Indigenous Community Recommendations

The purpose of this section is to provide practical guidance to emergency clinicians (doctors and nurses) to help reduce cultural barriers and improve Māori patient outcomes during COVID 19. ACEM has made a commitment to Māori through its health equity strategy, Te Rautaki Manaaki Mana, to provide excellent and equitable care to Māori patients, whānau (family) and staff. This has not changed due to the outbreak of COVID 19.
 
Please note that this section cannot be taken as a catch all complete guide. It outlines recommended key principles as a starting point. The principles outlined in this Section are based on ACEM’s Manaaki Mana vision that emergency departments in Aotearoa New Zealand provide excellent and culturally safe care for Māori.
 
It is now more important than ever to be aware that inequities are exaggerated during pandemics and to do as much as possible to mitigate them. The evidence from previous pandemics consistently shows higher mortality rates for Māori compared to non-Māori. For example:

• 1918 Influenza Pandemic: Māori mortality rate 7 times more than the rate of the European settler population.
• 1957 Influenza Epidemic: Māori mortality rate was 6 times more than the European rate.
• 2009 H1N1 Swine Flu Pandemic: Māori mortality rate almost 3 times higher than the European rate 

Be your patient’s advocate for excellent emergency care. This includes ensuring patients do not suffer racial, ethnic or cultural discrimination in the Emergency Department. 
 
Advice for clinicians
 
We recommend:

• Ensure that your patient feels safe in your care and knows that you and your staff will ensure their safe management during their time in the ED and the hospital.
• Provide care that is culturally safe to Māori and which upholds tikanga as far as is possible under the restrictions of the higher alert levels as defined by the New Zealand and Australian governments.
• Be aware of and demonstrate respect for key Te Ao Māori values when providing care – when this is sincerely done it helps to reduce cultural barriers and misunderstandings. These values also benefit the patient-clinician relationship in all other cultures:
  • Manaakitanga: Treat patients with kindness, care, respect and aroha (love). For example, you can demonstrate this by making an effort to say their name and Māori words such as whānau, correctly. Acknowledgement of whānau who are present is another important way to demonstrate manaakitanga. This link can assist you with pronunciation.
  • Tika me Pono: Be fair, be honest, be just, in how you treat your patient.
  • Whanaungatanga: Understand the importance that Māori patients often place on involving whānau in their health decisions. Their individual health issue may be seen as a whanau health issue.
  • Whakamana: Recognise that the patient has inherent mana and is worthy of your respect.
• Demonstrate compassion and care in your words and actions. Respecting mana is an important part of communication, regardless of the amount of PPE you are wearing. Remember you may have to be more overt and demonstrative of this when your facial expressions are covered by your PPE.
• Discuss resuscitation limits and ceiling of care decisions early, preferably before the patient becomes critically ill. This is a highly sensitive area for many Māori whānau. Trust is built by involving whānau and allowing as much time as possible to come to terms with medical decisions. Be honest and open. Invite questions. Ensure mutual understanding has occurred. Useful guidance can be found here.
• Understand that for Māori, kaumatua and kuia (elders) are taonga (treasures) that need to be protected from COVID 19. Should they be admitted to hospital they need to be treated with the utmost care and compassion as befits their special status within Te Ao Māori.
• Recognise that restriction on visitors to the hospital may disportionately affect Māori, as the extended whānau often wish to be with those who are sick or critically unwell. It is to be expected that whānau will be distressed by these restrictions – we must therefore uphold these restrictions with kindness and compassion, but also feel empowered to allow restricted visitors (where practical/possible) for compassionate or practical reasons.
• Respect cultural beliefs and practices around death and dying. For spiritual reasons many  Māori whānau will desire time with the dying or the tūpāpaku (the deceased). Traditionally the tūpāpaku is never left alone. This may include karakia (prayer) or waiata (song) immediately before or after death. Where this can occur within government guidelines, it should be allowed. If this is not possible due to visitor restrictions alternatives such as video calls should be encouraged and facilitated if possible.
• Recognise diversity within the Māori world, just as there are differences within other cultures and mainstream societies. Don't make assumptions about patients or their cultural practices. If in doubt, ask respectfully.
• Remember we all have implicit bias. This manifests most when we are stressed and overwhelmed and can lead us to make decisions based on assumption. Being aware of our own biases is the first step to reducing their effect and improving patient outcomes. 

For more assistance work with your local Māori Health unit, Manaaki Mana champions in your ED or to find out more about becoming a champion yourself please contact the ACEM Kairuruku Iwi Taketake (Indigenous Heatlh Coordinator).
 
