Providing Culturally Competent Care to Patients with Religious Sensitivity.
APTA-CSM February 21-24, 2018 New Orleans, LA
Session Objectives
1. Explain basic unique beliefs/practices of Judaism, Christianity & Islam.
2. Recognize differences in outlook on health, wellness, sickness, and death between each Abrahamic religion.
3. Analyze influence of religious beliefs and practices on health care decision-making for each monotheistic religion.
4. Create a religiously sensitive plan of care for patients of Jewish, Christian & Muslim heritage.
Session Outline
• Explore: – unique beliefs/practices of Judiasm, Chritainity, and Islam, – outlook on health, wellness, sickness, and death, – influences on health care decision-making; and
• Create a religiously sensitive plan of care the patient with Jewish, Christian, & Islamic heritage
1 Cultural Considerations for People of Jewish Heritage
Ronnie Leavitt Ph.D., MPH, PT
Cultural Competence
• Acknowledges and incorporates – at all levels - the importance of culture • Assesses cross-cultural relations • Vigilant towards the dynamics that result from cultural differences • Expands cultural knowledge • Adapts services to meet culturally unique needs.
What does it mean to be Jewish?
• Being Jewish can be a personal and/or group identity having to do with one’s religion, culture, ethnicity, or lifestyle
• Huge INTRACULTURAL VARIATION with a wide variety of beliefs and practices within and across “streams” of Judaism
• Orthodox, Conservative, Reform, secular
2 Jewish Sub-Cultures
• Orthodox – (~10% in USA) – most traditional and serious with regard to practicing rules of observance and piety. – Ultra orthodox (Chasidic, Lubavich); modern orthodox • Conservative (~18%) – middle ground alternative • Reform – (~35%) – • Secular – (30%) -identify as Jews but do not practice organized religion. May be without a belief in God. Likely to be highly assimilated in mainstream society. 2013 Pew Research Center Survey of U.S. Jews.
A “Minority” Group Within the USA • ~ 2% of population or ~6.6 million people – ~85% born in USA Greatest number of immigrants from Soviet Union, Israel • ~17 million Jews in the world, including ~6.6 million in Israel • Ashkenazi Jews (~82% of Jewish population worldwide and ~ 90+% in USA) • Sephardic Jews • Sensitive to anti-Semitism • Zionist movement – led to founding of Israel in 1948
The oldest monotheistic faith
• Belief in one god who entered into a covenent with Abraham and his descendants • The heart of Judaism are the words “Hear O Israel, the Lord is our God, the Lord is One” • The Jewish conception of God is of a moral God who demands moral, ethical living and justice for all humankind • The writings of Judaism, or Hebrew Bible, include the five books of Moses which were handed down from God at Mt. Sinai – Christians refer to this as the “old testament”
3 Religious Life
• based on the commandments (mitzvot) that are found in the Torah 5 books of Moses) and other Jewish literature – Mishnah (written code/ commentary by Maimonides, a 12th C sage) • A compendium of what Jews should and should not do with regard to all aspects of living – Talmud - (oral tradition based on Mishnah) – Halacha – Rabbinic interpretation of Jewish law
Religious Life
• Synagogue, shul, temple – Jewish house of worship and cultural center – A synagogue will have Torahs – handwritten, parchment scrolls of Hebrew writings in the “holy ark” under an “eternal light” • Rabbi – spiritual leader of a congregation • Cantor – leads chanting at services • Sabbath – A day of rest and spiritual reawakening – Saturday is the holy day (sundown to sundown)
Jewish Living through Mitzvot and Jewish Values • Love of family and community (ahavat mishpachah) • Learning and education (study of Torah) • Tikun olam – to better the world • Justice and charity (Tzedakah) • Kindness (Chesed) • Joyfullness (Simcha)
4 Language and Communication
• American Jews primarily speak English • Tend to speak openly and be informal and lively • Among ultra-orthodox, no touching between non-married men and women • Hebrew – the language of rituals and prayers and the spoken and written language of Israel • Yiddish – a Judeo-German dialect nosh, bagel, pastrami, mensch, meshugaa, kibitz, shlepp, tuchus, kvetch, schmata, yenta, and more Multiple spelling alternatives -eg. Shabbat or Shabbos; Hanukah, Channukah
Major Jewish Holidays
• “High Holy Days” • Rosh Hashona – celebrates creation of the world – our “new Year” • Yom Kippur – “Day of Atonement” (fasting) • Sukkot – signifies the end of harvest and remembers 40 years wandering in the desert on way to “promised land” • Hanukkah – symbolizes time when Macabees led a successful revolt against anti-semetic oppression in 167 B.C.. – Light candles in a menorah, for 8 nights
