Anatomic Pathology: Cultural and Religious Considerations

Vol. 22 • Issue 18 • Page 8

The Joint Commission has several requirements for respecting the cultural and religious beliefs of patients during treatments, procedures and tests. Personnel in anatomic pathology laboratories rarely see patients, yet re performing tests on their tissues, and are required to be sensitive to these beliefs. (Joint Commission. Human Resources 01.04.01, Provision of Care 02.03.01, and Rights and Responsibilities 01.01.01. Available at: www.jointcommission.org. Last accessed Sept. 13, 2010.)

How do we become aware of these beliefs, support our patients and set up the necessary policies? The first step is to contact your institution’s resources, such as Pastoral Care, Nursing Office, Bereavement, Hospice and Legal Department. Your institution probably already has policies in place, but never thought to consider the laboratory in their policies. These departments have probably established contacts within local religious and cultural communities, who can help you to establish laboratory-related policies. These departments would also know the local and state laws.

Throughout history, the human body has been treated with respect. For most religions, different parts of the body have been endowed with varying degree of importance. Often, the heart, brain, blood and eyes are considered more central to the person’s identity than, say, hair or saliva. But for some religions, all body parts are considered to be endowed with equal degrees of significance.

Most religions and cultures do support surgical procedures and laboratory tests. The areas of most variations for anatomic pathology include: the disposition of surgical specimens and deceased persons; handling of a fetus; and how to show respect during an autopsy. But within any culture or religion, there are differences based on areas of the country, places of worship, in individuals, and also how closely tied someone is to their original country of origin.

Amputations/Surgical Excisions

Most religions do not put a restriction on performing surgery. Anatomic pathology laboratories might not notice those religions/cultures that do restrict or try to avoid surgery (i.e., Christian Science, Rastafarianism, Shinto, Hmong), as no tissues or organs would ever be received. However, some religions and cultures do put limitations on tissue removal:

Burial: Some require the amputated limb or removed organ be buried in consecrated ground (Roman Rite Catholic, Greek Orthodox, Ukrainian Orthodox, Jehovah’s Witness, Islam, Judiasm). Does your facility have a relationship with a funeral home to honor this request?
Previously disposed tissue: What if the family asks for tissue or a limb for burial, months after it has been disposed of by the lab? Ask the family if extra H&E slides cut from the blocks, or possibly some of the blocks themselves, would be acceptable, and send directly to the funeral home. Remember to document the request and the lab’s response.
Transplants: Many religions allow and encourage transplants. Some religions will allow certain organ transplants, such as eyes or bone marrow, but not the major organs, such as heart or lung (e.g., Greek, Russian and Ukrainian Orthodox). For some religions, it is an individual choice, while for others it is not permitted (Rastafarianism, Shinto, Taoism). If a transplant is allowed, Anatomic Pathology would receive the removed organ. Consider whether it has to be buried by that religion/culture.
Placentas: Some religions and cultures, such as Native American, African, South Pacific, Mexican, Jewish and Hmong, want the placenta returned to the family for ceremonial handling. One tradition is for the placenta to be buried outside, often with a tree planted with it. This is thought to bind the child to that area and culture, and the tree is a memorial of the birth. Sometimes objects are buried with the placenta, such as money or a book, indicating what the family wants for the child’s future (wealth, being smart). In some cultures, such as Vietnamese and Chinese, the placenta is eaten. It is full of nutrients such as proteins, prostaglandins to shrink the uterus, and oxytocin to start the milk production. Consider whether you can return specimens to the patient.

Fetus/Newborn Death

Within your institution, there may be a gestational age determining whether a fetus received in the lab is handled as a surgical specimen or as an autopsy.

Legal: Check with your Legal Department to make certain of the gestational age in your state. Be aware various religions or cultures may have other opinions of how a fetus is to be handled.
Formalin fixed: If a fetus is sent to your lab in formalin, what do you do if a family wants to see their child? What is your lab’s policy about allowing the family to see and hold their child once it has been in fixative? After it’s been dissected? Work with the Nursing Department on establishing this policy, because they will be the ones explaining to the parents why they can’t see their child.
Delay autopsy: Consider delaying an autopsy on a fetus or newborn until after the mother has been discharged. The parents often want to see their baby several times.
Request for disposed fetus: What if the parents come back a year later and want to bury their fetus that was properly disposed of 10 months ago by your institution? Ask if slides or blocks would be acceptable, and then send them directly to the funeral home to have them place it in the casket or urn. Remember to document this.

Autopsy

Most religions allow autopsies (see Sidebar for more information). In some religions, autopsy is not allowed, because it is considered a desecration of the body. For others, it would only be allowed in a medical or legal case. Other things to consider for the body include:

Vigil: Some religions do not want the deceased to be left alone. Does your morgue cooler area have a place nearby where people can sit comfortably, with privacy, near a drinking fountain and restrooms, and have access to food acceptable to their religion?
Washing: Some cultures and religions require the body be washed by a person of their faith or culture authorized to do so, or that a special ritual be performed. Encourage this to be done on the nursing floor, not in the morgue area.
Orientation: Someone of the Muslim religion may request the face and right shoulder of the deceased face Mecca.
Clothes or markings on body: Some religions may tie a string or drape a cloth on the body, or may wish the feet or jaw be tied. They may ask a particular religious piece of jewelry remain on the body. If an autopsy is performed, these wishes should be honored as much as possible. If these need to be removed to be kept clean, they should be stored with reverence, and promptly returned to the deceased.
Time constraints: Judaism and Islam, like many other Middle Eastern religions, would like the body of a deceased person buried within the same day of death. However, in Judaism, accommodation may be made to allow for family members traveling. The laboratory should have a plan in place to try to accommodate these wishes.
Return organs to body: Be aware some religions, such as Greek Orthodox, Jehovah’s Witness and Judiasm, require all organs be returned to the body. In teaching hospitals, this may not be the usual practice, so routines must be changed.

Returning of Specimens

Some patients ask their specimens be returned to them due to cultural or religious considerations. Some ask because they want to satisfy their curiosity or to show their friends and relatives. What the laboratory has to consider is:

Legality: Is it allowed in your state to return specimens directly to a patient? Is it only allowed to be released to a funeral home for embalmment before it is given to the patient? Who pays? How long does the lab have to retain the tissue before being allowed to release it? Does it make a difference if it is for religious reasons versus “show and tell?” Contact your legal department for advice, and write a policy.
Patient safety: How do you keep the patient and his loved ones safe? From fresh tissue and bloodborne pathogens? From chemicals such as fixatives? Contact your Legal Department, Epidemiology and Safety Department. Work on a policy. If allowed to give out the specimen, write up material about the various hazards to give to the patient receiving the specimen. Have the patient sign forms, acknowledging the hazard and accepting responsibility.
Return to whom: Is the patient under 18? Over 18? Remember, HIPAA still applies.

Peggy Wenk is program director, Schools of Histotechnology; supervisor, Mortuary Services Laboratory; safety officer and disaster preparedness coordinator for the Department of Anatomic Pathology, Beaumont Hospital, Royal Oak, MI.

Material in this article was based on a 3-hour workshop titled “Cultural and Religious Considerations in Pathology,” presented at the 2009 NSH Symposium in Birmingham, AL, by Reverend D. Carl Buxo, M. Div., BCC, (APC) and Peggy A. Wenk. Special thanks to Rev. Buxo for all his research.

Religions and Autopsies

Those religions typically only allow an autopsy when medically necessary or legally required: