Download CASE STUDY #2: RABBI SILVERSTEIN Case Study #2: Rabbi

CASE STUDY #2: RABBI SILVERSTEIN 1
Case Study #2: Rabbi Silverstein
Andrea Rodriguez, RN
New York City College of Technology
NUR 4050 OL30
Family Centered End-of-Life Care across the Lifespan
Prof. Lynda M. Konecny
November 11, 2015
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1. In hospitals with no identified religious affiliation, what limitations and challenges exist
to religious faith-based practices for the Orthodox Jewish male client? Be specific in your
response; remember the client is a faith leader (Orthodox Rabbi). You need to identify
and fully explain five (5) limitations/challenges Orthodox Jewish males encounter when
hospitalized in a public funded municipal hospital. Each identified faith-based limitation
and/or challenge along with its detailed explanation is 3 points. (15 points)
A challenge that Orthodox Jewish males encounter when hospitalized in a public funded
municipal hospital is privacy to pray as their Jewish religion requires. Orthodox Jewish males
pray three times a day; in the morning, in the afternoon, and in the evening. According to
Williams (2014), the prayer should occur in an area where interruption will not occur.
Health care workers who do not know about the orthodox Jewish religion, will perform care
during times of prayer, interrupting the orthodox Jewish patient. Interruption during prayer is
a challenge orthodox Jewish male patient’s face during hospitalization. Also any patients the
orthodox Jewish male is paired with be a will challenge to the prayer. According to
Cleveland Clinic Foundation (2012), men and women are separated during time of prayer. If
an orthodox Jewish male is paired with a female patient, prayer cannot occur.
Another limitation/challenge that orthodox Jewish males encounter when hospitalized in
a public funded municipal hospital is modesty. According to Ehman (2012), some Jewish
patients may have culturally-based concerns about modesty, especially regarding treatment
by someone of the opposite sex. Orthodox Jewish males will not interact or communicate
with a health care provider or nurse of the opposite gender as it is prohibited to do so by
Jewish law. Jewish law prohibits males to interact with a woman that is not their wife. In
public hospitals, any nurse and health care provider can be assigned to patients and an
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orthodox Jewish male could get a female nurse. This will challenge the Jewish law orthodox
Jewish males have about interacting with the opposite sex. This will challenge the patient and
nurse relationship.
A limitation that orthodox Jewish males encounter when hospitalized in a public funded
municipal hospital is nutrition. According to Ehman (2012), orthodox Jewish culture follow a
kosher diet. Kosher diet is a set of laws to prepare meals. At public funded hospitals with no
identified religious affiliations, will not have a kosher diet available for orthodox Jewish
patients. This will refrain the Jewish patient from eating, affecting their nutritional status and
healing process.
Another limitation that orthodox Jewish males encounter when hospitalized in a public
funded municipal hospital is resources to make proper care related decisions. According to
Ehman (2012), family members and patients often wish to consult with a rabbi about the
specific circumstances and decisions regarding end-of-life care. In a hospital with no
religious affiliations, a Rabbi will not be available to consult with the family in regards to
decisions regarding care. Therefore limiting the orthodox Jewish patients to make appropriate
decisions about their care that are in accordance with their religion. According to Cleveland
Clinic Foundation (2012), orthodox Jewish patients value life and believe in prolonging life.
Consulting with a rabbi will allow for decisions to be made to prolong life that are
appropriate in Jewish religion.
Another limitation/challenge that orthodox Jewish males encounter when hospitalized in
a public funded municipal hospital is communication. Some orthodox Jewish patients only
speak Yiddish. According to Ehman (2012), the older orthodox Jewish patients may speak
Yiddish. If Jewish patients only speak Yiddish, they will not be able to communicate to the
CASE STUDY #2: RABBI SILVERSTEIN 4
health care workers their needs and concerns. Neither will the health care workers be able to
provide the best care for the orthodox Jewish patient. Creating a challenge in communication,
which is key in providing care.
2. What changes can the registered professional nurse (RN) make within the public funded
municipal hospital care environment that would address the faith-based limitations and/or
challenges identified in thematic question #1? Be specific in your response. You need to
include at least five (5) changes the RN can implement that would improve the situation.
Each modification in Rabbi Silverstein’s plan of care is 3 points. (15 points)
A change the registered professional nurse can make within the public funded municipal
hospital care environment that would address the challenge of privacy to pray is to provide a
private room for the orthodox Jewish patient or room the orthodox Jewish patient with
another orthodox Jewish patient of the same gender. Also during the times of prayer, the RN
could avoid giving medications and performing any activities until the prayer is done.