• Passover or Pesach – commemorates miracle of the exodus from Egypt and the beginning of Jewish nationhood. – Sedar – read the Hagaddah which tells the story of the exodus. – Many rituals associated with the sedar such as eating Matzah or unleavened bread (no time for bread to rise during the exodus)
• Purim – signifying the deliverance from Haman • Shavuot – giving of the Torah
5 Shabbat
• Generally Orthodox Jews must: • Be home before sundown on Fri. evening • (may be willing to work on Sunday) • Home based rituals – Lighting of candles; reciting Kiddush, Motzi (prayer over wine and Challah) and berachot (over food) • May not “work” or travel – Can not drive; use money; turn electric appliances or lights on or off • Havdalah ceremony ends Shabbat – separates holy from ordinary
Family and Gender Roles
• Historically a patriarchal society • Judaism passed down through mother (Reform movement no longer “requires” this) • Marriage is considered a sacred covenant and couples are expected to build a Jewish home – Mixed marriages are common among reform and conservative streams – Gay and lesbian lifestyle accepted by reform and conservative streams • Women traditionally responsible for home and children
• Procreation encouraged and adoption supported – Every child is created pure – All children are to be treated equally including a child with a disability • Contraception and abortion allowed for Reform and Conservative movements • Rituals associated with children – Bris – circumcision of boys – Bar or Bat Mitzvah ceremony (usually 13 years old) to mark the rite of passage for children into adult religious responsibility
6 • Elders are treated with deference, honor and respect • General equality between men and women and increasing blurring of gender roles within the Conservative and Reform movements • More restrictions for women among Orthodox
Food and the Practice of being Kosher • Foods commonly associated with Jewish living – Chicken soup, bagels and lox, knaidle, chopped liver, kugel, blintzes, tsimmis/brisket • Jewish dietary regulations are defined according to Jewish laws of kashrut • Certain permitted foods must be prepared in a specific way and labeled “kosher” • Meat (fleishik) and dairy (milchik) foods are separated in preparation, serving, and eating • Certain foods are restricted – Pork, shellfish or nonscaled fish
Hereditary and Genetic Conditions
• Ashkenazi Jews have genetic link to: – Tay-Sachs, Niemann-Pick, and Canavan’s diseases – Familial dysautonomia, torsion dystonia, cystic fibrosis – Gaucher’s disease • Increased predisposition to breast cancer 1 gene mutation • Higher rate of side effects with clozapine • Protective gene effect against alcoholism by genetic mutation (ADH2*2) • Greater than expected frequency of inflammatory bowel diseases, colorectal Ca
7 Healthcare Practices
• Sanctity of life is core tenet • Health maintenance and care of the body are human responsibilities – Permanent tattooing, illegal drugs, suicide are illegal – Life-saving medical ministrations are expected but generally permissible to let nature run its course if a cure is not possible • Receiving blood and blood products is OK • God is recognized as the ultimate healer • Social supports are an adaptation to stress
Death and Associated Rituals
• Death is when one is “brain dead” • Autopsies and organ donation generally allowed if it will give life to/ benefit another individual • Sacredness of grief, sympathy and memory but not “obsessive” • Specific rituals for Orthodox • Burial is as soon as possible – cremation is forbidden but is increasing among reform and conservative Jews
• Funeral Services is in a synagogue or chapel – Prayers, eulogy, mourner’s kaddish • Dress is modest – many will cover their heads • Return to the home for a traditional meal • “Sitting shiva” - ~one week mourning and consolation period, with visits by friends and family
8 Folk Practices
• To prevent “evil eye”, may say kayn aynhoreh after a compliment or expression of luck • May touch mezuzot to ward off disease
People of Jewish Heritage
• Reflect a very wide array of beliefs and behaviors, both religious and cultural • Are generally cognizant of the fact that many do not know much about Judaism • Will likely welcome your questions • Appreciate your efforts at becoming culturally competent
Reflective Questions
• What is your level of familiarity with people of ____ heritage? • What stereotypes and biases do you hold toward individuals from ____ heritage? • What do you believe are the values of people who are of the _____ faith? • What values and traditions do you hold dear from your religion? • How often do you make an effort to learn about a different faith or go to a cultural event related to a different faith?
