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Cultural safety


Respect for patients and families

Finding the right balance


  • Physicians are not obligated to provide absolute accommodation in all situations, but rather to reasonably accommodate cultural diversity.
  • While physicians recognize that professional standards vary among countries and cultures, they must meet Canadian practice standards.
Doctor discussing with couple

Although it is laudable to respect every patient's cultural background and plan care around those values, physicians need to strike the right balance between respect for culture and the provision of competent care.

For example, in some cultures, it is considered taboo to address issues of mental health, sexuality, HIV, cancer, or resuscitation status. Nevertheless, the practice of medicine in Canada recognizes that questions about sexual orientation and other sensitive issues are appropriate when such issues are clearly medically relevant to establishing the diagnosis or treatment plan.

  • To decrease the chance of an allegation of discrimination, provide an explanation of the reasons for potentially sensitive questions.
  • Physicians should not avoid addressing a certain aspect of a patient's health because they are culturally uncomfortable.
  • Strive to educate patients in a respectful and sensitive manner, when patients' non-scientific beliefs may lead them to make choices which may be detrimental to health.
  • Aim to provide advice to patients and make decisions about treatment based on sound medical grounds and principles.

Case: An allegation of discrimination is dismissed
Close up of young male's hand holding pills

Background

A pain specialist terminates a patient from his practice after discovering that the patient has been selling some of the drugs he prescribed.

The patient complains to the College that this is discrimination on the basis of a disability.

Outcome

The College found no wrongdoing on the part of the physician, who had carefully documented his assessment and advice. The patient had also signed a treatment contract which included a warning that a breach would result in termination.

The physician was deemed to have acted in accordance with the Code of Ethics, that is, terminating care for a legitimate reason.

Lessons learned

  • If it becomes necessary to terminate a patient from your practice, ask yourself if the reasons are "legitimate". (Refer to your College guidelines or contact the CMPA for advice.)
  • Document any discussions with the patient.
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Case: Respecting a patient's questionable choice
Lost and disheveled young female

Background

A 45-year-old woman is found wandering a hotel lobby without clothes, yelling at other guests. Upon assessment at the hospital, she is found to be acutely psychotic and not mentally capable (competent). Her husband indicates that she is aware of her mental illness and that she has chosen to take vitamins and cleansing baths based on her beliefs about the origin of her illness.

Think about it

What considerations are important for you?

Suggestions

The prudent physician should consider the standard of care for the clinical situation and be careful not to abdicate his responsibilities to advise the patient or her substitute decision maker about that standard. Respectfully pursuing a discussion with the patient's substitute decision maker and striving to educate him about the unscientific basis of their choices and about the available conventional medical therapies is important, even if a cultural difference is present.

Lessons learned

Physicians have a professional obligation to treat patients according to the recognized standard of care. Simply accepting a clearly erroneous position without discussion may be unacceptable. The prudent physician should try to understand the substitute decision maker's concerns, and educate the person about the appropriate medical therapies and their scientific basis. In this case, once given the explanation the husband agreed to the indicated therapy.
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Case: Reasonably accommodating treatment
Elderly female wearing a head scarf

Background

A 68-year-old devoutly religious woman undergoes evaluation just prior to the start of a period of fasting. She has a 10-year history of poorly controlled Type II diabetes managed with oral hypoglycemic agents and diet. She is accompanied by her 8-year-old grandson, who serves as her interpreter. The patient's diabetes is out of control and when you discuss the significant risks of fasting and not taking her medications in a timely manner, she refuses to alter her planned fast.

Think about it

How would you approach the patient regarding those concerns?

Is relying on the 8-year-old grandson as an interpreter appropriate?

What other resources could you use in managing this patient?

Suggestions

Devoutly religious patients may practise a complete fast (water and food) for a prolonged period. While exemptions from the fast are usually allowed for health reasons, some patients may nevertheless interpret the taking of oral medications or even the application of eye drops, as breaking the fast.

Your goal should be to partner with the patient to ensure she understands the importance of diet in the management of diabetes. Rather than telling her to act in the way you think she should, make reasonable efforts to provide the information she needs to make an informed choice. If the patient still chooses to fast, respect that decision and manage the patient as best as you can. This may include providing information about on how to recognize the signs and symptoms of a possible complication and how to seek care. Document all your efforts and the rationale for your decisions.

Relying on a young child to convey important health information is not appropriate. Finding a more suitable interpreter should be considered.

Ideally, the person should be able to act as both a cultural and language interpreter so that a better understanding between the physician and patient can be achieved.

Lessons learned

Consider enlisting the help of another family member in discussions about a patient's care.

Consider obtaining the help of a trusted member of the clergy from the patient's community to translate and explain who is exempt from the fast.

Consider referring the patient to a physician of the same faith as the patient to assist in discussions and to provide a second opinion regarding the planned fast.

Think about it

How much do you know about fasting or other cultural practices that may affect patient care?

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