According to Cleveland Clinic Foundation (2012), orthodox Jews pray three times a day.
Also according to Williams (2014), the prayer should occur in an area where interruption will
not occur. Providing privacy for the orthodox Jewish patient will allow them to pray when
needed without disturbing anybody or having any interruptions. The registered professional
nurse can also teach the nursing assistants and health care providers about the Jewish practice
of praying three times a day to increase the health care cultural knowledge on orthodox
Jewish religion. This will decrease interruption from health care workers during times of
prayer.
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Another change the registered professional nurse can make within the public funded
municipal hospital care environment that would address the challenge of modesty is provide
to orthodox Jewish males and provide a female nurse to orthodox Jewish female patients.
According to Cleveland Clinic Foundation (2012), modesty is very important in orthodox
Jewish religion, males prefer male physicians/nurses. If a male nurse is available, the
registered professional nurse should teach him about the Jewish religion and their laws about
modesty. Also if possible, assign the male nurse to the orthodox Jewish male. If the patient is
a female, assign a female nurse. If a male nurse is unavailable, the nurse should ask a male
nursing assistant to see the patient with her. Having the male nursing assistant present with
the female RN, will allow the orthodox Jewish male patient to communicate without
breaking the Jewish law on modesty. Also ask the male nursing assistant to perform activities
within scope of practice to the orthodox male patient.
Another change the registered professional nurse can make within the public funded
municipal hospital care environment is consult with a Rabbi to provide adequate meals for
orthodox Jewish patients. According to Cleveland Clinic Foundation (2012), Jewish meal is
required to be kosher. In order to provide adequate meals for orthodox Jewish patients, a
rabbi can be consulted to teach the health care workers meals orthodox Jewish patients can
eat and the rules that are followed to prepare the meals. Also a rabbi can approve of meals
that are provided in the hospital as appropriate for orthodox Jewish patients. Kosher meals
should be available upon request.
A change to the registered professional nurse can make within the public funded
municipal hospital care environment to address the limitation in resources is to have a rabbi
available within the hospital for orthodox Jewish patients to consult with when needed.
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According to Ehman (2012), family members and patients often wish to consult with a rabbi
about the specific circumstances and decisions regarding end-of-life care. Orthodox Jewish
patients consult with rabbis in regards to decisions in health care. Having a Rabbi available
for orthodox Jewish patients and their families to consult with when decisions regarding
health care need to be made, will allow orthodox Jewish patients and their families make
proper decisions in accordance with Jewish religion. When orthodox Jewish patients are
unsure of health care decisions, they want to consult with a rabbi about the options available.
According to Loike et al. (2010), having both the family and rabbi will give the opportunity
to ask appropriate questions and express concerns to the health care provider. The rabbi in
the Jewish religion plays a huge role in making decisions and is highly respected by the
Jewish community. Having a rabbi present will allow for proper decisions to be made about
care.
A change the registered professional nurse can make within the public funded municipal
hospital care environment that would address the challenge of communication is having an
interpreter that speaks Yiddish available either in person or on call. According to Ehman (2012),
the older orthodox Jewish patients may speak Yiddish. If orthodox Jewish patient only speak
Yiddish, having an interpreter that can translate what the orthodox Jewish patient needs will
allow healthcare workers to provide the best and proper care. Also the interpreter can translate to
the orthodox Jewish patient care the health care workers will be performing to satisfy their needs.
This provides better communications between the health care workers and the orthodox Jewish
patient. Having a translator will allow orthodox Jewish patients to receive answers to any
questions or concerns they may have.
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3. During Rabbi Silverstein’s hospitalization what distinctive religious practices would the
RN observe Rabbi Silverstein performing? Be specific in your response, remember the
client is a faith leader (Orthodox Rabbi). Include at least five (5) observed religious
practices with explanations. Each example and its detailed explanation are 3 points. (15
points)
Distinctive religious practices that the registered professional nurse would observe Rabbi
Silverstein performing is praying three times a day. According to Mindel (2015), Jewish law
makes it a duty to pray three times a day. There is a morning prayer, afternoon prayer, and
evening prayer. During prayers, Jewish males wear a “kippah” which a skull cap and some
wear shawls (Ehman, 2012). The registered professional nurse will observe Rabbi Silverstein
wearing a skull cap and a shawl during prayer. According to Williams (2014), the prayer
should occur in an area where interruption will not occur. Also the prayer is made in the
direction of Jerusalem (Williams, 2014). Upon wakening the orthodox Jews are to wash their
hands and pray (Cleveland Clinic Foundation, 2012). The registered professional nurse will
observe Rabbi Silverstein wake up in the morning, wash his hands, and pray in a certain
directions. Throughout the day, Rabbi Silverstein will pray two more times in the same
direction.