9 Providing Culturally Competent Care to Patients with Religious Sensitivity
APTA CSM 2017 February 22, 2017
Providing culturally competent care for persons of Christian faith and beliefs
Key Points of Discussion
1. Common Christian considerations generally known but not necessarily well understood: • Why persons who practice the Christian denomination Jehovah’s Witness do not accept blood transfusions
• Why Christians may not accept medical recommendations for termination of pregnancy in life‐threatening situations
10 Key Points of Discussion
2. How to competently engage in patient/therapist interactions around belief‐ specific considerations. 3. The role of the physical therapist in facilitating patient consultation with a religious chaplain, priest, minister. 4. Educating patients and families on the HIPPA regulations and steps needed to assure that religious personnel can visit the patients and provide sacraments when desired.
Introduction
• Freedom of religion in the United States is an inalienable right for all individuals. • Patient autonomy is a fundamental principle in biomedical ethics • Informed consent for medical and therapy related procedures is a best‐practice standard in healthcare delivery • Duty to “do no harm” in medical/surgical/rehabilitative care must include respect for persons religion, faith, belief systems
Illustrations of Christian religious beliefs influencing therapeutic options • Congregation of Jehovah’s Witnesses (JW) • Watch Tower Bible and Tract Society aka Watch Tower Society • Founded in 1870s in Pittsburg, PA • In 1945 Watch Tower Society determined that blood transfusions are contrary to divine law. • To accept a blood transfusion meant you were excommunicated from the congregation of Jehovah’s Witnesses
11 Biblical Scripture Basis for JW Belief: “Blood transfusions are contrary to divine law” • Genesis 9:3‐4 “Every moving thing that liveth shall be meat for you; even as the green herb have I given you all things. But flesh with the life thereof, which is the blood thereof, shall ye not eat.” • Leviticus 17:10 “And whatsoever man there be of the House of Israel, or of the strangers that sojourn among you that eat any manner of blood; I will even set my face against that soul that eats blood and will cut him off among his people.”
Biblical Scripture Basis for JW Belief: “Blood transfusions are contrary to divine law” • Leviticus 17:12 “Therefore I said onto the children of Israel, No soul of you shall eat blood, neither shall any stranger that sojourns among you shall eat blood.” • Leviticus 7:14 “For it [blood] is the life of all flesh; the blood of it is for the life thereof: Therefore I said onto the children of Israel, Ye shall not eat the blood of no manner of flesh; for the life of all flesh is the blood thereof; whoever eats it shall be cut off.”
Biblical Scripture Basis for JW Belief: “Blood transfusions are contrary to divine law” • Deuteronomy 15:25 “ Only thou shall not eat the blood thereof; thou shall pour it upon the ground as water.”
The biblical verses cited refer to food but JW interpret the verses to refer to blood transfusions. Food and blood transfusions are seen as the same thing—sustenance and nutrition.
Failure to comply with the commandment of God results in being “cut out” or excommunicated.
12 Watch Tower Society Considerations for Life‐ Saving Procedures Using Blood Products • Not acceptable—any stored blood products – Whole Blood – Red Blood Cells – White Blood Cells – Platelets – Plasma • Acceptable • Autologous blood if it does not leave the body • Extracorporeal circulation • Blood Fractions—”minor” blood components – Immunoglobulins – Albumin
Watch Tower Society Considerations for Life‐ Saving Procedures Using Blood Products • Beginning in 1998 the ban on using blood products for JW relaxed the rule of excommunication providing: – the transfusion occurred against the persons will – the individual was coerced at a time of weakness and is contrite and repentant • 2000 The Watch Tower Society reiterated that JW may receive blood fractions but may not receive blood transfusions of whole blood. • Persons who knowingly accept transfusion are excommunicated by their own doing and actions.
Physical Therapy Implications: Acute Care and Orthopedic Care • Patients with major surgical conditions often require blood transfusions;
• Patients with revision of total joint replacement often require blood transfusions
• Failure to replenish blood loss results in hemodynamic instability and anemia
• The post operative rehabilitation process may be compromised in the presence of hemodynamic instability and anemia.
