Board Guidelines

Topic

Goal

To provide services within the Auckland District Health Board (ADHB) that are responsive to Mäori rites/rights, needs and interests.

Objective

To ensure the wairua (spiritual), hinengaro (psychological) and tinana (physical) wellbeing of tängata mäuiui (Mäori consumers/ clients/ patients) and their whänau (family and extended family group).

Responsibility

All ADHB employees (including contracted staff) are responsible for ensuring this policy is implemented.

Guiding Principles

As soon as tängata mäuiui (Mäori consumers/ clients/ patients) and their whänau are involved with a healthcare service they are deemed to be in a state of noa (being beyond one’s own physical and/or spiritual power) e.g. disempowered. Acknowledging a person’s rites/rights and respecting their beliefs restores the tapu (well being/empowerment) of tängata mäuiui and their whänau (e.g. permission is always asked for and an explanation given prior to any intervention). If informed consent and compliance with tikanga is not carried out in a respectful manner during the care of tängata mäuiui then a mahi hë (offence) has been committed. This is regardless of how small the mahi hë may appear. Another action is then required to correct the mahi hë to bring about muru hë (restoration and healing).

Note: This policy is inclusive of all Mäori seeking or requiring assistance from a health professional (i.e. Ngä wähine hapü (pregnant women.)

Central to the policy is the expectation that all users of health services are treated with dignity and respect. In turn, users of health services are expected to behave respectfully. In exercising the principles of the policy it is anticipated that the awareness and confidence of the health workforce will be raised and in doing so staff will demonstrate consideration of wider cultural needs and expectations.

Tikanga Recommended Best Practice offers choice to the community about how health care is delivered. The document outlines processes for all staff to follow that are integral to best practice and will assist in the delivery of quality health services within the ADHB.

Associated documents

The table below indicates other documents associated with this procedure.

Type

Document Title(s)

Board Policy Manual

• Bicultural Policy
• Ärahi Whänaungätanga Policy
• Body Parts – Surgical Procedures
• Body Parts - Autopsy
• Deceased Tüpäpaku – Adult Care of
• Deceased person – Release of
• Death Reported to the Coroner
• Informed Consent
• Research – Application & Approval Process
• Code of Rights
• Significant Events Policy

Policy & Procedure Manuals

Placentas/Whenua

Deceased Persons/Tupapaku Transport

National Womens’ Policy & Procedure Manual

Location Manuals

Tikanga Recommended Best Practice Community Child Health and Disability Service

Reference

Hauora o te Tinana me öna Tikanga: a guide for the removal, retention, return and disposal of Mäori body parts, organ donation and post-mortem: Mäori and their whänau (1999). Te Puni Kokiri

Hauora o te Tinana me öna Tikanga: a guide for the removal, retention, return and disposal of Mäori body parts, organ donation: Service providers (1999). Te Puni Kokiri

Body Parts, Tissue, & Substances Review Panel Report (Hollings).

• At all times tängata mäuiui and whänau will be verbally offered (from early in the care process) the choice of having karakia. In particular this needs to be offered before and after surgery.

• Staff will make arrangements for the chaplain to attend if required. This will be offered to all tängata mäuiui and whänau.
• Staff will support the need for karakia at all times during tängata mäuiui care.
• Staff will offer and support karakia in a variety of heightened situations e.g. psychotic incidents. This may involve discussion with whänau and/or appropriate Mäori staff.
• Time will be allowed for karakia.

• Karakia will not be interrupted unless the physical care of tängata mäuiui is compromised.
• If karakia cannot occur due to extreme circumstances, staff will explain the reasons in a sensitive manner and discuss alternative options.
• Access to appropriate water and containers will be made available for the purpose of spiritual cleansing.

(family & extended family)

• Tängata mäuiui and whänau will be actively encouraged, included and supported by staff to be involved in all aspects of care and decision making. This includes care plans, discharge planning and multi disciplinary team meetings. A copy of the care plan may be shared with the tangata mäuiui and whänau.
• Staff will ask whänau and/or tängata mäuiui if they wish to nominate a person to speak on behalf of the whänau.
• Staff will acknowledge and actively involve the nominated person.
• In agreement with tängata mäuiui and whänau, staff will include the appropriate Mäori staff e.g. kaiatawhai in the care and decision making process.
• A private room and adequate time will be allocated for whänau consultation and decision making throughout the care of tängata mäuiui.
• Staff will consult with whänau regarding suitable meeting times and needs.

