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Culturally competent Care for patients and ethical dilemmas

Presented by

Agenda

Introduction

Ethical Decision-Making Model

Ethical Dilemma 1

Ethical Dilemma 2 by

Ethical Dilemma 3 by

Conclusion

References

Ethical Decision Making

1) Articulate the Problem

2) Collect information and perspectives on differing moral claims

3) Explore options

4) Choose and implement an option

5) Evaluate outcomes

Ethical Dilemma – Multicultural Patients DILEMMA

Some nurses lack confidence when working with patients from other cultures.

Sobel and Sawin (2016) found that many nurses are uncomfortable working with Hispanic patients due to language barriers.

Nurses have a duty of care for their patients, but have dilemmas between properly caring for a patient and helping them express their own autonomy of choice

Patients are “at the mercy of the system” (Sobel and Sawin, 2016, p. 229)

Both nurses, other healthcare providers, and the patients have vested interest in providing sound care with cultural competence

Nurses want to provide ideal care, but may lack skillset to communicate a procedure’s Pros and Cons

Translators are available, but time restraints prevent their regular use and staff may need to make in the moment decisions on the patients behalf

Ethical Dilemma – Multicultural Patients STAKEHOLDERS/DECISIONMAKERS

Ethical Dilemma – Multicultural Patients GOALS

Multicultural patients often want to include homeopathic and traditional medicine

Some traditional medicine treatments involve herbs or smoke that cannot be used in a hospital

Prayer regimes and rituals may interrupt normal flow of routine care

Ethical Dilemma – Multicultural Patients SOLUTIONS

Like all patients, multicultural patients want to be understood and feel a sense of teamwork with medical staff

Medical staff should plan time for culturally sensitive care among medicinal therapies

Medical staff can work to find assistance from multilingual resources and ensure patients understand daily routines

Medical staff should seek to find ways to incorporate traditional care into treatment regimen

Ethical Dilemma – Muslim Patient DILEMMA

Health care professionals need to provide culturally competent care when caring for a patient of a different religious background.

According to Lisa Blankinship, ethical dilemmas arise within the western medicine paradigm when a care plan is being developed for a patient of the Islamic faith (2018).

Examples of cultural/spiritual needs of a Muslim Patient:

“…providing adequate notice of or delaying procedures while the patient finishes Qur’an readings or prayers, help with kneeling for prayers, indicating the direction of Mecca, providing access to the Qur’an, and facilitating use of holy water…” (Blankinship, 2018).

“[m]ost Muslims greatly value modesty and prefer care to be provided by same gender healthcare providers” (Blankinship, 2018).

It is imperative for the health care team to fully incorporate the patient’s faith beliefs within the plan of care and to identify possible barriers r/t conflicts with a western medical approach

EXAMPLE:

EOF care involves, “[s]pecific last rites, such as readings from the Qur’an, prayers, facing toward Mecca, lying on the right side, and inclusion of the family in caring for the dying patient…” (Blankinship, 2018).

It is the nurse’s duty to accommodate for these cultural practices.

The stakeholders include the patient, the patient’s family and the interprofessional team.

The patient’s family is very involved in medical decisions pertaining to the patient. Normally, the nurse would consult the patient, but when providing cultural care, it is important to fully involve family members in the plan of care.

Ethical Dilemma- Muslim Patient STAKEHOLDERS/DECISION-MAKERS

Ethical Dilemma- Muslim Patient GOALS

In recent years, two models of care were developed for patients of Islamic faith. They include Leininger’s Cultural Care Theory and the Crescent of Care Model (for individuals of Arabic and Arabic-descent patients) (Blankinship, 2018).