• Modification of the physical therapy interventions is essential for patient safety.
• Patient decisions around blood product replacement must be observed and religious beliefs respected.
• Patient education in this area should be restricted to those amenable to the patient given their religious belief system.
13 Why Christians (not only Catholic Christians) are not likely to terminate a pregnancy in the presence of medical or genetic anomalies
How to be supportive of patients faced with difficult religious and belief‐based decisions during pregnancy.
Factors that may prompt discussion on pregnancy termination • Pre‐natal screening test results that indicate genetic or chromosomal abnormalities – Down Syndrome – Neural tube defects – Anencephaly – Trisomy 13 – Trisomy 18
Physician Recommendations for Therapeutic Termination of Pregnancy Medically indicated termination of pregnancy or medical abortion is recommended to a mother for the following reasons:
• The life of the mother is at risk if the pregnancy continues
• The fetus will likely die in utero or shortly after birth
14 Thou Shall Not Kill
• The Christian faiths regard the commandment "Thou shalt not kill“ as the principle for banning abortion.
• The debate of when the fetus’ soul emerges in gestation has been ongoing over the centuries.
• Over the ages abortion was permitted when the fetus was thought to be without a soul.
Christian Beliefs and Pregnancy Termination • The Catholic Church has consistently taught that abortion ‐‐ at any stage of development ‐‐ is evil. • Circa 100 to 150 CE: The Didache (also known as "The Teaching of the Twelve Apostles"), was a document written for the guidance of Christians. It forbade all abortions. • The church penalty for abortions at any stage of pregnancy was, and remains, excommunication. • The sin of abortion can be forgiven by a bishop or a priest if the bishop permits the priest to do so.
Current Catholic Teaching on Abortion
• Today, the Catholic church teaches that a human person comes into existence at conception, perhaps two weeks before pregnancy begins.
• The fertilized ovum, pre‐embryo, embryo and fetus are considered by the church to be full human persons.
15 Current Catholic Teaching on Abortion
• The Church teaches the unborn child has an equal right to its life with its mother;
• The mother, nor the medical practitioner, nor any human being whatever can lawfully take that life away.
• Because abortion is considered an evil act, evil is never to be done that good may come of it; in other words, a good end cannot justify a bad means.
Culturally competent discussions regarding medical termination of pregnancy • Do not judge negatively the individual who goes against medical advise and chooses to continue with a pregnancy
• Do not judge negatively the individual who chooses to follow medical advise and terminates a pregnancy.
Culturally competent discussions regarding medical termination of pregnancy • Do not describe the worst case scenario when discussing developmental outcomes— physical, cognitive, socio‐emotional for children with developmental disabilities.
• Do not paint a rosy picture as though there will be no difficulties or challenges to overcome with a child with developmental disabilities.
16 Support for Post‐Medical Abortion Patients • Grief counseling with a member of the clergy • Sacrament of Reconciliation—confession • Support group for medical termination of pregnancy
Other Christian‐based factors which may influence patient interactions • A patient asks you to pray with them before the treatment begins and you are not a person of prayer – Tell the patient that s/he can pray prior to the treatment – Let the person know you do not share their faith beliefs but respect their need to pray
Other Christian‐based factors which may influence patient interactions • A patient begins to evangelize to you and you are uncomfortable with the way the patient is interacting – Try to avoid the discussion of religion by focusing on the educational teaching related to the treatment being offered
– Respectfully tell the patient you have a belief system and are not looking to change
17 Other Christian‐based factors which may influence patient interactions • You become aware that a patient has no family, the medical chart states the patient’s religion is Catholic, the patient is seriously ill – HIPPA regulations restrict sharing of patient information without the patient’s consent – Advocate for patients who may not know the HIPPA regulations and get them to complete the process that allows the clergy to visit the patient – Especially advocate for patients to receive the sacrament of the anointing of the sick
References
• Harwin SF, Pivec R, Johnson AJ, Qais N, Mont MA. Revision Total Hip Arthroplasty in Jehovah’s Witnesses. Orthopedics.2012; 35(8): e1145‐e1151.
• Petrini C. Ethical and legal aspects of refusal of blood transfusion by Jehovah’s Witnesses, with particular reference to Italy. Blood Transfu. 2014;12(suppl1):s395‐s401.
