.

The Religious Context Consider… The religious traditions of Taoism, Confucianism, and Buddhism are integrated into Chinese culture. Patients may be influenced by more than one tradition. Religious values may be a key component of a patient’s decision- making without the patient being directly aware of it. In Taoism, illness is considered to be caused by an imbalance between the forces of Yin and Yang. Chinese patients may believe that using Western medicine increases this imbalance. Expressing “disruptive” emotions, such as pain, may be considered harmful to maintaining harmony, a central purpose of Confucianism. Pain can be seen as connected to kharma, but how this connection is viewed and how it influences health care decisions will vary. Dhingra, L. (2008, Winter). Pain in ethnic Chinese cancer patients: Role of cultural factors in assessment and treatment. The Pain Practitioner, 28-34. Im, E., Yi, L., Young, K., & Wonshik, C. (2008). Asian American cancer patients' pain experience. Cancer Nursing, 31(3), 17-23. Rundle, A., Carvalho, M., & Robinson, M. (2002). Cultural competence in health care: A practical guide. San Francisco, CA: John Wiley & Sons, Inc.

Taking a Spiritual History: Keep in Mind… Leverage curiosity & ask respectfully Listen to understand – not to agree or disagree Be mindful of your lens – keep an open mind Acknowledge the patient and his or her family’s concerns Prepare for course correction Ask for help! Reassess periodically