Friday, November 12, 2010

PATIENT MODESTY, VALUES, & RIGHTS




CORE VALUES AND PATIENT RIGHTS & RESPONSIBILITIES

WHAT THEY “SAY” ABOUT PATIENT MODESTY

by Doug Capra (c) 2010

When you enter a hospital, do you have the right to expect same gender care for intimate needs if that‘s your desire? Note that I’m not wondering whether you have the right to request this, or whether the hospital has the obligation to attempt to grant your request. Of course you do and of course they should.

But first -- I want make it clear that I’m limiting this discussion to non emergency, non life-threatening situations. I’m not suggesting that modesty has no place in these other areas -- but I think their specific contexts need a separate discussion. For now, though, read this article to see how patient modesty can be handled in emergency situations. So often, when I’ve debated the modesty and gender preference issue with medical professionals, they quickly move the discussion to the ER or other extreme situations. I’ve gotten used to this diversion and bring them right back to the main issue. Let’s talk about basic exams that happen thousands of times every day in clinics and hospitals -- procedures and tests of the more intimate variety.

The question I pose is -- do hospitals have an ethical and legal obligation to accommodate you? Since I’m not a lawyer, I won’t go into the legal interpretations here -- but I will attempt to parse and deconstruct an example of a core value statement and another example of a patient bill of rights to see what the hospitals are implying about modesty and gender preference. My contention is that, although the word “modesty” is rarely used, the concept is present.
When you go to a hospital, you should be given these documents. I wonder how many patients actually read them. You should. In fact, although I won’t be delving into the “Your Responsibilities” part of the patients’ rights document, I don’t want to underestimate the importance of that section. It represents the other side of the same coin.

CORE VALUES

If you do a google search online using terms like “hospital or core values,” you’ll get many hits. These can vary considerably, but most seem to contain basic elements. As an example, I’ll be using the core values of the Providence Hospital system because I find them to be especially well-written with clear implications regarding patient modesty.

The Providence Hospital system divides their core values into five categories: Respect, Compassion, Justice, Excellence and Stewardship.
The first two are the most relevant to the modesty issue.

RESPECT -- “We welcome the uniqueness and honor the dignity of every person. We communicate openly and we act with integrity.”

Here’s how I read this relative to the modesty issue: Every human being is unique and that uniqueness must be respected by treating the patient with dignity. Since we’re unique, we may each define our dignity in different ways. Some may find it completely dignified to have intimate care done by the opposite gender. Others may find that undignified. The idea of “dignity” doesn’t rest within the mind and behavior of the medical provider. It rests primarily within the patient and their unique value as a human being.

COMPASSION -- “ We nurture the spiritual, physical and emotional well-being of one another and those we serve. We embrace those who are suffering.“

Here’s how I read this relative to the modesty issue: It’s not just about your body, your physical being. Your spiritual and emotional well-being are at least as important to us. Note that two out of three words in the first sentence represent the non physical -- spiritual and emotional. How patients feel (the emotional) about who sees and works with their bodies under especially private situations is embedded within these words. In some cases, one’s spiritual and/or religious beliefs and values are directly connected with the modesty issue. We will respect this. We realize that “suffering” doesn‘t just mean physical pain; it includes spiritual and emotional anguish as well. For some patients, this may involve modesty issues.

Of course, assumed in all this is that providers “know” your individual and unique concept of dignified treatment and your feelings and spiritual values. How will they know? Well -- you’ll either tell them, or they’ll ask. What benefit is there to such lofty core values unless polices are embedded within the health care system to find out individual patient values? The systems answer might be -- Well, it’s up to the patient to tell us, that’s their “responsibility.” There is some truth to that -- and that’s where patients need to speak up.

On the other hand, health care systems that want to insure that their core values filter down into everyday operations, need to create policies that specify how they will practically accomplish these lofty goals. I have been unable to find any specific policy statements from American hospitals (including Providence) that address how they will handle modesty issues and requests for opposite gender care. I have found several policy statements from the UK, Australia and Canada.

Providence does state in its first core value that “We communicate openly and we act with integrity.” That implies to me that they see their leadership role in opening up communication with patients about this issue. True empathy from providers involves leadership in communicating and helping to empower patients.

