484. AMISH CASE STUDY Elmer and Mary Miller, both 35 years old, live with their five children in the main house on the family farmstead in one of the largest Amish settlements in Indiana. Aaron and Annie Schlabach, aged 68 and 70, live in the attached grandparents cottage. Mary is the youngest of their eight children, and when she married, she and Elmer moved into the grandparents cottage with the intention that Elmer would take over the farm when Aaron wanted to retire. Eight years ago, they traded living space. Now, Aaron continues to help with the farm work, despite increasing pain in his hip, which the doctor advises should be replaced. Most of Marys and Elmers siblings live in the area, though not in the same church district or settlement. Two of Elmers brothers and their families recently moved to Tennessee, where farms are less expensive and where they are helping to start a new church district. Mary and Elmers fifth child, Melvin, was born 6 weeks prematurely and is 1 month old. Sarah, aged 13, Martin, aged 12, and Wayne, aged 8, attend the Amish elementary school located 1 mile from their home. Lucille, aged 4, is staying with Marys sister and her family for a week because baby Melvin has been having respiratory problems and their physician told the family he will need to be hospitalized if he does not get better within 2 days. At the doctors office, Mary suggested to one nurse, who often talks with Mary about Amish ways, that Menno Martin, an Amish man who gives treatments, may be able to help. He uses warm hands to treat people and is especially good with babies because he can feel what is wrong. The nurse noticed that Mary carefully placed the baby on a pillow as she prepared to leave. Elmer and Mary do not carry any health insurance and are concerned about paying the doctor and hospital bills associated with this complicated pregnancy. In addition, they have an appointment for Wayne to be seen at Riley Childrens Hospital, 3 hours away at the University Medical Center in Indianapolis, for a recurring cyst located behind his left ear. Plans are being made for a driver to take Mary, Elmer, Wayne, Aaron, Annie, and two of Marys sisters to Indianapolis for the appointment. Because it is on the way, they plan to stop in Fort Wayne to see an Amish healer who gives nutritional advice and does treatments. Aaron, Annie, and Elmer have been there before, and the other women are considering having treatments, too. Many Amish and non-Amish go there and tell others how much better they feel after the treatments. They know their medical expenses seem minor in comparison to the family who last week lost their barn in a fire and to the young couple whose 10-year-old child had brain surgery after a fall from the hayloft. Elmer gave money to help with the expenses of the child and will go to the barn raising to help rebuild the barn. Marys sisters will help to cook for the barn raising, but Mary will not help this time because of the need to care for her newborn. The state health department is concerned about the low immunization rates in the Amish communities. One community-health nurse, who works in the area where Elmer and Mary live, has volunteered to talk with Elmer, who is on the Amish school board. The nurse wants to learn how the health department can work more closely with the Amish and also learn more about what the people know about immunizations. The county health commissioner thinks this is a waste of time and that what they need to do is let the Amish know that they are creating a health hazard by neglecting or refusing to have their children immunized. Study Questions 1. Develop three open-ended questions or statements to guide you in your understanding of Mary and Elmer and what health and caring mean to them and to the Amish culture. 2. List four or five areas of perinatal care that you would want to discuss with Mary. 3. Why do you think Mary placed the baby on a pillow as she was leaving the doctors office? 4. If you were the nurse to whom Mrs. Miller confided her interest in taking the baby to the folk healer, what would you do to learn more about their simultaneous use of folk and professional health services? 5. List three items to discuss with the Millers to prepare them for their consultation at the medical center. 6. If you were preparing the reference for consultation, what would you mention about the Millers that would help to promote culturally congruent care at the medical center? 7. Imagine yourself participating in a meeting with state and local health department officials and several local physicians and nurses to develop a plan to increase the immunization rates in the counties with large Amish populations. What would you suggest as ways to accomplish this goal? 8. Discuss two reasons why many Old Order Amish choose not to carry health insurance. 9. Name three health problems with genetic links that are prevalent in some Amish communities. 10. How might health-care providers use the Amish values of the three-generational family and their visiting patterns in promoting health in the Amish community? 11. List three Amish values to consider in prenatal education classes. 12. Develop a nutritional guide for Amish women who are interested in losing weight. Consider Amish values, daily lifestyle, and food production and preparation patterns. 13. List three ways in which Amish express caring. JEWISH CASE STUDY #1 Selecting a typical Jewish client is difficult. An ultra-Orthodox Jew has a particular set of special needs. Yet, it is more common to see a Jew who is a middle-of-the-road Conservative. Sarah is an 80-year-old woman who is a first-generation American. She was raised in a traditional Conservative home. Her husband died after 50 years of a strong marriage. She has three children. Although her home is not kosher, she practices a variation of kosher-style eating, avoiding pork and not making dishes that combine meat and milk. Two months ago, she was diagnosed with pancreatic cancer. Surgery was attempted, but the cancer was already in an advanced stage. Chemotherapy was started, but the cancer has progressed and is not responding to the medications. She is having difficulty eating because of the pressure of the tumor on the gastrointestinal tract. Discussions are being held to determine whether or not treatments should be stopped and whether hospice care should be initiated. Her hospital room is always filled with visitors. Study Questions 1. What must you anticipate in discussing with Sarah her wishes regarding the continuation of medical care? 2. How would you respond to her initial decision to have surgery and initiate chemotherapy? 3. What questions do you need to ask in the initial patient interview to assess her degree of religious practice? How will you determine her spirituality needs? 4. What is your understanding of the reason she has so many visitors in her room? 5. Is hospice care appropriate for this patient? 6. Sarah dies with her family at her bedside. What interventions can you take at the time of death to demonstrate religious sensitivity to the family? What questions do you need to ask the family? 7. Describe three genetic or hereditary diseases common with Ashkenazi Jews. 8. Describe Jewish burial rituals and grieving process. 9. Discuss the laws of Kashrut in regard to food practices for observant Jewish clients. 10. What should the health-care provider keep in mind when entering a Jewish home to provide care? 11. Distinguish between the terms Sephardic and Ashkenazi. 12. How might a non-Jewish and a Jewish coworker share holidays in the workforce? 13. What is the official language the Jewish people use for prayer?