Advice for departments
 
ACEM acknowledges Māori as tangata whenua in Aotearoa New Zealand and recognises our obligations to Māori as Te Tiriti o Waitangi partners. Amongst other things this means we advocate for the following:

• Consulting with Māori in the preparation and running of the emergency department and hospital to care for those unwell due to COVID 19 as well as those experiencing health issues not related to COVID 19.
• Working with St John and other ambulance services and primary care providers to ensure that those that need hospital level care reach us.
• Working to provide equitable access to care for Māori by addressing fears of safety, separation from whānau and care of tūpāpaku (the deceased) by providing information that reaches its target audience.
• Commitment to transparent and robust processes that seek to eliminate bias in treatment decisions, especially those which place limits on care (such as whether mechanical ventilation is offered) by working with Māori and colleagues in intensive care and other specialties.
• Offering clinicians guidance and processes to mitigate implicit bias, which is likely to be accentuated when making decisions under the stress of an overwhelmed health service.
• Collection and rapid analysis of data on outcomes to ensure these are equitable. 

Culturally safe behaviour from emergency physicians improves health outcomes for all patients including Māori. Demonstrating kindness and compassion is key to providing culturally safe care, take the time to understand the needs of patients and their whānau and explain with sensitivity where government restrictions will prevent particular practices taking place.
 
This guidance is relevant for future pandemics/epidemics. It is important to be aware that whilst the Australian and Aotearoa New Zealand health systems have not been overwhelmed due to Covid-19  as we have seen elsewhere, existing inequities in care are likely to be exacerbated when our health system is under pressure.  The advice in this guideline will help guide clinicians to deal with the inequity that existed pre-COVID 19, which is expected to be amplified post COVID 19. It can also be used as part of an ongoing approach to Māori health inequity in the future.
 
If you would like to learn more about the impacts of COVID 19 restrictions on Māori, please visit Te Rōpu Whakakaupapa Urutā (National Māori Pandemic Group) online. You can also read ACEM’s joint statement with Te Tumu Whakarae and Te Ohu Rata Aotearoa (Te ORA).
 
For COVID-19 Restrictions on Māori Customs for Burial and Funeral, please see the latest Ministry of Health Guideline on restrictions for deaths, funerals, tangihanga.

The following resources were used in the preparation of this section:

• Ministry of Health Covid-19 Guidelines
• Understanding Equity in a Aotearoa New Zealand Context
• Review of Australia’s Health Sector Response to Pandemic (H1N1) 2009: Lessons identified. Commonwealth of Australia 2011.
• An Ethics Framework for Making Resource Allocation Decisions within Clinical Care: Responding to COVID-19. Sydney Health Ethics, University of Sydney. Version 1: 2 April 2020.

This section has been developed to assist clinicians with decisions about appropriate healthcare in Emergency Departments in Australia and Aotearoa New Zealand during the COVID-19 outbreak. It is a framework for planning and responding to this pandemic, including the assessment and management of patients.
 
This section is targeted at clinicians only. Patients, parents or other community members using it should do so in conjunction with a health professional and should not rely on the information in the guideline as professional medical advice.
 
The section has been developed by an expert team of practising emergency physicians, by consensus and based on the best evidence available. The recommendations contained do not indicate an exclusive course of action or standard of care. They do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type.
 
The section is a general document, to be considered having regard to the general circumstances to which it applies at the time of its endorsement.
It is the responsibility of the user to have express regard to the particular circumstances of each case, and the application of the section in each case.
 
The authors have made considerable efforts to ensure the information upon which it is based is accurate and up to date. However, the situation is rapidly evolving, and a certain amount of pragmatism needs to be employed in maintaining such a ‘living document’. Users of this section are strongly recommended where possible to confirm that the information contained within the document is correct by way of independent sources. The authors accept no responsibility for any inaccuracies, information perceived as misleading, or the success or failure of any treatment regimen detailed. The inclusion of links to external websites does not constitute an endorsement of those websites nor the information or services offered.
 
The section has been prepared having regard to the information available at the time of preparation and the user should therefore have regard to any information, research or other material which may have been published or become available subsequently.

Whilst we have endeavoured to ensure that professional documents are as current as possible at the time of their creation, we take no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently.

Resources that are relevant to this section can be accessed through the Clinical Guidelines web-based material [Link]. COVID-19 related ACEM Resources [Link], COVID-19 related external resources [Link], and the latest Government advice on COVID-19 [Link] are also available.