PATIENT RIGHTS & RESPONSIBILITIES

When you enter a hospital, you should also be given a copy of their Patient Rights and Responsibilities. Read it carefully. The example I’m using is from the Carolinas Medical Center-NorthEast in North Carolina. I find these to be especially well-written with clear implications regarding patient modesty.

Almost all patient rights documents say something about treating patients with dignity and respect -- using those specific words. Those words alone should be enough to cover basic modesty and even patient gender preference for intimate procedures. Unfortunately, that’s not always the case. Here are a few selected patient rights, given their assigned numbers, from Carolinas Medical Center-NorthEast, followed by my comments:

3. “A patient has the right to every consideration of his privacy concerning his own medical care program. Case discussion, consultation, examination, and treatment are considered confidential and shall be conducted discreetly.”

Note, “every consideration of his privacy.” That should pretty much cover it. Modesty and gender selection considerations are certainly aspects of any medical care program. “Examination” and “Treatment” would cover some of the issues patients bring up, such as gender of the examiner and those who do bed baths or procedures like foley catheterizations, as well as chaperone and/or observer issues.

Don’t let someone tell you that your choice of one gender over the other for intimate care is discrimination, in the legal sense of the word. Don’t let them compare it to racial discrimination. A racist is someone who negatively stereotypes a whole race and/or thinks that race is inferior to his own. If, as a man, you believe that all women are inferior to men and can’t do the kinds of procedures you need, then, indeed, you are practicing discrimination.

But that’s not what most people believe who request same gender care. Most patients welcome basic care from either gender. It’s only for the most sensitive, intimate care that they prefer a same gender provider. Their assumption isn’t that both genders can’t do the job equally as well. For modesty and privacy reasons, these patients just prefer a specific gender. So -- don’t accept this “discrimination” argument if it’s used.

13. “A patient has the right to medical and nursing services without discrimination based upon race, color, religion, sex, sexual preference, national origin or source of payment.”

Well, there are only two sexes (although there are various sexual preferences -- but let’s not go there for now). If one sex is granted gender preferences for whatever reason, the other sex should also be granted the same right. Pretty basic. Most hospital bills of rights provide this basic right in pretty much the same words. Just because they may not practice it regularly, doesn’t mean they haven’t stated it as foundational to their institution and the work they do. You may have to remind them.

18. “The patient has the right to medical treatment that avoids unnecessary physical and mental discomfort. “

Now, we can debate what constitutes “unnecessary.” But patients do have the right to ask:

“What have you done to ‘avoid” this kind of mental discomfort I feel with opposite gender intimate care?
Do you consider gender preference when you schedule? Have you made hiring efforts to balance out caregiver gender?
Why do you consider it ‘necessary’ for me to deal with this mental discomfort?”

In other words, if you need to debate, use the specific language found in the hospital’s core values and bill of rights. Have a copy handy that you’ve highlighted and annotated.

25. “A patient, and when appropriate, the patient’s representative has a right to have any concerns, complaints and grievances addressed. Sharing concerns, complaints and grievances will not compromise a patient’s care, treatment or services.”

Although this doesn’t address the modesty issue specifically, it does cover concerns some patients have about possible repercussions. I’ve included it because on Dr. Maurice Bernstein’s recent modesty blog, (on Wed., Nov. 10, 2010 at 11:52 a.m.) someone challenged me when I defended female nurses (Yes, I have great respect for nurses of both genders). The blogger called me na├»ve and stated that if a patient dares to “refuse the same female caregiver twice…she’ll throw a tantrum. This happens with female patients as well. And Heaven forbid you have an argument with them, because you will almost certainly face retaliation.”

I’m not saying this has never happens. It’s possible but, in my opinion, rare. I am saying that here you have a specific statement that protects you specifically from that kind of bullying behavior. If it does happen, don’t tolerate it.

30. “The patient has the right to personal privacy. Privacy includes a right to respect, dignity, and comfort as well as privacy during personal hygiene activities (e.g. toileting, bathing, dressing), during medical nursing treatments.”