• Flexibility will be given to visiting times and visitor numbers where possible.
• Staff will give serious consideration to a whänau member requesting to stay overnight with the tangata mäuiui.
• Staff will give serious consideration to whänau who ask to be present during a surgical procedure. Health and Safety and Infection Control considerations will be explained in this situation.
• Staff will be especially supportive of whänau visiting when death is expected and/or imminent.
• Where appropriate, staff will support and encourage whänau to bring food and share meals with the tangata mäuiui. Particular food may be requested by the tangata mäuiui. It is important that staff support whänau in this and especially when death is expected and/or imminent.

• During all initial encounters, staff will introduce themselves and explain their role and service to the tangata mäuiui and whänau.

• When obtaining registration details, staff will accept that the Mäori concept of "next of kin" may be broadly interpreted.
• Where appropriate, staff will ensure that tängata mäuiui are offered an interpreter.
• Staff will ensure that the tangata mäuiui and whänau are aware of the ADHB Accommodation Services, preferably prior to admission and make referrals when requested.
• Staff will notify the appropriate Mäori staff (i.e. kaiatawhai) of tängata mäuiui in their care as soon as possible e.g. on admission/referral.
• Staff will inform the tangata mäuiui and whänau of internal and external resources e.g. Internal: Kaiatawhai, whänau rooms and dedicated spaces to support whänau wellbeing. External: Mäori providers, primary providers, support services and relevant agencies outside of the health sector.
• Services will maintain a current list of contacts to assist tängata mäuiui and their whänau e.g. Mäori chaplains.

• Staff will offer the choice of having the chaplain attend. Staff will make the arrangements if this is requested.
• Information will be delivered clearly and in terms the tangata mäuiui and whänau understand.

• Staff will ensure the tangata mäuiui and whänau understand the information given.
• Information will be provided in more than one way where possible e.g. spoken and written, Mäori and English.
• Staff will inform tängata mäuiui and whänau of the advocacy service provided by the Health Advocates Trust.
• If a health advocate is required, staff will make the arrangements unless stated otherwise by tängata mäuiui and whänau.
• Staff will provide verbal and written information and support regarding complaints procedures.

• Staff will ask tängata mäuiui and whänau if they have any special cultural, spiritual, language or other needs.
• These needs will be documented in the relevant notes e.g. treatment plan, needs assessment, clinical file. Staff will actively seek to ensure they are met.

• Staff will respect and support the importance and use of rongoa (Mäori methods of healing) during tängata mäuiui care.
• Staff will be prepared to negotiate, document and work collaboratively with Mäori healers, tängata mäuiui and whänau regarding the use of rongoa.

• Staff will ensure they attempt to pronounce Mäori names correctly and ask when unsure.
• Staff will endeavour to use the preferred name of the tangata mäuiui.

• A simple request and explanation will be given and consent obtained from tängata mäuiui and/or whänau before touching tängata mäuiui anywhere on the body and especially on the head.

• Food will never be passed over the head.

• Fridges/freezers used to store food or medication for human consumption will be clearly identified and not used for any other purpose.
• Microwaves used for food will not be used for heating anything that has come into contact with the body.
• Tea towels will only be used for the purpose of drying dishes.
• Tea towels will be washed separately from all other soiled linen.
• Anything that comes into contact with the body or body fluids must be kept separate from food e.g. combs or brushes should not be placed on surfaces where food is placed.
• Receptacles used for drinking water will be solely used for this purpose.
• Staff will not sit on tables or workbenches and particularly on surfaces used for food or medication.

Taonga/ Valuables-

• Only remove taonga (valuables/heirlooms) if leaving them on places tängata mäuiui at risk; wherever possible taonga will be taped to their person.
• If risk is involved, consent will be obtained from the tangata mäuiui or whänau before removing taonga.
• Tängata mäuiui and whänau will have the option of removing taonga.

• Whänau will have the option of caring for taonga.

• If whänau are not caring for the taonga, it will be kept in the identified valuables safe, where provided.
• Tängata mäuiui and whänau will be informed of the risk of storing taonga.

