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

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