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The woman collapsed at home and even if my colleagues knew how it happened, they didn't understand why.
The thorough clinicians asked enough questions for the 80-year-old to begrudgingly admit that she hadn't had anything to eat or drink all day. No one asked why an elderly woman with diabetes would do that. And, certainly, no one dared to ask if her religion might have affected her health.
Well, almost no one. My patient, admitted to the hospital for a fall due to dehydration and hypoglycemia, had abstained from food and water all day as a testament to her religious faith.
This year, millions of Muslims around the world will fast from just before sunrise to just after sunset in celebration of Ramadan, the ninth month of the Islamic calendar. Despite the availability of medical exemptions, many Muslims with pre-existing medical conditions will fast. Most will never consult a clinician before doing so.
The thorough clinicians asked enough questions for the 80-year-old to begrudgingly admit that she hadn't had anything to eat or drink all day. No one asked why an elderly woman with diabetes would do that. And, certainly, no one dared to ask if her religion might have affected her health.
Well, almost no one. My patient, admitted to the hospital for a fall due to dehydration and hypoglycemia, had abstained from food and water all day as a testament to her religious faith.
This year, millions of Muslims around the world will fast from just before sunrise to just after sunset in celebration of Ramadan, the ninth month of the Islamic calendar. Despite the availability of medical exemptions, many Muslims with pre-existing medical conditions will fast. Most will never consult a clinician before doing so.
Because Muslims follow a lunar calendar, the dates of Ramadan change each year. In 2012, Ramadan starts after sunset on July 19 and, in North America at least, Muslims will fast during the longest, hottest days of the year. Muslim leaders exempt certain groups from fasting, including children, travelers, pregnant women, the elderly and the sick.
However, some Muslims with chronic conditions may still choose to fast; they may not consider themselves sick or they may simply prioritize their religious dedication over the perceived health risks. They may discontinue medications or alter their treatment regimens to fast. Some develop dehydration and hypoglycemia.
In many cases, primary care providers are not even aware their patients are fasting.
However, some Muslims with chronic conditions may still choose to fast; they may not consider themselves sick or they may simply prioritize their religious dedication over the perceived health risks. They may discontinue medications or alter their treatment regimens to fast. Some develop dehydration and hypoglycemia.
In many cases, primary care providers are not even aware their patients are fasting.
Preventing Negative Outcomes
The best way for providers to prevent negative outcomes from fasting - and to improve their relationship with patients - is through an open discussion. It is easy to start:
As part of your social history, ask your patients if they practice any particular religion. (For most, this is no more intrusive than asking about drug use or sexual history.)
If patients disclose that they are Muslim, ask what their plans are for Ramadan. It is important to allow patients to fully explain their religions customs and priorities because fasting practices can vary widely depending on the community, religious leader or person.
As part of your social history, ask your patients if they practice any particular religion. (For most, this is no more intrusive than asking about drug use or sexual history.)
If patients disclose that they are Muslim, ask what their plans are for Ramadan. It is important to allow patients to fully explain their religions customs and priorities because fasting practices can vary widely depending on the community, religious leader or person.
For example, some Muslims fast by abstaining from anything that gives them strength or energy. This may include food and water but may not include medications like an albuterol inhaler.
Other Muslims may consider fast broken if anything enters the "5 holes": the ears, nose, mouth, vagina or anus. For these patients, an inhaler would break their fast - and so would a pelvic or rectal examination.
Other Muslims may consider fast broken if anything enters the "5 holes": the ears, nose, mouth, vagina or anus. For these patients, an inhaler would break their fast - and so would a pelvic or rectal examination.
Once a clinician fully understands a patient's practices during Ramadan, the provider can explain any medical risks and allow the patient to make informed decisions about fasting.
Minimizing Risks
Because of widely varying fasting criteria and the innumerable health differences among patients, no single set of recommendations is appropriate for every patient.
Once a clinician has completed the most vital first step - listening to the patient - he or she can apply medical expertise and clinical experience to minimize the health risks while still respecting cultural priorities enough to ensure adherence.
Once a clinician has completed the most vital first step - listening to the patient - he or she can apply medical expertise and clinical experience to minimize the health risks while still respecting cultural priorities enough to ensure adherence.
A young man with type 1 diabetes told me he is now considered an adult in his community and would like to fast during Ramadan. "This is a condition I have had my entire life," he said. "It is just something I deal with. I don't consider myself sick."
I posed this scenario to a pediatric endocrinologist who suggested changing his medication regimen from regular insulin and NPH at mealtime to a long-acting insulin glargine given after sunset each evening.
We made an agreement with the patient that he would regularly check his blood sugar throughout the day (not breaking his fast) and have a target glucose level at which he would break his fast and eat, if needed.
We made an agreement with the patient that he would regularly check his blood sugar throughout the day (not breaking his fast) and have a target glucose level at which he would break his fast and eat, if needed.
Patient-Centered Decision Making
Every patient determines his or her religious priorities and, when fully informed, how they weigh against any medical risks.
Patient-centered decision making has gained popularity as clinicians increasingly focus on protecting the ethical principle of patient autonomy. While medical providers are influential voices, they can rarely force someone to abandon a lifetime of strong cultural or religious practice.
Patient-centered decision making has gained popularity as clinicians increasingly focus on protecting the ethical principle of patient autonomy. While medical providers are influential voices, they can rarely force someone to abandon a lifetime of strong cultural or religious practice.
Muslim patients have told me that they often assume their medical providers disapprove of their fasting and never broach the subject at check-ups.
One woman told me she often rearranged her own medication dosing during Ramadan. When she went to her primary care provider for help, he told her she could no longer fast.
"I just went and found a new provider," she said. "One who understands and will work with me and my medications."
One woman told me she often rearranged her own medication dosing during Ramadan. When she went to her primary care provider for help, he told her she could no longer fast.
"I just went and found a new provider," she said. "One who understands and will work with me and my medications."
As healthcare providers, we often anguish over patients who, in our perspective, do not take the most straightforward and logical approach to their health.
During Ramadan this year, clinicians should focus on improving their cultural awareness with each patient. A better provider-patient relationship - and improved health outcomes - will follow.
During Ramadan this year, clinicians should focus on improving their cultural awareness with each patient. A better provider-patient relationship - and improved health outcomes - will follow.
- Author's note: Information for this article was provided by Muslim chaplains at Yale University and Yale New Haven Hospital.
Harrison Reed is a student in the physician assistant program at Yale University in New Haven, CT.
| Copyright ©2012 Merion Matters 2900 Horizon Drive, King of Prussia, PA 19406 • 800-355-5627 Publishers of ADVANCE Newsmagazines www.advanceweb.com |
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