• Lorentzen K, Kjaer B. Jorgensen J. Supportive treatment of severe anaemia in a Jehovah’s Witness with severe trauma. Blood Transfus. 2013 Jul; 11(3): 452–453
• Barker J. New Watchtower Blood Transfusion Policy. http://www.watchman.org/articles/jehovahs‐ witnesses/news‐watchtower accessed on November 1, 2017.
• Gillon R. Is there an ‘new ethics in abortion’? Journal of Medical Ethics. 2001;27 suppl II:ii5–ii9
• Hirsch JF, Bhagwati SN, Epstein F, Hoppe‐Hirsch E, Mutluer S, Raimondi AJ. Medical abortion: ethics, laws and religious points of view, A study by the 1994‐1995. Ethics and Morals Committee of the ISPN. Childs Nerv Syst. 1996 Sep;12(9):507‐14
Principles of Islam: Applications to Healthcare and Physical Therapy
Aliya N. Chaudry, PT, MBA, DPT, J.D. APTA-ELI Fellow Professor School of Physical Therapy Langston University
18 Objectives 1. Describe Islamic perspective on sickness & healing.
2. Explain Islamic influences on health care decision- making.
3. Incorporate 3 strategies to provide religiously sensitive PT care to a patient who is a muslim.
4. Defend need to provide culturally competent care with religious sensitivity to patients who are muslim.
Outline
1. Islam: What-when-where-who-why?
2. Articles of Faith & Practices of Faith
3. Demographics of muslims globally & nationally
4. Additional key considerations: a. cleanliness/hygiene in Islam b. role of family & visitation of the sick in Islam c. gender related considerations in Islam
What is Islam?
19 Basic Meaning of the Word “Islam”
• Peace and submission to the will of Allah (‘the God’.)1,2
• Submission to will of God means: - abiding by laws &commandments of Allah2
Islam: The Religion1 •Also referred to as an ‘Abrahamic’ monotheistic religion after Judaism & Christianity.
•Took birth: • in Saudi Arabia •in 7th century C.E. •through efforts of an orphan named Mohammed who was ordained a prophet at age 40 (pbuh).
•Followers of Islam are called Muslims.
•Fundamental Muslim belief: •there is only one God; and •Prophet Mohammed is the messanger of God .1,2
Sources of Islamic Beliefs2,3
• Quran =Sacred scriptures revealed by God o Prophet Muhammad
• Sunnah = the ‘doings’ of Prophet Muhammad - i.e. practices from the Propht’s life
• Hadith = sayings of Prophet Muhammad
• Ijtehad = the use of ‘law of deductive logic’ - ruling by consensus of community and/or precedent in absence of specific guidance - Fiqh or Islamic Jurisprudence—use of Islamic scriptures & traditions of the Prophet to come up with practical rulings18
20 Basic Tenets3
• Six Articles of Faith (Imaam or Aqueedah)
• Five Practices of Faith (Pillars of Islam)
Articles of Faith4
Belief in: 1. one sovereign God 2. prophets of God: from AdamMuhammad 3. the existence of angels 4. the day of judgment & life after death 5. predestination i.e. everthing happens by God’s decree 6. revelations of God—i.e. holy scriptures
Practices of Faith4
5 Fundamental Pillars:
1. ‘Shahada’ = state there is only one God 2. ‘Salah’ = prayers (5times/day) 3. ‘Zakat’ = giving to the poor/needy (2.5%) 4. ‘Hajj’ = performing holy pilgrimage to Mecca 5. ‘Sawm’ = fasting (during ‘Ramadhan’ i.e. 9th month of lunar calendar).
