120326P - RE-DISCOVERING THE PATIENT: INTEGRATED and BALANCED CARE CURRENT MODELS OF HEALTH CARE

Prof Dr Omar Hasan Kasule Sr. MB Ch B (MUK), MPH (Harvard), DrPH (Harvard) Department of Bioethics KFMC presented at the 5^th International Nursing Symposium under the theme 'Nursing Innovations and Excellence in Patient and Family Centered Care ' held at the Main Auditorium on 26^th March 2012

1.0 OLD TIMES

Slide showing ancient picture of patient surrounded by doctors and family

2.0 MODERN TIMES

Slide showing doctor with patient in a high-tech environment he is busy with machines or lap top and not paying attention to the patient

3.0 SOS (SAME OLD STUFF)

·      ‘plus que ca change plus que c’est la meme chose’

·      7000 years ago: patient-centered and family-centered, integrated and balanced; limited technological input, home based care herbs + spiritual + TLC

·      100 years ago: Biomedical (BM) model: disease-centered technology-based ignored the mind, emotions, spirit

·      35 years ago: Biopsychosocial (BPS) model: reintroduced the psychosocial dimension

·      Today: Holistic care (HC) model: total care

·      Today:  Patient-centered (PCC) model: individualized care

4.0 ANCIENT MEDICINE: integration and balance

·      Mesopotamian medicine: magico-religious + physical remedies

·      Ancient Egyptian medicine: mystical, priestly + physical remedies + surgery

·      Ancient Chinese medicine: balance (yin & yang) and balance among the 5 elements: wood, fire, earth, metal, water). + herbal + acupuncture + massage + diet + mental + physical exercises

·      Ancient Indian medicine: Balance among three elementary substances representing divine forces: spirit (air), phlegm, and bile that produce the contents of the body + diet, hygiene, mental prep, herbs + surgery

5.0 GRECO-ROMAN MEDICINE: integration and balance

·      Closely related to religions and the temples.

·      Balance of 4 humors (blood, phlegm, yellow bile, and black bile), 4 elements (earth, air, fire, and water), and 4 qualities (hot vs. cold and wet vs. dry).

·      Disease treatment directed to restoration of the balance.

·      Rest and diet were used in treatment.

6.0 ROOTS OF THE BM MODEL

·      Rudolf Carl Virchow (1821-1902)- cell theory à cellular basis of disease

·      The microbial basis of disease became firmly established when Louis Pasteur (1822-1895) and Robert Koch (1843-1900) developed the germ theory through experimentation.

·      Anti-microbial agents: salvasan for syphilis by Paul Ehrlich (1854-1915), sulfonamides by Gerhard Johannes Domagk (1895-1964), penicillin by Sir Alexander Fleming (1881-1955)

·      By 1920: Single axis: cause-disease-treatment

7.0 CHARACTERISTRICS OF THE BM MODEL…1

·      Focus on the physical and rejection of the psychosocial and spiritual

·      Focus on disease and not illness

·      Physician sees organ pathology and not the whole patient

·      Commodization of health & medicalization of life

·      Demystification of the human body

8.0 CHARACTERISTRICS OF THE BM MODEL…2

·      Dehumanization of the patient: 'thing' 'machine'

·      Depersonalization of the patient: case, number, pathology

·      Control of decisions in the hands of the physician

·      Lack of balance in disease definition and disease treatment

·      Can not explain illnesses with multiple cause and no simple cure

9.0 THE BIOPSYCHOSOCIAL (BPS) MODEL

·      Alternative to the BM model first described in 1977

·      Integration biological, psychological, social, emotional, religious factors, and patient factors in disease understanding, treatment and prevention

·      Call for research, education, and practice to address health and not illness

·      Consider interrelations among Xple disease causes

·      Take into account the social network of the patient

10.0 HOLISTIC CARE (HC) MODEL

·      Term holistic coined in 1926 from Greek halos meaning all or whole

·      Opposite of reductionism: understanding by breaking apart

·      Body operates as a whole cannot be understood as parts

·      Social, psychosomatic, spiritual, emotional dimensions

·      Complementary and alternative medicine

·      Requires cultural competence

·      Concept of total care for the body as a physiological entity (prophetic hadith)

 11.0 PATIENT CENTERED CARE (PCC) MODEL

·      The patient is final common pathway for all models

·      Rrespect for the patient and the family by incorporating their desires in treatment

·      Looking at care from the vantage point of the patient

·      Doing the best for the patient even of routines are changed

·      It integrates and individualizes care

·      Requires cultural competence

12.0 PHYSICIAN ETIQUETTE AT THE BEDSIDE …1

·      The physician-patient interaction is both professional and social.

·      The human relation before the professional technical relation.  

·      The bedside visit is a brotherhood duty visiting the sick, 'iyadat al maridh.

·      Reassurance, psychological and social support, love, and sharing.

·      Seek permission, isti'dhaan

·      Every action of the caregiver must be preceded by basmalah.

·      Everything should be predicated with the formula inshallah,

13.0 PHYSICIAN ETIQUETTE AT THE BEDSIDE …2

·      Greeting the patient, salam

·      dua for the patient

·      Good encouraging words

·      Asking about the patient’s feelings

·      Doing good/pleasing things for the patient

·      Making the patient happy

·      Encouraging the patient to be patient

14.0 PHYSICIAN ETIQUETTE AT THE BEDSIDE …3

·      Discouraging the patient from wishing for death

·      Sincere advice, nasiihat for the patient

·      Reminding the patient about dhikr.

·      good thoughts about the patients, husn al dhann

·      Caregivers must have an attitude of humbleness, tawadhu'u

·      No secret conversations, najwa

·      Empathy; no emotional detachment to be professional

15.0 DEALING WITH THE FAMILY

·      Family visits are a social obligation and are encouraged

·      The family members are honored guests with all the shari’at rights of a guest.

·      Family needs psychological support; they are anxious and worried

·      Family reassurance about the patient without breach of confidentiality

·      Involving the family in some support care gives them pleasure

·      Family visits should not interrupt routines and procedures

·      Caregivers must avoid involvement in family conflicts.

16.0 ETIQUETTE WITH THE DYING

·      Comfort: pain relief, communication, hygiene, wudhu all the time

·      'Ibadat-friendly hospital

·      Spiritual preparation: allay anxiety, present death as a positive event

·      Legal preparation: debts and a will

·      Prepare family for mourning

17.0 THE TAUHIDI PARADIGM

·      Lack of integration due to atomistic view of the cosmos: analytic but not synthetic

·      Integration is not addition but is fitting according to the laws, sunan

·      Problems of BM, BPS, HC, and PCC due to lack of an integration paradigm

·      The tauhidi paradigm provides a conceptual basis for integration.

·      Tauhid al rububiyyat = once Creator for the cosmos = all things must relate to and integrate with one another if we know the laws, sunan, to follow.

·      Integration calls forth balance among the components integrated.