ACEM - Indigenous Community Recommendations

“Let us not be distracted by the pressing needs for acute care; instead let us keep close to our hearts the humanistic principles of medicine that we should all live by, and that is, that at the end of every swab, every test, every ventilator is a patient with generations of history that we all need to be culturally, emotionally and professionally respectful of so that we can continue to provide the gold standard care to all of our patients, no matter the crisis that is unfolding around us.”

Dr Shannon Springer, Vice-President, Australian Indigenous Doctors Association, writing for The Guardian Australia (23 April 2020: ‘As doctors, we must remember that behind every test is a patient with cultural and emotional needs’)

ACEM acknowledges that vulnerable groups currently have health outcomes that are not only avoidable but unfair and unjust. The COVID-19 pandemic is likely to further exacerbate inequities and biases, including through the current reduction in services due to the pandemic response. Equitable, transparent decision making is vital at this time and should incorporate local community perspectives.

Emergency departments across Australia and Aotearoa New Zealand must strive to provide culturally safe, equitable access to care to vulnerable groups, in particular Aboriginal, Torres Strait Islander peoples and Māori, who are at greater risk of increased severity of disease and death from COVID-19.

Culturally safe care improves health outcomes for all patients, including those who are vulnerable. Special consideration should be given to people who:

Are living in social precarity - including people experiencing homelessness, poverty or incarceration.
Have barriers to accessing appropriate health care - including people living remotely, of lower socioeconomic status, or living with a disability.
Are marginalised – including the LGBTIQ community, people from culturally and linguistically diverse backgrounds, people experiencing mental health issues, or people living with addiction.
Have increased susceptibility to COVID-19 - including the elderly and frail, people with comorbidities, or people living in overcrowded conditions.

Staff working in our emergency departments who experience increased risk from COVID-19, or have close family members who are at increased risk, should also be given special consideration with respect to work duties.

Caring for Māori Patients in the Emergency Department
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.
Aboriginal and Torres Strait Islander Health
The COVID-19 pandemic is likely to further exacerbate health inequities for Aboriginal and Torres Strait Islander Peoples. Consultation and collaboration with Aboriginal and Torres Strait Islander communities must underpin both local and broader responses.

The Australian Health system has provided inequitable resourcing to meet the specific needs of Aboriginal and Torres Strait Islander Peoples, who are more likely to have poorer health outcomes and lower life expectancy than non-Indigenous Australians.

Historic experiences of Government policies, coupled with personal and family experiences of institutional racism, and disrespectful communication may contribute to mistrust in the system and an unwillingness for Aboriginal and Torres Strait Islander Peoples to engage with healthcare services.

Pandemics have profoundly impacted Indigenous peoples throughout history, even in recent times, and despite modern health responses. In 2009, Indigenous Australians suffered death rates six times higher than the general population in the H1N1 Swine Flu pandemic.

The COVID-19 pandemic is likely to further exacerbate health inequities for Aboriginal and Torres Strait Islander communities, and may result in:
- Increased severity of disease and death from COVID-19.
- More rapid spread of COVID-19, particularly within discrete communities.
- Diagnostic testing delays for COVID-19.
- Reduction in overall health service provision, disproportionately affecting Aboriginal and Torres Strait Islander Peoples due to pre-existing chronic disease burden.
ACEM demands the highest standards of culturally safe and ethical behaviour from all Fellows and Trainees. Emergency physicians must advocate for excellent emergency care for all patients with COVID-19, show respect and sensitivity for the different cultural needs of Aboriginal and Torres Strait Islander patients, mitigate unconscious biases likely to emerge under stress, and address systemic barriers to ensure patients do not suffer racial, ethnic or cultural discrimination in the emergency department.

ACEM advocates for pandemic planning that supports, sustains and values Aboriginal and Torres Strait Islander perspectives. Consultation and collaboration with Aboriginal and Torres Strait Islander communities must underpin both local and broader responses, and should be tailored to the unique circumstance of each community and each setting.

