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Caring for the Hindu patient: cultural and clinical aspects

Strict vegetarianism, the circle of life and death and the enactment of important rituals for dying relatives are key to understanding strict Hindu patients ­ by Dr Manju Chandiramani, Dr Samir Srivastava and Dr Vinod Patel

Hinduism is India's oldest religion and can be traced back 5,000 years. It is an amalgamation of a family of traditions, incorporating a spectrum of philosophical ideas, beliefs and practices. One-third of Indo-Asians in the UK are Hindus. Caring for the Hindu patient is not complicated, but GPs need to treat the patient sensitively within the realms of their religious and cultural beliefs to provide holistic and appropriate medical care.

Hinduism

Hinduism has no common roots with the Abrahamic religions (Judaism, Christianity and Islam). It is based on the relentless pursuit of absolute truth and higher consciousness with the ultimate aim of uniting the individual soul (Atman) with God (Brahman). There is no formal book of catechism for all its aspects. The Vedas (akin to the Old Testament) are the foundation scriptures and the Bhagavad Gita and the Upanishads (akin to the New Testament) are their ultimate distillation.

However, there is immense diversity within the religion, depending on a person's origin, caste and sometimes even their family's beliefs. An individual's belief in the core principles of the religion and his ability to adapt to modern society has allowed this religion to persevere for thousands of years. Hinduism emphasises the spirit of balance in all aspects of life, which can be used positively to influence medical care.

Basic concepts

Hinduism is a very complex belief system, grounded in religion and culture. Hindus talk of their religion as a way of life rather than a set of dogmas. It is through behaviour that Hindu values are best expressed, rather than adherence to a specific set of beliefs.

Among the essential features that typify Hindu beliefs is the concept of samsara, the cycle of birth, death and rebirth. In this manner, the three functions of God are exemplified as Brahma the Creator, Vishnu the Preserver, and Shiva the Destroyer1.

Liberation from samsara can be found only through the pursuit of the ultimate goal in life, moksha. This means liberation, spiritual freedom from the bondage of the cycle of birth, death and rebirth.

Hinduism teaches that human beings should seek to achieve spiritual freedom through non-attachment and spiritual knowledge, by performing good deeds without seeking selfish gains, and being devoted to God1.

The theory underlying karma (action) relates to the law of cause and effect1. Belief in karma is very important to many Hindu patients and will influence the way they perceive health and health care.

Each person is reborn so that the soul may be purified and ultimately attain divine cosmic consciousness2. It is not possible for anyone to escape from the consequences of what one does, knowingly or otherwise. Every action and deed in this lifetime, whether good or bad, will be carried into the next3,4.

Many Hindus believe that any experience in this lifetime, including serious illness, helps to balance their soul. When a Hindu acknowledges the experience and uses it to make

himself into a better person, that karma is resolved and the person is freed from it.

The end result is that a soul gains a variety of experiences and wisdom over a series of lives, and eventually sees the world as God does. Rewards in this lifetime are considered the result of gains made in the last.

Another important concept is ahimsa (non-violence), which emphasises that no harm shall be caused to other living beings, either by action, word or thought. Many Hindus are vegetarian as an indication of their spirituality. Eating meat would mean taking the life of another living creature, which contains the life of God, and thus harming God's soul, and ultimately your own sou · 4.

Hindu festivals

Hinduism is characterised by its many festivals, periods of feasting and fasting of one to nine days' duration. Their timing is based on the lunar calendar, consequently they occur on different dates in the solar calendar from year to year.

Consecrated food is distributed in temples after services, particularly at festival times. These consecrated foods tend to be based on fruits and nuts, not fat and sugar. The GP needs to be aware of approaching fasts and festivals to advise on self-management and glycaemic control, especially in the diabetic patient.

Family structure

The family structure is often complex and extended. Many generations live under one roof. Traditionally, the male will be the provider and protector; he will look after matters outside the home while the female will be in charge of the home and the family. Mothers are sacred and treated with respect. When discussing medical issues and a management plan, it is best to involve not only the patient but also the extended family.

Medical care

Illness is thought to be a punishment for bad deeds in a former life. Most patients will understand the need to go through the experience in order for their karma to be resolved and to be freed from it in subsequent lifetimes.

Most Hindus have respect for the medical profession, but can be wary of medicines. They need to have detailed explanations of why certain medicines are prescribed in order to be compliant with treatment.

Many Hindus may not take insulin that is made from animals and a detailed explanation of the contents needs to be given if the patient is to comply with the management plan. Patients will often admit to taking natural, homoeopathic medicine. This information must be specifically elicited when taking a history.