Another distinctive religious practice the registered professional nurse would observe
Rabbi Silverstein performing is praying before and after eating and when washing hands.
According to Williams (2014), prayers are said before and after eating, when washing hands,
and at other times as well. When Rabbi Silverstein washes his hands, the registered
professional nurse would observe him praying as well. Also the RN would observe Rabbi
Silverstein saying a prayer before and after he eats.
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During Sabbath, the registered professional nurse would observe Rabbi Silverstein not
performing any activities that include the use of electricity or that would require him to work.
According to Williams (2014), during Sabbath, activities such as use of electrical devices
such as lights, TV’s, phones of any kind, call bells, and elevators are prohibited. Therefore,
the RN would observe Rabbi Silverstein refrain from the use of electricity during Sabbath.
During that time, Rabbi Silverstein will not use the call bell nor will he switch on lights.
According to Cleveland Clinic Foundation (2012), preparation for Sabbath usually begins at
2 to 3 hours prior. The RN may also observe Rabbi Silverstein preparing for Sabbath two to
three hours before Sabbath begins by keeping the lights on or performing any activities that
are prohibited during Sabbath.
Another distinctive religious practice the registered professional nurse would observe
Rabbi Silverstein perform is praying with a group of about 10 adults. According to Cleveland
Clinic Foundation (2012), orthodox Jews visit the sick as God did too. Also according to
Lewis, Dirksen, Hetikempter, Bucher, and Camera (2011), the Rabbi may pray with the sick
in a minyan, a group of 10 adults over age 13. Orthodox Jewish males will visit Rabbi
Silverstein to pray with him. During prayer, men and women are separated (Cleveland Clinic
Foundation, 2012).
Another distinctive religious practice the registered professional nurse would observe
Rabbi Silverstein is fasting and neglecting personal care during the Jewish holiday Yom
Kippur. According to Cleveland Clinic Foundation (2012), Yom Kippur is the most
important holiday of the year and Jews refrain from eating and drinking, washing and
bathing, anointing one's body, and wearing leather shoes. During this holiday, Rabbi
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Silverstein will not perform daily personal care activities. Also the RN would observe Rabbi
Silverstein not eating or drinking anything for 24 hours.
4. What unique dietary practices would Rabbi Silverstein follow (10 points) and how would
a public funded municipal hospital be able to provide for these unique dietary needs? (5
points). Be VERY specific in your response. (15 points)
The Jewish religion has unique dietary practices that must be followed called kosher
laws. Rabbi Silverstein’s diet will be based on these kosher laws. According to Silvestri
(2014), orthodox Jewish believers are only allowed meats from animals that are vegetable
eaters, cloven-hoofed animals, and animals that were ritually slaughtered (p. 39). Rabbi
Silverstein will only eat certain meats and those meats should have gone through a ritual to
be considered kosher. Also according to Silvestri (2014), orthodox Jewish believers are only
allowed fish with scales and fins (p.39). Rabbi Silverstein’s diet does not consist of shellfish
such as shrimp, or crabs, or lobster. Orthodox Jewish patients are not allowed to eat shellfish.
Another unique dietary practice is “any combination of meat and milk is prohibited”
(Silvestri, 2014, p. 39). Rabbi Silverstein will not mix milk dishes with meat dishes.
According to Lewis et al. (2011), strictly observant Jews will never eat pork. Rabbi
Silverstein will not eat any meals consisting of pork.
On certain Jewish holidays fasting occurs. According to Silvestri (2014), during Yom
Kippur 24 hour fasting is observed in orthodox Jews (p. 39). Also during Passover only
unleavened bread is eaten (Silvestri, 2014). Another unique dietary practice Rabbi Silverstein
would follow is praying before and after eating. According to Cleveland Clinic Foundation
CASE STUDY #2: RABBI SILVERSTEIN 10
(2012), it is important for orthodox Jews to bless a meal before eating and say Grace after the
meal when finished.
A public funded municipal hospital will be able to provide for these unique dietary needs
by consulting with a rabbi to provide appropriate and adequate meals for the orthodox Jewish
patients. The rabbi can teach health care workers meals that are appropriate for orthodox
Jewish patients. The rabbi can teach health care workers that dairy and meats cannot be
combined in a meal, any animal meats eaten must only be vegetable eaters, and only fish
with scales and fins can be eaten. Also the rabbi can teach what kosher means and how a
meal is prepared to be considered kosher. Kosher meals for orthodox Jewish patients should
be available upon request at the hospital. The rabbi can also assess the food in the hospital
approve or reject the foods as being kosher for the orthodox Jewish patients.
Health care workers should also be taught about the Jewish religious holidays. According
to Silvestri (2014), during Yom Kippur, 24 hour fasting is observed in orthodox Jews (p. 39).
Teaching health care workers about the Jewish holiday Yom Kippur and what the Jewish
population practices, will allow for the orthodox Jewish patients to perform their dietary
practices if health permits. Health care workers should also be taught that if refraining from
nutrition will put in jeopardy the client’s health, a rabbi should be consulted to speak with the
patient. According to Silvestri (2014), pregnant women, children, and ill individuals are
exempt from fasting. Therefore, having a rabbi speak with the client about not fasting during
Jewish holidays will make the patient feel at ease when not performing this dietary practice.
5. Design a general nursing care plan that would address Rabbi Silverstein’s care needs in
the physical domain. Remember to include symptom control of advanced prostate cancer
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and androgen therapy. Include at least five (5) evidence-based nursing interventions with
scientific rationales. Each evidence-based intervention and its scientific rationale are 3
points. (15 points)
According to Lewis et al (2011), common problems experienced by the patient with
advanced prostate cancer include fatigue, bladder outlet obstruction, and pain (p.1392). An
intervention for fatigue is to encourage activities that promote rest like music. According to
Lewis et al. (2011), music decreases anxiety and it evokes the relaxation response which
assists in the elicitation of sleep in individuals (p. 106). Playing relaxing music will promote
relaxation and rest. Prostate cancer can also cause bladder outlet obstruction causing urinary
obstruction. An intervention for urinary obstruction is encourage client to void every 2 to 4
hours and when first feeling the urge. According to Lewis et al., encouraging clients to void
every 2 to 4 hours will minimize urinary stasis and acute urinary retention. Also maintaining
normal fluid intake should be encouraged. According to Lewis et al. (2011), restricting fluids
causes symptoms to worsen and increasing fluids causes bladder distention. Prostate cancer
can also cause pain. An intervention to treat pain related to prostate cancer is by
administering prescribed medications for pain. Also to relieve pain, non-pharmacologic
techniques for pain relief should be taught. According to Lewis et al (2011), pain control is
managed through ongoing pain assessment, administration of prescribed medications and the
use of non-pharmacologic methods of pain relief. Before administering pain medications, the
pain level should be assessed to provide the best intervention for the pain described.
According to Irwin et al. (2014), cancer-related moderate pain is relieved with weak
narcotics like codeine and non-narcotics. For severe pain, strong narcotics are used like
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morphine (Irwin et al., 2014). Pain medications should be administered around the clock to
maintain pain control.
The prostate is an androgen dependent organ and androgens are needed for the growth of
the prostate (Lewis et al., 2011). Androgen therapy for prostate cancer is an androgen
suppression. Androgen therapy causes adverse effects such as hot flashes and skeletal
morbidity such as fragility fractures (Sountoulides & Rountos, 2013). An intervention for
controlling hot flashes during androgen therapy is administering Megestrol acetate.
Megestrol acetate is a progesterone derivative. According to Sountoulides and Rountos.
(2013), Megestrol acetate achieved an 85% reduction in hot flashes. When on Megestrol
acetate, patient PSA levels should be monitored. An intervention for fragility fractures due to
skeletal morbidity is to administer a bisphosphonate such as zoledronic acid and maintaining
patient safety. According to Sountoulides and Rountos (2013), zoledronic acid reduced bone
reabsorption and increased bone mass density in prostate cancer patients undergoing
androgen therapy. Also zoledronic acid shown to be effective in preventing bone metastases
and decreasing pathological fractures after 20 months of treatment. Routine bone mass
density should also be screened to monitor it. Maintaining patient safety is also important to
prevent fractures. Patient safety should include maintaining bed rails up when patient is in
bed and providing patient with non-slid socks to prevent slipping during ambulation.