Could this be any clearer in regards to your modesty and your desire for the gender of your caregiver for intimate needs? And remember, within reason, you get to define your own definition of “dignity” and “respect” as a patient. If challenged, ask the hospital for their definitions. I’m convinced you’ll find they have no definitions. That doesn’t mean they don’t care about dignity and respect. It does mean that little thought has gone into policy standards that cover patient modesty and gender preference under the umbrella of those overly used and idealistic words -- dignity and respect.

I will admit that I haven’t found this specific wording on any other patient bill of rights from other hospitals. That’s why I picked Carolinas Medical Center-NorthEast as my example. For a hospital to even use this wording suggests to me some thoughtful analysis of the modesty and gender preference issue.

A few closing thoughts.

1. If you have a choice of hospitals, go online and check various mission statements, core values, and bill of rights. They do vary.

2. Find a hospital whose values reflect yours.

3. Print out copies of those documents. Study them and bring copies with you to the hospital.

4. Don’t go looking for a fight. You’ve read the documents. You know the kind of care to expect. Expect it.

5. Finally, consider your responsibilities as a patient. Carolinas Medical Center-NorthEast lists this as a patient’s first responsibility: “Patients, and their families when appropriate, are responsible for providing correct and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to their health.”

If those “other matters” for you include modesty and gender preference, it’s your responsibility to provide that information to caregivers. Their responsibilities, as I see it, are quite clearly delineated in most core value and bill of rights statements. Unfortunately, you can’t depend upon them offering you these kinds of choices -- even though they should. So make sure you communicate your values to them.

Be proactive. Be an empowered patient. Know your rights and responsibilities and the values of the hospitals you choose.


NOTE -- How about readers providing some other specific core values and patient rights statements from other hospitals? Also, how about some examples of experiences you had with these documents.

3 comments:

~Charlotte said...

Doug, I was very interested to see that you used Carolinas Medical Center's patient bill of rights in your article. You noted patient's rights #13 which I find interesting because the departments that I dealt with do not have doctors of both sexes so I don't know how they can even guarantee this right??
What I think they mean here is that a patient can not be denied care based on the patient's sex or sexual orientation/preference. I doubt very much that they are guaranteeing a patient same-sex. I have had surgery, tests, hospitalization, radiation treatment etc. and I don't know how they could, for example, guarantee an all male nursing team or, as in my situation, a female radiation oncologists or a female gynecological oncologist (although the later should be honored, there is not one on staff at the facility that I was.)

Anonymous said...

Thanks for your comment Charlotte. I obviously don't know what the situation is at either Providence or Carolinas -- staff-wise. I'm just interpreting what they're writing.
Now, regarding patient rights # 13 -- if they regularly grant same gender intimate care for women, then they must do the same for men. That's what I interpret that statement saying, whether they're intending it or not. Not to have it available for men if available for women is certainly discrimination based upon sex, isn't it? Frankly, I can't see them turning down a women who refuses to have a male nurse give her a bed bath or insert a foley. They may try to convince her to go along, but they won't push it. Based upon the written patient rights statement 13, men have that same right, too. How they handle it staff-wise is a problem they need to solve. And, if they can't meet these needs, they need to be open and up front about it before patients get into a situation where the procedures becomes essential.
How hospitals implement these lofty goals and patient rights statements is the issue. Most don't have written policy statement as to how they will deal with patients who ask for same gender care. Most don't have policies for use and gender. Not having written policies allows them to interpret these core values and patient rights statements as they want.
My point is they are "guaranteeing" it whether they intend it or not. It's unfortunate if staffing doesn't match up with their core values and patient rights statements. Can they demonstrate they're actively working to balance staffing.
These are my points.
By the way, I'm not necessarily advocating for same gender OR teams. Personally. I think that's too extreme for me. Having said that -- providers need to find out how people feel about that issue and work with them to mitigate their modesty issues.
Doug/MER

Anonymous said...

Mer

The article was excellent and I'd like to make a few points.Some
may ask well how does one know if
a hospital has made concessions to
females requesting same gender care
which if they make such concessions
to women then the same considerations
must be made to men.
There are about 3200 hospitals
in the United States. Of this about
2600 have Labor and Delivery and
about 1900 have a mammograpgy suite.
If a hospital offers either of
these services then those concessions
have already been made to women and
those facilities much therefore do the
same for men.


PT