Bedpans/ Urinals

• Bedpans/urinals and food will never be present at the same time.

• Excreta and food will always be kept separate. Excreta will not be placed on surfaces where food is placed e.g. bedpans/urinals will not be placed on surfaces used for food trays.

• Bedpans/urinals will not be placed on bedside lockers or nightingales.

• Always place bedpans/urinals on the equipment used for this purpose.
• Always store bedpans/urinals in the designated area.

Linen

• Different coloured pillowcases will be used to differentiate pillows for the head and those used for other parts of the body.

• Pillowcases will not be used for any other purpose.

• Staff will support whänau if they bring their own pillowcases.

• Where possible different coloured pillows will be used to differentiate pillows for the head and those used for other parts of the body.

• Different flannels will be used for the washing of the head and body. Where possible use different coloured flannels to differentiate. Washing will follow a strict order starting from the neck to genital and then anal area.

These are areas observing tikanga Mäori.This includes both current and future areas permanently governed by Mäori protocols e.g. Mäori Accommodation Services, Marae.

• Tikanga governs.
• Mäori protocols are followed.

These are areas used on occasion for a Mäori specific purpose. This includes rooms that are not permanently governed by Mäori tikanga and protocols except on specific occasions.

• Tikanga governs and Mäori protocols are followed e.g. pöwhiri.
• All areas used in the care of Tüpäpaku e.g. Whänau/Family Rooms, Tühono Tahi (Whänau/family waiting areas close to critical care) Wä Märie (Bereavement Room) will follow the Tikanga Recommended Best Practice outlining the procedures for Tüpäpaku (Deceased Person).

Whänau/Family Rooms are designated rooms located on the ward. All Whänau/Family Rooms are governed by tikanga principles and protocols. This room supports the needs of whänau/family of tängata mäuiui on the ward. The Whänau/Family Room is available to all tängata mäuiui, staff, and whänau/families regardless of ethnicity.

• Tüpäpaku and whänau caring for the Tüpäpaku must be awarded first priority.

• Whänau caring for tängata mäuiui throughout the process of dying.

• When the Whänau/Family Room is occupied by Tüpäpaku, staff will ensure that the Tikanga Recommended Best Practice outlining the procedures for Tüpäpaku are followed.

Further Requirements

Whänau/Family Rooms will be guided by the following:

• Everyday use of the Whänau/Family Rooms will be determined by consultation between ward staff and appropriate Mäori staff e.g. kaiatawhai.

• Staff will negotiate with whänau the use of the space for other meeting purposes.

(also refer to Board Policy Manual)

• The Treaty of Waitangi principles of partnership, participation and protection will be actively addressed and undertaken in good faith. This will occur from the outset of the project i.e. from the negotiating and formulation of the research to the final outcome.

• Researchers must address how the research will benefit Mäori, including how information will be shared with Mäori.

• Before research is initiated, consent may be required from iwi groups, particularly if the research may potentially breach tikanga or involve sensitive issues. This is over and above individual consent.

• Some issues may also require consent from iwi and/or hapu especially where ownership may belong to collective stakeholders.

• Informed consent (written and verbal) must be sought from Mäori participants and/or whänau involved in the research. This includes requests for body parts/tissue and/or substances (including genetic material) to be collected for research purposes.

• Return, retention or disposal procedures will be discussed and agreed to by participants. This will be documented.

• Time will be allowed for consultation and decisions to be reached.

• Confidentiality will be maintained, in particular where individuals may be identifiable.

(Note: this includes whenua/placenta and genetic material)

Guiding Principle:

Regardless of how minor the part/tissue or substance is perceived to be by staff, the following process will be followed. All discussions will be non-directive and follow an informed process.

• Staff will talk with the tangata mäuiui and/or whänau giving a true and clear verbal explanation regarding the full procedure and options as early as possible.

• Staff will offer the option of further support from the appropriate Mäori staff e.g. kaiatawhai. Where possible this must happen prior to any intervention.
• Staff will offer the option of karakia and make the arrangements if required.