6. What is cyberknife? (5 points) and how is it used to specifically treat prostate cancer? (10
points). Be VERY specific and comprehensive in your discussion.
(15 points)
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According to Accuray (2012), cyberknife is a non-invasive procedure for the treatment of
cancerous and non-cancerous tumors anywhere in the body. More specifically, cyberknife is “a
frameless stereotactic radiotherapy system produced from a small linear accelerator, which has a
robotic arm that allows the beam to be directed from any direction, and which monitors
movement of implanted markers to deliver real-time image-guided radiotherapy” (Oxford
Dictionary, 2010). The Cyberknife procedure uses a “robotic” arm and advanced imaging to
deliver high doses of radiation directly to the organ (Accuray, 2012). Cyberknife treats prostate
cancer by delivering high doses of radiation directly to the prostate with the use of advanced
imaging to accurately deliver treatment. Before the patient receives the treatment, the patient
undergoes a CT scan to assess the size, shape, and location of the tumor and develop a treatment
plan (Accuray, 2012). According to Seisen et al. (2013), about 10 days before treatment, markers
are implanted at the apex, intermediate lateral zone, and base of the prostate (p. 762). The
advanced imaging and use of the markers allows patients to breathe normally during treatment
and provide accurate location (Seisen et al., 2013, p. 763). According to Accuray (2012), the
cyberknife system rotates around the patient to deliver radiation. According to Koh, Kim, Kim,
Chang & Kim (2014), in a retrospective study conducted, data supports that treatment of prostate
cancer with Cyberknife system is feasible.
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Resources:
Accuray (2012). What is the cyberknife system? Retrieved from
http://www.cyberknife.com/cyberknifeoverview/whatcyberknife.aspx?linkidentifier=id&i
temid=34
Cleveland Clinic Office of Diversity (2012). Diversity toolkit: Patient care guide. Cleveland
Clinic Foundation, 146-149.
Ehman, J. (2012, May 8). Religious diversity: Practical points for health care providers.
Retrieved from
http://www.uphs.upenn.edu/pastoral/resed/diversity_points.html#jewishpoints
Irwin, B.J., Arnoldussen, B., Burckhardt, J.A., Dobish, B., Finesilver, C., Gardner, P., Mahoney,
E., & Redemske, M. (2014). NCLEX-RN content review guide: Preparation for the
NCLEX-RN examination. New York, NY: Kaplan.
Koh, D., Kim, J., Kim, H., Chang, Y. & Kim, H.J. (2014), Cinical outcomes of cyberknife
radiotherapy in prostate cancer patients: Short-term, single-center experience. Korean
Journal of Urology, 55(3), 172-177.
Lewis, S.L., Dirksen, S.F., Heitkemper, M.M., Bucher, L., & Camera, I.M. (2011).
Medical-surgical nursing: Assessment and management of clinical problems. St. Louis,
MI: Elsevier Mosby.
Loike, J., Gillick, M., Mayer, S., Prager, K., Simon, J.R., Steinberg, A., Tendler, M.D., Willig,
M., Fischback, R.L. (2010). The critical role of religion: Caring for the dying patient
from an orthodox Jewish perspective. Journal of Palliative Medicine, 13(10), 12671271.
CASE STUDY #2: RABBI SILVERSTEIN 15
Mindel, N. (2015). The three daily prayers. Retrieved from
http://www.chabad.org/library/article_cdo/aid/682091/jewish/The-Three-DailyPrayers.htm
Seisen, T., Drouin, S.J., Phe, V., Parra, J., Mozer, P., Bitker, M., Cussenot, O., & Roupret, M.
(2013). Current role of image-guided robotic radiosurgery (cyberknife) for prostate
cancer treatment, BJU International, 111(5), 761-766.
Silvestri, L.A. (2014). Saunders comprehensive review for the NCLEX-RN examination. St.
Louis, MI: Elsevier Saunders.
Sountoulides, P., & Rountos, T. (2013). Adverse effects of androgen deprivation therapy for
prostate cancer: Prevention and management. ISRN Urology, 3, 1-8.
Williams, E.G. (2014). The orthodox Jewish patient: Five things we should know. Retrieved
from: http://www.ausmed.com.au/blog/entry/the-orthodox-jewish-patient-five-things-weshould-know-1