21 ‘Shahada’
•recitation of above verse which merely states: - there is only one God and Muhammad is his Prophet
‘Salah’—Prayers5
•2nd pillar-- becomes obligatory from puberty onwards
•performed at 5 predetermined times/day Fajr • ‘Fajr’—early morning before dawn • ‘Zuhr’—early afternoon • ‘Asr’—late afternoon—early evening • ‘Magrib’--sunset • ‘Isha’—night time
•performed individually or with others facing «Mecca»
•exceptions to general prayer rules permisible per individual’s health status, age, travel
‘Salah’—Prayers5,6,7,8 • Both a physical & mental practice
• Physically: • helps keep the body clean: • must perform “Wadhu” • i.e. cleanse body with water in prescribed manner pre- prayer • helps exercise the body—lowmoderate form of exercise • perform prayer in a preordained routine • during each prayer an individual changes posture a minimum of 14 times & upto 119 times/day • postures similar to postures adopted in yoga • cannot eat, drink, or talk during prayer
22 Physical Benefits of ‘Salah’—Prayers5,6,7,8
Contributes towards overall physical health by:
• facilitatating relaxed breathing • increasing blood flow • improving musculoskeletal fitness - exercises major joints - promotes neck range of motion - strengthens back core muscles - improves posture - stengthening & stretching exercise
‘Salah’—Prayers6,7,8
Mentally—a spiritual exercise •involves recitation of quranic verses
•reaffirmation of faith “Pray unto me and I will hear you” (Holy Quran 40:60)8 •when performed correctly provides: - inner peace—knowing of being in the presence of God - comfort in times of hardships/fear - hapiness in times of prosperity
Concerns
Patient may: • appear depressed and/or disinterested due to inability to perform physical movements required during prayers - e.g. quadriplegics, other bedbound patients.
•get upset at a Healthcare provider: - who interrupts their prayers or inadvertantly - walks in front of the praying patient.
•decline Physical Therapy sessions scheduled during prayer time.
23 Suggestions •Demonstrate respect & convey link to patient between their belief practices & PT plan of care by: - scheduling P T sessions at times that will not interfere with patient’s prayer schedule (p.m. treatment session).
- setting goals & designing tasks/exercises that will assist patient to become independent with performing their prayer ritual.
Suggestions Physical therapist should also:
• request facility chaplain to contact muslim clergy (“Emaam”) to reiterate to patient: - manner , mode and timing of prayers may be modified during illness/need - e.g. okay for patient to pray sitting or lying in bed because “necessity overrides prohibitions”
• improvise by providing clean sheet for prayer if no prayer rug is available.
• identify North-Easterly direction in room for prayer
• request nursing post «DO NOT DISTURB» sign outside patient’s door for prayers times to avoid interruptions.
‘Hajj’—Holy Pilgrimage9
• obligatory pillar that should be performed by adults in good health with affordability at least once in a life time in the 12th month of Islamic calendar (Zilhaj)
- considered “the largest & most long-standing annual mass gathering event on earth.”9
- 2.5 Million pilgrims from 160 countries with varied ethnicities—walking, in wheelchairs, or even carried.
24 Stressors of ‘Haj’9 Requires travel to Mecca & other religious sites in Saudi Arabia • must meet stringent travel requirement to enter Saudi Arabia e.g.: - obtain visa - women under age 50 must travel with male family member - undergo medical check-up - wear appropriate attire - follow prescribed path & timed iternary to complete pilgrimage
• physically challenging venture that reuires dealing with: - extereme weather---exposure to sun and heat - mass crowds & close physical contact with others • risk of contracting communicable illneses e.g. respiratory infections - environmental stressors—walking long distances, uneven terrains, steep inclines, multiple stairs, long days, keeping pace, etc.
The Pilgrimage Journey
12 stops 6 days
Suggestions
• educate patient regarding their limitations - but do not discourage going on pilgrimmage
• set realistic PT goals
• stress need for long term rehab, strengthening, and endurance building prior pilgrimmage as appropriate/patient condition
25 ‘Sawm’—Fasting9,10 Occurs at a prescribed time of year: • 9th month of Islamic calendar (Ramadhan).
• obligatory pillar from puberty onwards - exceptions to general fasting rules permisible per individual’s health status, age, travel - Individuals with chroni illness will still fast e.g. heart disease, Diabetes, HTN
• refrain daily from eating & drinking from dawnsunset
• duration = 29 or 30 days
• intense time for prayer –sharing-giving-forgiving
Concerns Patients may decline to:
• eat hospital food due to: - inclusion of pork & pork derivatives; and - lack of being kosher
• to eat anything between dawn & dusk
• take pain medication prior PT session
• take any medications between dawn-dusk
• participate in a.m. PT treatment sessions
Suggestions • inform nursing of patient’s dietary needs/limitations
• recommend need for consult by dietitian to ensure: - patient’s dietary needs are met without burden on family
• recommend facility chaplain to contact muslim clergy (Emaam) for patient to explain permissible: - exceptions/alternatives to fasting during illness/injury - to intake/consume life saving medications/schedule if needed
• schedule activity related PT sessions closer to end of work day • schedule shorter more frequent sessions e.g. 3 times/ week for 30 minutes vs. twice/week for 45 minutes.