We align with:
- Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19): Management Plan for Aboriginal and Torres Strait Islander Populations (March 2020).
- The Bellagio Meeting on Social Justice and Influenza: Statement of Principles.
We advocate for:
- Transparent, robust and consistent decision-making regarding aeromedical retrieval, advanced care resource allocation, limits of care and futility that ensures equity and cultural safety is maintained for Aboriginal and Torres Strait Islander Peoples.
- Research, data collection and analysis that is inclusive of Aboriginal and Torres Strait Islander knowledge and is used to inform future clinical guidelines.
Key Principles

Unconscious bias must be recognised and racism must be mitigated. We recommend that all staff working in the emergency setting:
- Understand that Aboriginal and Torres Strait Islander heritage is not a co-morbidity. Avoiding assumptions about race and socio-economic status is critical during clinical care.
- Seek to understand each unique patient and their individual circumstances, so as to prepare an accurate care plan based on clinical facts, not racial stereotypes.
- Appreciate that clinical scoring tools contain bias and can perpetuate current health inequities if used in isolation. The co-morbidities that score poorly and may determine limitations or exclusion from care occur at disproportionately higher rates for Aboriginal and Torres Strait Islander Peoples due to the social determinants of health and other non-medical factorsii.
- Respect the diversity of First Nations Peoples and languages, values and customs. When this is done sincerely, it helps to reduce cultural barriers and misunderstandings that can impact the therapeutic relationship between the emergency physician, the patient and their family.
- Be mindful of communication that could be perceived as disrespectful. Appreciate that casual or unintentional racism impacts the recipient, regardless of the intent.
- Ensure equity in testing for COVID-19 and access to chronic disease management generally.
Specific considerations for Aboriginal and Torres Strait Islander communities:
- Multi-generational family groups commonly live under one roof and may be in close proximity to each other.
- The ability to access a mobile phone service, phone credit, or internet may be limited or non- existent and impacts on accessibility to telehealth consultations.
- Inadequate basic infrastructure, such as clean water and housing, may be an issue, particularly in remote communities.
- Transportation options may be limited, with some family groups sharing a private vehicle and licensed driver.
- People are often highly mobile, with travel linked to cultural and family obligations.
- Poverty may reduce the capacity of families and communities to adapt to rapidly changing emergencies.
- Communities and families already dealing with significant inter-generational trauma related to Stolen Generations, dispossession, and ongoing cultural disruption may be more prone to the psychological and social impacts of the COVID-19 pandemic.
Population Settings of the Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19): Management Plan for Aboriginal and Torres Strait Islander Populations provides further detail on issues for remote and very remote communities; urban and regional communities; other settings including hostels, town camps, aged care facilities, prisons and homeless populations.

Aboriginal and Torres Strait Islander patient clinical care

We recommend:
- Aboriginal Liaison Officers are involved wherever possible with patient care, including by phone.
- Shared decision-making that focuses on the patient perspective and understanding.
- Facilitating family-centred care that respects cultural values to ensure patients can remain connected with family while in hospital.
- Use of interpreters where English is not a first language (The FirstVoices Keyboards App can be helpful if no interpreter is available).
- Healthcare service messaging includes images/graphics, is available in local language, and includes input from local community to increase effectiveness and trust.
- End-of-life care is informed by local Aboriginal and Torres Strait Islander community cultural protocols and obligations.
- Pathways for continuity of care into and out of EDs are developed in partnership with local Aboriginal Community Controlled Organisations (ACCHOs).
- Discharge planning that takes into consideration limited transport options and financial constraints, including prescription collection.
- Ensuring that self-isolation is feasible, and arranging alternate housing or hospital admission if necessary.
- Understanding that Aboriginal and Torres Strait Islander patients may not be familiar with or feel comfortable in mainstream health services.
- Avoiding being judgmental if a patient presents late in the course of illness. This may reflect complex social circumstances, and concerns about racism, feelings of shame and mistrust of mainstream health services.
- Clarifying advanced care decisions early:
  - Address patient and family concerns with honesty.
  - Be transparent and take the time to be inclusive.
  - Involve an Aboriginal Liaison Officer if possible.
  - Involve an Emergency Physician, Intensivist or Palliative Care specialist where possible.
  - Ensure you use reliable information, rather than assumptions, to inform the discussion.
- Promoting influenza vaccination (and pneumococcal vaccination if the patient is 50 years or older).
- That Aboriginal and Torres Strait Islander healthcare workers who experience increased risk from COVID-19, or have close family members who are at increased risk, are supported with flexible workforce strategies to continue to contribute to patient care.
References
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.
Section disclaimer

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

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.

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