When a patient’s cultural practices, such as traditional healing, are incorporated into the treatment plan, it can go a long way toward ensuring that patients follow the plan of care, says Catherine M. Mullahy, RN, BSN, CCRN, CCM, president and founder of Mullahy and Associates, a case management education, training, and consulting firm in Huntington, NY.
“It’s not usually an all-or-nothing situation. Many practices don’t interfere with Western medicine and it may enhance communication because the patients will feel that the hospital staff respects what they believe,” she says.
Sometimes the case manager has to get in the middle and act as a mediator between the treatment team and the patient and family when the family has strong beliefs that need to be accommodated, says Vivian Campagna, RN-BC, MSN, CCM, chief industry relations officer for the Commission for Case Manager Certification.
“If the team doesn’t know about the patient’s beliefs, the case manager should educate them and work with them to modify the plan,” Campagna says.
For instance, some members of the Jehovah’s Witness faith don’t believe in blood transfusions, Campagna points out. “If we don’t make allowances for their beliefs, we may find ourselves at odds with the patient and family if someone of that faith has lost a lot of blood. As a treatment team, we need to look at alternatives,” she says.
Mullahy recommends that case managers think outside the box and look for ways to work around patient’s beliefs while delivering the needed care.
She describes how a case manager in the Aberdeen, SD, area was able to accommodate the spiritual beliefs of a Native American patient with severe diabetes who refused to consent to surgery to have his leg amputated. When the case manager called the Indian Health Service for assistance in understanding his position, she learned that many Native Americans believe that in order to go to heaven, they have to be buried in sacred burial grounds and that the patient was afraid he would be without his leg in heaven.
“The healthcare team made arrangements for the leg to be transported to the reservation and buried in the sacred burial grounds. They could accommodate the patient’s beliefs without changing the treatment plan,” she says.
In another instance, Mullahy tells of an Orthodox Jewish patient at high risk for a preterm birth who refused to use an electronic device to monitor contractions on the Sabbath when her religion forbids the use of electrical appliances. “The case manager encouraged the woman to take extra special care and stay on bed rest on the Sabbath,” she says.
The same patient needed someone to take care of her children and household chores while she was on bed rest, but the family resisted because they kept a kosher home and the home health agency did not have any employees who kept kosher.
“The case manager worked around the problem by contacting the family’s rabbi, who found someone in the community who could take care of the patient. The case manager worked with the patient’s insurance company to pay for the service,” she says.
The home health nurses at Dependable Home Health in Tucson, AZ, often encounter Mexican-American patients who resist following their treatment plans because they believe in folk remedies, such as drinking herbal tea for everything from hypertension to diabetes, says Jill Lanning, RN, BSN, chief nursing officer. (To learn about Dependable Home Health’s readmission reduction initiative, see related article in this issue.)
“When we encounter practices that involve non-traditional medicine, we try to incorporate it into the treatment plan. For instance, we don’t tell them not to drink the herbal tea. We tell them to take the tea along with their medication,” she adds.
Flagstaff (AZ) Medical Center serves a large Navajo population who live on the reservation, and many of them have very strong Native American beliefs when it comes to health. Case managers and other clinicians make every effort to accommodate their beliefs, says Lisa Brugh, MS, BSN, RN, ACM, system director of case management for the two-hospital system. (For details on how the hospital provides care for its Native American patients, see related article in this issue.)
For instance, talking about death is taboo in the Navajo culture, as is dying in your home. Instead of telling a family member that the patient has only a short time to live, the palliative care team says, “someone like your mother would have only a few months to live.” Since home hospice is not an option, the palliative care and case management team arrange for terminally ill patients to receive hospice care at an assisted living center so the patients won’t die at home.
The Navajo language doesn’t have words for some Western medicine terms, such as “cancer” or “dementia,” Brugh says. In addition, the Navajo language has ways of explaining what is happening in the body without using words. When they are working with a Navajo patient who is not fluent in English, the case managers as Flagstaff Medical Center bring an interpreter who can talk about diagnoses and explain the patient’s disease without using terms, she says.
The Chinese population tends to be family-oriented, Campagna says. “If the patient is Chinese and elderly, the family may not agree with your recommendation to transfer the patient to a skilled nursing facility. Instead of finding out at the last minute that the family is balking at a nursing home stay, the case manager should work with the family to come up with an alternative,” she says.
End-of-life is a serious time for the Chinese, and many have strong feelings about ending treatment, Campagna says. “If case managers don’t understand what their feelings are, they may alienate the family. Instead, they should help the patient and family approach care in the best possible way,” she says.
When a patient’s cultural practices, such as traditional healing, are incorporated into the treatment plan, it can go a long way toward ensuring that patients follow the plan of care.
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