GOALS:

To educate oneself on the Islamic culture and beliefs

To provide culturally competent care

To anticipate differences in religious practices versus western medical models

Ethical Dilemma- Muslim Patient CRESCENT OF CARE MODEL

Spiritual care- e.g., statement of religious phrases before starting I.V. fluids, giving injections, or performing wound care

Cultural care- e.g., use of a combination of folk remedies and Western medicine, providing for modesty

Psychosocial care- e.g., involvement of family in decisions

Interpersonal care- e.g., fasting, diet (no pork or pork products)

Clinical care- e.g., family involvement in interventions or care performed for patient (Blankinship, 2018).

Ethical Dilemma – Transgender Patient

Physicians face a moral dilemma when providing care to transgender patients who desire gender reconstructive surgery (GRS) to fully achieve their gender identity.

Also, gender reconstructive surgery involves replacement of functional organs with non-performing organs, which is a moral issue among doctors.

Physicians have to balance between doing no harm and respecting patients’ autonomy when deciding where or not to remove a healthy sex organ (Pomara et al., 2015).

Physicians have to determine whether the removal of a healthy sex organ profoundly and negatively affects the well-being of other people.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) reserves gender dysphoria for transgender patients whose gender nonconformity causes significant distress. As a result, GRS is deemed morally permissible (Gerritse et al., 2018).

Although it is believed the distress caused by transsexuality can be fixed by changing bodily appearance, physicians should consider whether the patients understand the risks and benefits.

Women and men who do not want to bear children undergo tubal ligations and vasectomies which incapacitates their sexual reproductive organs.

The key stakeholder are the physicians, and patients and their families.

When GRS is performed, it is expected to make the patients realize their gender identity and identify with the opposite gender both mentally and physically.

Perspective of the Dilemma – Transgender Patient

Keystakeholder / Decision Makers

Physicians are faced with the dilemma of weighing between the distress caused by gender dysphoria and the perceived satisfaction that would arise from GRS.

Surgeons are liable for negligence if a patient is dissatisfied with the functional outcomes operative procedure and can file a lawsuit against the surgeon (Pomara et al., 2015).

Before patients undergo a GRS, they must be examined by at least two mental health professionals.

There are cases of postoperative suicide where patients are dissatisfied with the outcomes, especially when GRS was conducted without proper evaluation.

Patients denied GRS can obtain it illicitly and have horrifying outcomes due to due to use of inferior surgical procedures and lack of adequate care.

Ethical Dilemma Outcome for a Transgender Patient

Due to the ethical dilemmas, lack of knowledge and the consequences of GRS on physicians and patients, it should only be done in health institutions involved in medical research aimed at finding answers to pertinent clinical questions (Pomara et al., 2015).

The ethical principle of autonomy comes against the principle of “do no harm.” Therefore, since there is no guarantee that the patient will suffer no harm after GRS, it would be better to withhold the procedure.

Respecting patients’ autonomy cannot be used as a defense against poor outcomes of a GRS.

Other less invasive interventions such as psychotherapy and hormonal treatment can be used to treat patients distress from gender nonconforming experiences.

Conclusion

Restate Ethical Decision making framework – 30seconds

Restate examples given

Final closeout – leave audience with final question or thought?

References

Blankinship, Lisa. (2018). Providing Culturally Sensitive Care for Islamic Patients and Families. Journal of Christian Nursing, 35, 94-99. http://doi.org/10.1097/CNJ.0000000000000418

Metzler Sawin, Erika, PhD, RN, Sobel, Linda & PhD, RN. (2016). Guiding the Process of Culturally Competent Care With Hispanic Patients: A Grounded Theory Study. Journal of Transcultural Nursing, 27, 226-232. https://doi.org/10.1177/1043659614558452

Nathaniel, A. 2012. Chapter 7: Ethical decision making. [PowerPoint slides]. Retrieved from Resurrection University Brightspace, 10DEC2020.

Pomara, C., Brincat, A., Cassar, D., Martelloni, M., Turillazzi, E., & D’Errico, S. (2015). Ethical issues for the practitioner work in the transgender care. In Management of Gender Dysphoria (pp. 325-335). Springer, Milano. https://doi.org/10.1007/978-88-470-5696-1_38

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