Communication is important. Some patients may not speak English to a standard high enough to guarantee a good understanding of what is communicated by the GP. Multi-lingual link workers are very helpful in this situation. The main languages spoken by Hindus in the UK will be Gujarati, Punjabi and Hindi.

Pregnancy and childbirth

The conception of a child is sacred in the Hindu culture. It signifies the rebirth of a person who has had previous lives. Throughout the pregnancy, prayers are said at various intervals for the healthy development and protection of the child. The soul is believed to enter the child at seven months. If a woman miscarries before this time, no special requirements are needed, but after this time a religious ceremony is required4.

Abortion is condemned in Hindu tradition as it is perceived as a disruption to the cycle of birth and rebirth. It is only permitted if the mother's life is in danger4.

Hinduism does not prohibit contraception. Sex is a way of life. The Kama Sutra, written by Vatsyayana in the early fourth century, and other works digress on the celebration of love5.

Differences in husband-wife communication, sex roles, access to contraceptives, and traditional family values will have more of an effect on contraceptive use and fertility than theological barriers or the social class of religious groups6.

Babies are named by their birth star, which is calculated by the position of the child and the moon at the time of birth. At times, parents may not be able to complete the

birth certificate in the hospital.

Breast-feeding is preferred to formula, and some women may breast-feed their babies until they are two or three years old. Circumcision is not practised in Hinduism4.

Death and dying

It is important that the family be kept fully informed of illness progression, especially if death is imminent. Special prayers must be said and often a relative must be present at the moment of death. If the necessary rituals are not carried out appropriately the family may become distressed about the well-being of their relative's soul and the consequences for themselves.

A pandit (priest) may be called in to do a puja (prayer). Pujas may involve adorning the person's head with sandalwood paste, holy ash and red kum kum powder.

A red or yellow string may be tied around the wrist. After death, close family members will wash the body, close the eyes and straighten the legs. A death needs to be registered as soon as possible and the body cremated within 24 hours3.

Management of the Hindu patient is not complicated, but to do it in an appropriate and sensitive manner a basic understanding of religious beliefs and practices, culture and tradition is essential. The doctor must recognise the concept of karma and reincarnation. In matters of diagnosis, treatment and consent, the patient's relatives must be involved, while ensuring the individual patient's wishes are respected. Communication is vital and every effort must be made to ensure the Hindu patient understands the treatment they are receiving.

Hindu festivals

Diwali and New Year's Day The 'festival of lights' is the most important one in the Hindu year and has a significance similar to Christmas. It celebrates the return of Lord Rama from exile: the 'lights' refer to the illumination of his path by diwas, small oil lamps, by the celebrating people of Ayodhya. Diwali is usually a time of feasting, presents and fireworks.

Navratri or Dussehra This celebrates the death of the demon Ravana at the hand of Rama, although in the south of India it has a different meaning. Strict Hindus will observe this festival by daily fasts which allow only one meal a day, usually in the evening. Oral beverages (and often fruit) are permissible throughout the day. There are usually nightly folk dances.

Holi is the festival of colours and held in the spring for a single day. Jamnastami celebrates the birthday of Lord Krishna. In both, single meal fasting is often observed. Ram-nawmi celebrates the birthday of Lord Rama and Sivratri celebrates Lord Siva.

Advice for diabetic Hindu

patients during festivals

Patients on oral treatment

 · Omit metformin and short-acting insulin secretagogues when meal is missed. Take 500mg metformin with breakfast beverages and

850-1,000mg metformin with the larger meal when fast is broken.

 · Long-acting agents are not advisable. Reduced doses of glimepiride and gliclazide MR are probably safe.

 · Continue glucose testing during fast. Carry snacks to avoid hypoglycaemia during the festival dances.

Patients on insulin

 · Reduce dose of insulin with the lighter breakfast as lunch will be omitted. Beverages with milk and sugar help prevent hypoglycaemia.

 · Increase evening dose of insulin as post-fast meal will

be larger than normal.

 · Increase insulin 10-20 per cent ad hoc to cover increased refined carbohydrate intake, unless consumption is minimal.

References

1 Richards C (ed.) The Illustrated Encyclopaedia of World Religions. Singapore: Element Books, 1997

2 Radhakrishnan S. The Principal Upanishads. London:

Allen and Unwin, 1968

3 Jootun D. Nursing with Dignity. Part 7: Hinduism. Nurs Times 2002;98:38-40

4 Sukumaran A. Hinduism and Medicine: A Guide for Medical Professionals. Published online in 1999 at www.angelfire.com/az/ambersukumaran/medicine.html

5 Srinivas MN. A part of life. The Hindu view. Asiaweek 1993 (Oct 27):59

6 Schenker JG, Rabenou V. Contraception: traditional and religious attitudes. Eur J Obstet Gynecol Reprod Bio 1993;49:15-8

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