• Staff will give a clear verbal and written explanation to the tangata mäuiui and/or whänau regarding the interpretation of the terms body parts, human tissue and substances.
• The removal, retention, return or disposal of body parts/tissue/substances will follow ADHB policy and written information will be made available to whänau and/or tängata mäuiui where applicable.
• Staff will ensure that the tangata mäuiui and/or whänau have the correct information to make an informed choice. This is especially critical when staff request body parts/tissue be retained and/or examined.
• Staff will consult with the tangata mäuiui and/or whänau regarding their intentions for removal, retention, return or disposal.

• The process used to discuss this will be done in a sensitive, non-judgmental and consultative way.

• Time will be allowed for the tangata mäuiui and/or whänau to consult and reach a decision unless immediate physical care is severely compromised e.g. urgent amputation.

• Explicit consent must be obtained (in writing) for the removal of body parts and tissue.
• Explicit consent must be obtained for the retention of body parts.
• Informed acceptance must be obtained for the retention of tissue.

• Where retention is consented to, the purpose for retention will also be agreed to through an informed consent process i.e. for the purpose of education and teaching. This will be documented.

• Future use will only be the original purpose as agreed to by tängata mäuiui and/or whänau.
• In most cases informed acceptance will be obtained (verbally) for the collection, retention, return and or disposal of substances e.g. blood.

• Staff will respect all decisions made by the tangata mäuiui and/or whänau.
• Staff will document all discussions and decisions in the clinical notes, using the appropriate documentation.

• Staff will ensure all body parts/tissue and substances are correctly labelled and documented. This is especially crucial if returns are requested.

• All body parts/tissue/substances will be returned when requested if this does not involve a high risk to safety.

• Staff will ensure any special requests regarding the retention, return or disposal of body parts/tissue/substances are documented and monitored.

• Where body parts/tissue/substances are not immediately returned, they will be retained for a reasonable time to allow for the tangata mäuiui and/or whänau to consent to a process for return, retention or disposal. Flexibility will be allowed.

• Staff will make every attempt to ensure body parts/tissue and substances are returned quickly.

• Staff will inform the tangata mäuiui and/or whänau of any necessary safety precautions regarding the handling and disposal of the returned body parts/tissue/substances.

• The return of body parts/tissue/substances will be carried out in a way that is consistent with tikanga and in consultation with appropriate Mäori staff.

• Body parts/tissue/substances will be returned in containers that are durable and reflect tikanga practices. This will be determined in consultation with appropriate Mäori staff.
• Staff will record and carry out the wishes of the tangata mäuiui and/or whänau for the return or disposal of body parts/tissue/substances if the original purpose for retention changes e.g. later found unsuitable for use. Returns will follow tikanga practices and protocols determined in consultation with Mäori staff.

Contd.

• The return of unconsented body parts/tissue/substances will follow existing protocols and be governed by tikanga practices and protocols. If return or retention is not requested, staff will discuss and agree to disposal and/or burial of the body parts/tissue/substances with the tangata mäuiui and/or whänau. This will be carried out in a considered and consultative manner that respects tikanga processes.
• An honest explanation will be given as to how and where disposal and/or burial is carried out.
• The process described will then be carried out in a respectful manner.
• All body parts/tissue/substances will be stored or retained in accordance with tikanga practices and handled respectfully at all times.

Miscellaneous

• Staff will offer the return of all hair, fingernails and toenails. This will be documented in the clinical notes.

• These will be saved in a patient labelled snap closure plastic bag and returned to the tangata mäuiui and/or whänau.

Organ & Tissue Donation (Live donor or Tüpäpaku – Deceased person donor)

• Body parts and/or tissue will never be removed for donation without informed consent.
• Discussion will occur as early as is reasonable and carried out in a sensitive and non-judgmental way.
• Staff will offer the option of further support from the appropriate Mäori staff e.g. kaiatawhai.

