Clinical Scenario

L.C. is a 60-year-old Orthodox Jewish man who presented to the ED with complaints of fever and severe RUQ pain x2 days. The pain is radiating to his R shoulder. The pt says that in preparation for Yom Kippur, which will be beginning today at sundown, he has been eating a lot over the past two days. Just prior to coming into the hospital he ate a large meal despite not being so hungry which exacerbated the pain. He does admit to feeling a similar cramp like sensation in the RUQ over the past few months but the pain usually goes away after a few minutes. This time, he says that since the pain began it has not subsided despite use of ibuprofen. The pain is 10/10 in severity. He has associated nausea, non-bloody, non-bilious vomiting and loss of appetite. On exam in the ED, the patient has a HR of 105 and temperature of 100.9 F. A positive murphy sign was noted with gallbladder wall thickening and gallstones seen on ultrasound. 

Based on the clinical picture, vitals and exam findings, the patient is diagnosed with acute cholecystitis with sepsis. Surgery was consulted based on the diagnosis. The surgeon recommends immediate intervention to prevent further complications. When the patient heard the recommendation, he was reluctant due to the fact that it is the eve of Yom Kippur, the holiest day in the Jewish calendar. He expresses concern about undergoing surgery on a holiday of such religious significance and wants to discuss the situation with his rabbi before proceeding.

Cultural Factors

• Yom Kippur observance: Yom Kippur is a day of fasting and deep religious observance. Many Orthodox Jews refrain from any form of work, including medical treatments, unless it is absolutely necessary to preserve life.
• Consultation with religious authority: Decision making in Judaism is largely guided by rabbinical figures. This is especially true with more complex decisions including whether certain medical procedures should be done. In this instance, L.C. may feel it is necessary to consult with his rabbi to confirm whether undergoing surgery on Yom Kippur is permissible.
• Religious restrictions: On Yom Kippur, Orthodox Jews refrain from certain activities, such as eating, drinking, using electricity, and writing or signing documents. This may create additional concerns around surgery preparations (ex. signing consent) or recovery (ex. eating to help with recovery).
• Emotional and spiritual significance of the holiday: Yom Kippur is deeply personal and emotionally significant, as it involves introspection and repentance. Undergoing surgery on this day may carry additional emotional weight for the patient, being that he wasn’t able to do what is expected of the day.

Unique beliefs/considerations

As a medical provider, there are some unique considerations to take into account when dealing with Orthodox Jewish patients. The first, most important one is the idea of Pikuach Nefesh (preservation of life). Jewish law highlights the importance of life and ensuring the preservation of life above all else. Therefore, in the situation of undergoing a procedure on Yom Kippur, if the procedure is required in order to save a life, then it would be permitted. In clear cut cases, such as a trauma coming in requiring immediate life-saving surgery, then that would be done without a question. When it comes to slightly more obscure cases the patient may be unsure if the procedure would fall under the category of necessary due to Pikuach Nefesh and would likely want to consult with their rabbi. Rabbis are more proficient with the intricacies of Jewish law and the protocol in different situations. In these cases, medical professionals and rabbis come together to discuss the necessity of the procedure. Understanding the role that rabbis play in medical decision making is vital as a medical professional. Many rabbis have a broad understanding of medicine and explaining why a procedure is required in order to preserve life (in this case to prevent rupture or septic shock) will help them guide the patient following medical guidelines and their religion. Additonal consideration must be placed on the fact that it would be a fast day. This could possibly affect healing and strength after surgery. Whether the patient should fast or not would be guided by both medical professionals and a rabbi.

Areas of potential conflict

Some conflicts may come up when dealing with this patient. One of those is that initially the patient may refuse surgery, even though delaying it could lead to serious complications. Medical professionals want to help patients and heal them. Therefore, the urgency of surgery from their point of view should be held above all else. This conflicts with the point of view of the patient who holds his religion and holiday to a very high standard. Eventually, the patient may understand the severity of the situation and want to consult his rabbi. This introduces a third party to the decision making, which generally adds more dimension and possibly more tension to the conversation. Additionally, it may be difficult to get in touch with the rabbi especially because it is nearing the start of the holiday. This may lead to further delays in treatment. 

Expected Skills

• Cultural sensitivity in discussing medical urgency: When explaining the seriousness of L.C.’s condition, his religious beliefs should be respected, emphasizing the principle of “Pikuach Nefesh” and the need for timely intervention.
• Respect for religious consultation: L.C.’s desire to consult with his rabbi should be supported.  Help facilitating communication should be provided, if necessary, while also emphasizing the importance of making a timely decision. Providers should acknowledge availability to speak directly to the rabbi with the patient’s consent. 
• Flexibility and problem-solving: Any preoperative concerns related to fasting and hydration should be considered, offering alternatives where possible to respect the patient’s religious practices. Additionally, the fact that the patient cannot write should be respected with other options for consent being offered, such as signing consent before sundown, even if the surgery won’t be done until the next day. 
• Empathy and reassurance: Emotional support should be provided, recognizing the spiritual significance of Yom Kippur for L.C., and showing empathy for the conflict between his religious obligations and medical needs. Consider phrases like, “I understand this is a challenging time for you, especially with Yom Kippur approaching. However, addressing your health today is essential for your well-being. Let’s discuss how we can make this process as respectful of your beliefs as possible.”

Patient Education and Counseling

• Explain what acute cholecystitis is, emphasizing that it is an inflammation of the gallbladder often due to gallstones blocking the cystic duct.
• Discuss the potential complications of untreated cholecystitis, such as perforation or worsening infection, to stress the importance of timely intervention.
• Educate the patient on the necessity of undergoing surgery (laparoscopic cholecystectomy) within the recommended time frame (24 to 72 hours) to avoid complications.
• Encourage the patient to consult their rabbi to address any religious concerns and ensure their comfort with the decision to proceed with surgery.
• Discuss how the medical team will accommodate the patient’s fasting requirements as much as possible while ensuring safe surgical preparation (e.g., timing of last intake, clear fluids, etc.).
• Outline what to expect after the surgery, including:
  • Typical recovery time and activities to avoid.
  • Pain management strategies.
  • Signs of complications (e.g., excessive pain, fever, jaundice) that should prompt immediate medical attention.
• Discuss the importance of follow-up appointments for monitoring recovery and any necessary lifestyle modifications post-surgery.
• Acknowledge the significance of Yom Kippur and offer flexibility in scheduling follow-up visits, if possible, to accommodate their observance.
• Be open to discussing any other cultural or religious practices that may be important to the patient during their care.
• Recognize that undergoing surgery, especially close to a significant religious holiday, can be stressful. Offer reassurance and address any fears or concerns about the surgery, recovery, and the impact on their religious practices.