26 Demographics
• Do all muslims have the same beliefs?
• Where do these Muslims reside: • across the Globe? • across the U.S.A.?
Types of Muslims
• Two broad categories: - Shiite Muslimsorthodox minority approx. 10% • mostly in Iran, Iraq, Bahrain, Azerbaijan - Sunni Muslims majority approx. 90% • Middle East & S. Asia
• Many sub-categories exist - potentially 72
• Division occurred due to succession conflicts at time of Prophet Muhammad’s death
Muslim Stats & Facts in USA •7M Muslims live across USA13 •perceived as fastest growing minority in USA13 •will become 2nd largest religion in USA by 03014
•are most diverse religious group in USA due to countries of origin:3, 14, 15,16 •South Asian = 25% •Arab = 23% •African American = 14% •Sub-Saharan African = 10% •Iranian = 10% •Turks = 6% •Other Asian = 5% •Other Ethnicity = 5%
27 Examples of Languages Spoken • South Asians Bahasa = Indonesia - Urdu = Pakistan (+ provincial =Punjabi-Pushto-Sindhi-Balochi) - Hindi =India (+24 spoken by>1M & 114 spoken by>10,000 - natives) - Bengali = Bangladesh •Arabs = Arabic spoken in many different dialects in different countries
•Nigerians=Igbo (+Hausa spoken by muslims) •Iranians = Farsi (+7 languages)
•Turks = Turkish and Kurdish languages
Implications of Islamic Principles & Beliefs in Healthcare
• Suggestions for providing religiously sensitive clinical care to Muslim patients
Key Healthcare Related Concepts:
•perception of health, disease & illness •the left hand and cleanliness •family ties & visitation •modesty & privacy considerations
28 Perception of Health20 •Muslims believe in:
- the “absolute timeless knowledge of God…faith, & destiny.”
- taking care of one’s health = religious duty and favorably looked upon by God.
• Spiritual non-traditional healing is also prevalant
Perception of Disease, Illness, & Disability20 • Muslims view: - illness and dying with patience and as natural - part of living; and - calamaties such as illness and diisability as a way to absolve them of the sins of their past
• Religious teachings also direct Muslims to: - preserve their health - actively seek treatment when ill - face disease, disability, and death with acceptnce and patience
• Cultural differences in interpretation though may be present across borders.
Concerns
• Some patients who misconstue concept of destiny may ignore preventive measures nor seek curative treatment
• Some patients may be disinterested in seeking traditional medical care –e.g. as evidenced by: - refusal to participate in physical therapy ; or - displaying lack of motivation during physical therapy treatment sessions
• Some patients may also discuss their preference to use non-traditional medical treatment with their physical therapist
29 Suggestions • Express respect for spiritual non-traditional healing practices such as: – recitation of verses from the Qur’an & Sunnah; – sipping of “Zam Zam”—Holy water from a well in Mecca. – use of traditional healing methods/folk remedies o e.g. use of olive oil, honey, dates, etc. 14 • Stress need to continue with traditiona medical care in conjunction with spiritual healing practices – explain benefits ot treatment & concerns relating to lack of treatment – avoid scheduling conflicts with spiritual healing session – include family member/caregiver in discussions
The Left Hand & Cleanliness
•The Left hand is usually designated to take care of personal hygiene 21 - regarded as unclean for “eating, giving, or receiving” 21
• “Cleanliness is next to Godliness” (author unknown) - considered “half of the faith”21,22 - cleansing body of all dirt , urine, stool, and blood with water is pre-requisite for all religious practices
Concerns
Patient may express frustration and helplessnes because of: •use of left hand by healthcare personnel to : –give patient food /feed patient –take patient vitals –examine and/or treat patient •patient’s inability to cleanse self (hands-face-feet) with water (perform Waddu) before prayer when body soiled in urine, stool , or blood due to: –nursing unavailable to timely assist patient –limited mobility due to medical condition
30 Suggestions • Use right hand when engaged in patient care activities.
• Design PhysicalTherapy POC around patient’s goal to be able to independently cleanse self & perform prayers. e.g. work on: –rolling in bed to assist with cleansing self after using bed pan –transferring in & out of bath-tub to perform “Waddu” –ambulating to and from bathroom to cleanse self with water after toileting and during bathing.