• Staff will talk with the tangata mäuiui and/or whänau giving a true and clear verbal and written explanation regarding the full procedure and options.
• Staff will ensure that the tangata mäuiui and/or whänau are fully informed on all aspects of the donation process in order to make an informed choice and where agreed give informed consent.
• Staff will respect and comply with the decisions made by the tangata mäuiui and/or whänau.
• Staff will offer the choice of having karakia prior to and/or following any intervention.
• Staff will offer to make the arrangements if required.
• Staff will ensure tängata mäuiui and/or whänau are aware and agree to the possibility that certain body parts and/or tissue may be stored for use in the future. (Future use will only be the original purpose as agreed to by tängata mäuiui and/or whänau.)
• Staff will record and carry out the wishes of the tangata mäuiui and/or whänau for return or disposal if the original purpose for retention changes e.g. return or disposal
• All body parts and/or tissue will be offered for return if unused or unsuitable e.g. when a heart valve is used, the surrounding heart tissue will be offered for return.
• All returns will follow the Tikanga Recommended Best Practice (see previous section).
• Staff will document all discussions and decisions.
• Tüpäpaku procedures will follow the Tikanga Recommended Best Practice under Tüpäpaku (Deceased Person).

Pending Death

• Where possible, whänau will have the choice of taking their terminally ill relative home.
• Where death is expected imminently, whänau will be notified immediately.
• Where death is expected imminently, support staff involved in the care of the tangata mäuiui will be notified immediately e.g. kaiatawhai.
• Staff will make every attempt to ensure a single room is available.
• Staff will make every attempt to allow whänau to be present at all times.

• Staff will facilitate access to appropriate staff e.g. chaplain and facilities (Chapel).

• If there is the potential for involvement from the coroner, whänau will be informed at the earliest opportunity.
• If there is the potential of a post mortem request, whänau will be consulted immediately.

• When death occurs the whänau will be notified immediately.
• Support staff involved in the care of the tangata mäuiui will be notified immediately e.g. kaiatawhai.
• Whänau will be offered access to a phone to make arrangements.

• Staff will be guided by whänau on the cultural and spiritual practices for them at this time.

• Where possible, whänau will have the choice of either taking the Tüpäpaku home or contacting a funeral director.

• A single, private room will be allocated for the Tüpäpaku and grieving whänau at the earliest opportunity.

• Whänau will be offered the choice of washing and dressing the Tüpäpaku.

• Staff will allow time for whänau to grieve before moving the Tüpäpaku. Whänau will determine the time needed in liaison with staff.

• Food and drink will not be taken into the room.

• Staff will make every attempt to ensure a speedy release of the Tüpäpaku.

• Before the Tüpäpaku is removed and in particular before a post mortem, whänau will be given the opportunity and time to exercise their beliefs and practices.

Movement of Tüpäpaku

• The wishes of the whänau will always be respected as to how the Tüpäpaku is moved.

• The Tüpäpaku will always be wrapped in the allocated sheets. Everyday linen must not be used.
• Whänau will be able to accompany the Tüpäpaku when moved.

• Staff will always handle the Tüpäpaku in a sensitive and respectful manner.

• The Tüpäpaku will always be transported feet first.
• Transportation of Tüpäpaku will be conducted discreetly.

• All services will have a pre determined "pathway" for Tüpäpaku.
• Staff will ensure all linen, food cupboards, inpatient and staff pantry and toilet doors are closed during the moving of Tüpäpaku.
• The movement of Tüpäpaku through public areas will be avoided wherever possible. If not, staff will use the shortest route, avoiding food and waste areas. This will be carried out in an efficient, respectful and dignified manner.

• Staff will ensure that the designated lifts are used.

Following Removal of Tüpäpaku

• Karakia will be performed in the room/area as soon as the Tüpäpaku is removed.

• The room will not be physically cleaned until karakia has occurred.

• When a post mortem is required by the coroner, or requested by staff a true explanation will be given to whänau.

• At all times staff will continually update and inform whänau. This will be done as soon as possible so whänau are prepared and informed.
• Staff will respect the privacy of whänau during discussions.
• A quiet, private area will be allocated to whänau.
• Support staff will be notified as soon as possible e.g. kaiatawhai.

• The removal or cutting of Tüpäpaku hair is to be avoided unless absolutely necessary to any post mortem. Whänau will be notified of this prior to the procedure and offered the option of retaining the hair.
• Staff will make every attempt to ensure a speedy release of the Tüpäpaku.

• If a non-coronial post mortem is requested, staff will ensure whänau have the correct information to make an informed choice and if agreed, give informed and written consent.
• Time will be allowed for the tangata mäuiui and/or whänau to consult and reach a decision.
• The retention of body parts/tissue/substances must follow the Tikanga Recommended Best Practice outlined in Removal, Retention and Return or Disposal of Body Parts/Tissue and Substances and related Board policy.

