Reflections by Dr. Sheik Hassan & Dr. Hossam Fadel

Comments: Let us begin with two general questions:

1. " Was a biopsy done to establish the diagnosis of small cell carcinoma?
2. " Did the nurses attempt to schedule a meeting with the patient's son and/or wife to obtain information?

Specific comments on the case:

1. " One must be sensitive to both religious and cultural values. Muslims from different cultures, even within the same country, may have different values and may interpret some aspects of the religion of Islam differently.
2. " The nurses/physicians caring for the patient could have arranged a set time for the son to be interviewed with the patient to obtain the history. This could also have been done by telephone. Of course, federal law (HIPAA) necessitates that the patient's permission must be obtained. It is preferable that communication with the patient be done via a non-family member in order to reduce the likelihood of not telling the "whole truth." The best option would be a professional translator. The son probably wanted to protect the father from the bad news and felt he was helping him; but in reality he may have harmed him, because not knowing the seriousness of the disease may have led the father to refuse treatment that may have been beneficial.
3. " Muslims are prohibited from eating pork or anything with pork products. This includes foods that may have been prepared with pork or its products (before or after cooking), even if the products are removed before serving. Thus any Muslim who is following the religion of Islam to any degree will not take such food. Some Muslims will take the food if they are assured that the food was prepared without pork or pork products. Other Muslims may not take the food even with assurances, but particularly if they have had (or have heard of) prior experiences where pork or its products were found in the meal, despite assurances to the contrary. (We have personally experienced this sort of situation several times in the past.) The chief nurse's comment that "…while religious belief is important…" minimizes the religious belief and shows a lack of sensitivity to the values of the patient. She should have assured them that she would ask the dietary department to prepare pork-free meals for Mr. Tabrizi. She also should have voiced strong support and encouragement of the family and friend to bring outside food for the patient.
4. " Most Americans are aware that Muslims pray five times daily. The nurse or doctor asking the patient what the hospital can do to facilitate his prayers would likely have gained his confidence.
5. " Dr. Looke conducted himself appropriately when he asked the patient's permission to have someone translate his findings and plans. Recognizing that the patient does not speak English, Dr. Looke could have presented the bad news to the son away from the patient first. This would allow the son to clarify any questions he had, and he would have been more prepared to inform his father of the diagnosis and treatment options. Since Dr. Looke did not speak Farsi, he could have allowed the son to discuss the matter with the patient. He would later enter the room to answer any additional questions.
6. " Dr. Looke should have explained the consequences of no treatment and contrasted those consequences with the possible improvement in the patient's quality of life, even for the relatively short period of additional survival that the treatment would bring about. He also should have more carefully described the side effects of the therapy in a way that Mr. Tabrizi could have better understood them.

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Introduction to Culturally Competent Care 
Introduction to Culturally Competent Care for Muslim Patients

Sheik Hassan, M.D., is Associate Dean for Academic Affairs and Associate Professor of Medicine at the Howard University College of Medicine in Washington, D.C.

Hossam E. Fadel, M.D. is a Clinical Professor of Obstetrics and Gynecology at the Medical College of Georgia and specializes in maternal-fetal medicine at University Hospital, Augusta, Georgia. He is also the chairman of the Ethics committee of the Islamic Medical Association of North America (IMANA) and the Editor-in-Chief of its journal (JIMA).