• Make a clean area and clean rug/sheet available for prayer
Family Ties & Illness
Concept of family goes beyond nuclear family to include extended family, friends, and neighbors in caring for the sick. –most patients will have a same sex caregiver staying withpatient to attend to patient’s needs for: otoileting obathing oclothes change Attending to the sick is encouraged and perceived as an opportunity to receive blessings from God
Family Ties & Illness • Regardless of culture, muslims are expected to take care of their parents & the sick - in most cultures, parents live with eldest son - nursing home care for parents is an exception and not the norm - visting and caring for the sick is encouraged
• Health care decisions are made collectively by the family23, for e.g.. - led by elders in the family; or - led by male spouse or eldest son
31 Concerns
• L ack of patient autonomy in health care decision making;
• Lack of privacy & rest due to extended number of visitors and abuse of visitation hours;
• Fear of patient declining PT & other services
• Fear of violating patient confidentiality; and
• Fear of patient receving sub-standard care delivered by family member
Suggestions • Reiterate need for patient to make/be involved in all aspects of healthcare decision making related to the patient
• Post visting hours in patient room & strictly enforce it
• Obtain patint written permission prior to sharing patient protected information with family members
• Acknowledge, communicate with , & include family: –explain need for PT services by skilled personnel –encourage a caregiver to accompany patient to PT – suggest use of vistor’s lounge for extended visitation
Modesty and Privacy14,15 •Islam mandates modesty in dress for both men & women when in public or around members of the opposite sex : – men must cover body area between navel & knees – women must cover entire body with exception of face, hands, & feet
•Modesty in touch is also required—touching of women especially by male non-related family members is disfavored – e.g. shaking hands is prohibited – e.g. examination & treatment by member of the opposite sex o exception—medical necessity or lack of altenative – e.g. examination & treatment in public areas
32 Modesty and Privacy14,15 • Modesty in gaze is also required –e.g. women will typically avoid eye contact with male healthcare professional –e.g. younger generation is expected to avoid eye contact with the «elders» in the family
• Modesty in communication prevails –e.g. women may not bring up feminine health realted isues in presence of male family member or male healthcare provider –e.g. women may not challenge decision making by spouse or male elder –e.g. men may not publicly display their emotions
Concerns • Compromised examination/treatment due to: –inability to expose required body areas during examination &/or treatment –Inability to accurately assess patient responses due to lack of eye contact &/or lack of visible emotional responses to treatment
• Patient declining treatment due to lack of availability of private treatment areas and/or qualified personnel of same sex to render care
• HIPAA violation due to lack of patient autonomy in healthcare decisionmaking
Suggestions14, 15 • Ensure patient’s body is appropriately covered during treatment – encourage patient to wear personal clothing – explain need to expose body areas for treatment but assure exposure limited to minimal medical necessity – providesufficient time to dress--knock, wait, and announce arrival
• Solicit assistance from: – a same sex provider if posible or – request presence of same sex family member during treatment – explain purpose/nature of touching & obtain prior consent
• Exercise caution in discussing smoking, drinking alcohol, & extramarital sexual activity with women
• Use privacy screens to create a private treatment área
• Explain need to abide by HIPAA with family caregivers
33 Parting Thoughts: “What can I do tomorrow?”
Heartwarming Communications
•Refer to a patient who follows Islam as a “Muslim”
•Refer to God as “Allah”
•Refer to the ‘Koran’ as “the holy Qur’an”
•Refer to Mohammed as “Prophet Mohammed”
Heartwarming Communications Greet patient upon entering room by saying: o “Us-Salaam-Uh-lai-kum”—Hello (Praise be to you)
• Respond to patient greeting by saying: o “Waa-laikum-Us-Salaam”— and praise be to you too
Compliment patient efforts by saying: •“Mashallah”—Praise of God
• Recite the following to encourage patient: o “Inshallah”---God willing
• Say good-bye by reciting the following: • “Allah Hafiz”—(God be with you)
34 “Questions?”
References
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36 “Questions?”
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