• Discussion with whänau will also include information on the use of photography. Informed consent for this must be obtained.
• All procedures will be discussed in a sensitive, non-judgmental non-directive and consultative way.
• Staff will document all discussions and decisions in the clinical notes and appropriate documentation.

• All body parts and/or tissue will be returned as soon as possible and follow the Tikanga Recommended Best Practice outlining their return.
• All consents will be clearly documented. A record of parts/tissue retained will be kept.

• In coronial cases staff will offer whänau the choice of having an iwi constable. If requested, staff will advise police that the whanau are Mäori and require an iwi liaison officer.

• Whänau will be informed that they can stay with the Tüpäpaku when moved to the mortuary for a post mortem.
• Whänau will be informed that there are rooms in the mortuary where they can wait during the post mortem.

• In coronial cases staff must ensure that whänau have access to information regarding the autopsy procedures, it is for the coroner's office to ensure this information is provided. When body parts and/or tissue are required for further analysis in determining death it is the responsibility of the pathologist to ensure that appropriate liaison and/or consultation with the family/whänau occurs.
• Informed consent will be obtained for any procedures other than those needed to establish cause of death.
• Body parts, tissue and/or substances will only be taken if needed to determine the cause of death.

• Return, retention or disposal will follow the Tikanga Recommended Best Practice outlined in Removal, Retention and Return of Body Parts/Tissue and Substances and related Board policy.

• Retention of body parts and/or tissue from post mortems beyond the agreed and/or required examination time will not be retained unless written and verbal informed consent has been obtained.
• All consents will be clearly documented. A record of parts/tissue retained will be kept.
• All body parts and/or tissue will be returned as soon as possible and will follow the Tikanga Recommended Best Practice outlining their return.

Principles

The following principles are linked to Mäori wellbeing and must be respected as part of the healing process.

Term

Description

Mana

Spiritual power and authority to enhance and restore tapu. Health Services must empower tängata mäuiui and their whänau. In doing so the service’s own mana is enhanced.

Tapu

• Physical, psychological, emotional, spiritual and cultural well being.
• Dignity and sacredness.
• Restrictions and prohibitions that protect tapu (well being, dignity and sacredness) from violation.

Noa

• In the negative sense, it is the state of diminished tapu, of weakness and powerlessness resulting from violation.

• In the positive sense, it is the state of freedom of mind and spirit that comes about through being acknowledged, enhanced, restored and healed.

Hara

A sin of violation, a transgression.

Hë

An act of wrongdoing.

Muru hara

To restore tapu by addressing and repairing violation.

Muru hë

To restore and heal a wrong.

Definitions

Hapü

Sub tribe of a large tribe.

Pregnancy.

Hinengaro

Psychological.

Iwi

A nation or people with a shared identity and genealogy/tribe.

Kai

Food.

Kaiatawhai

Designated Mäori staff who focus on the spiritual and cultural needs of tängata mäuiui and their whänau.

Karakia

Blessings /incantation/ prayer.

Kaupapa

Policy, protocols.

Marae

Place of Mäori practice. Often comprising of a carved meeting house, marae ätea (sacred space in front of the meeting house), dining room and ablution facilities.

Pöwhiri

Mäori process of welcoming.

Rongoa

Mäori methods of healing including mirimiri (massage), te reo (language), karakia and herbal remedies.

Tängata Mäuiui

Consumers/ clients/ patients. Person seeking or requiring assistance from a health professional.

Taonga

Treasure, valuables.

Issues of principle/integrity of intent. Values and respect. Processes.

Tinana

Physical body.

Tühono Tahi

An area close to critical care for whänau/family to wait.

Tüpäpaku

Deceased person.

Wairua

Spiritual element. Wairua is an integral part of tapu and noa that is inextricably linked to wellbeing.

Wä Märie

Bereavement Room.

Whänau:

Family, including extended family group.

Whänau: Kärangarangatanga Tängata.

Relationships are intrinsically linked and connected through whänau, hapu and iwi. Whänau extends beyond the concept of the "family unit", "nuclear family" or "biological family".

Whenua

Placenta. Afterbirth. Land.