Queen's Medical Center in downtown Honolulu is Hawai'i's largest acute care hospital. - Image courtesy Queen's Medical Center

Queen's offers special Rx for Hawaiian heart problems

See also: Television special to mark 150 years

By Liza Simon / Ka Wai Ola Loa

Lomi lomi massage, ti-leaf poultices, and plenty of wala'au with 'ohana are nothing new in Hawaiian culture but they are now gaining new acceptance in treating Native Hawaiians admitted to Queen's Medical Center in Honolulu with congestive heart failure, a disabling and potentially deadly condition.

Queen's is offering Hawaiians a project in so-called "integrative cardiac care" to improve heart health by combining approaches that address the physical as well as spiritual and emotional needs of the patient. Reflexology, aromatherapy, and Hawaiian healing practices are combined with surgery and medication. But the real elixir in making this mixed plate effective may be the caregiver's ability to relate to the patient.

"We already know from statistics that Native Hawaiians will be more likely to smoke and have weight problems that aggravate heart disease, but it's not enough to give them a pamphlet on smoking cessation and tell them to stop eating too much salt. If you want to change behavior, you are sensitive to a person's culture. This helps to build trust in any relationship," said Diane Paloma of Queen's Native Hawaiian Health (NHH) program, which coordinates the integrative cardiac care for Kānaka Maoli.

Paloma said that members of the Queen's Medical Center board of directors want to eventually extend the NHH program beyond cardiac care to other lines of service, including oncology and obesity, to reduce the "terrible disparities" in health affecting Native Hawaiians.

"Overall, the goal is to make sure that Native Hawaiians are on par with the rest of the population," said Paloma. "The state has an active population that skews average rates of disease, but if you separate out Native Hawaiians, the figures are alarmingly low."

As Queen's celebrates its 150th anniversary, Paloma points out a striking irony: Referring to namesake hospital founder Queen Emma, she said Queen's was founded to "bring western medicine to natives to end their suffering from western diseases. But now we've come full circle," she said, pointing out that congestive failure and other chronic diseases are associated with a western lifestyle of processed food, lack of exercise and increased stress and are being addressed with Hawaiian values through the Queen's integrative cardiac care project.

Because cardiac care is a major strength of Queen's services, the NHH program selected it in 2006 as a starting point for the integrative medicine approach, Paloma said.

Queen's has received many awards for excellence in helping heart patients.
Hawai'i's largest acute care hospital, Queen's has one of the fastest rates in the nation for getting victims of congestive heart failure through the ER and into surgery to remove life-threatening blood vessel blockages, said Dr. Gerard Akaka, the chief medical director at Queen's.

But fast does not always equal good in medicine, Akaka stressed. "Research has shown that 17 seconds is the average time spent listening to a patient in the exam room. This is not enough. We have to sit down with the patient, attune to who they are, consider how they view their disease and what it might mean to other members of the family."

Akaka said the gold standard for integrative cardiac care is for Hawaiians to use caregivers from the Hawaiian environment. "They will know the little things that make a difference."

Like the impact of graduation time on heart symptoms, as Akaka notes: "Each year after parties are pau, plenty Hawaiian patients come in saying they don't feel well. I say, 'what you expect if you slamming the lomi salmon with plenty salt?' But I cannot just say to them, deny yourself spam and eggs for the rest of your life, because in our culture, food is a celebration. If we like mālama our health, we have to be sure that our caregivers can understand patients as they would their own family members," said Akaka, also the notably Kanaka-sounding and soft-spoken son of U.S. Congressman Daniel Akaka.

Under the NHH program, two nurse practitioners have the kuleana of designing individualized recovery plans for Native Hawaiians hospitalized in Queen's for congestive heart failure. A big part of their job is to follow Akaka's lead in talking patients into making important lifestyle changes by simply spending time "talking story." Often this helps patients reveal small things that could become big health problems, had they kept silent: A lack of transportation to the drugstore for medication refills, confusion about diet and exercise instructions, and so on. The list of "small things with big import" is long because recovery from heart failure involves a long list of self-care measures, said Akaka.

Previous assessments by the medical center have indicated Native Hawaiians frequently don't follow self-care recommendations after discharge. A major gauge of this is their disproportionately high rate of hospital readmission, adding to alarm over the grim findings on Hawaiian health disparities.

But recent studies offer something promising. Readmission rates for Native Hawaiians suffering from congestive heart failure are down at the Queen's ER, Paloma said.

Akaka said he hopes this speaks well for the NHH integrative cardiac care project, which is at the end of a three-year commitment of resources from the Queen's Medical Center board of directors. Akaka said it was far-sighted and unusual in today's cost-conscious healthcare industry for this project to go forward, since Queen's virtually offers it to patients free of charge. Nonetheless, the project needs to demonstrate effectiveness in order to justify a continued commitment of resources from the hospital, he said.

The justification could come from national support for so-called cultural competency in medicine. The federal Office of Minority Health has said that appreciation and understanding of cultural differences between groups is an essential component of quality healthcare.

Meanwhile, the hospital accreditation agency known as the Joint Commission has been developing standards for cultural competency, which are a factor in deciding whether or not a healthcare institution is eligible to receive Medicaid or Medicare reimbursement.

A clash of culture exists between technological or evidence-based Western medicine and spiritual or communal indigenous healing practices has become more widely recognized with the advent of cultural competency as a healthcare buzzword. Nevertheless, Paloma reflects on the historic effort to bridge the schism, when Queen Emma and King Kamehameha IV opened the first Queen's hospital 150 years ago in Honolulu to stop the spread of contagious European diseases that would eventually reduce Hawai'i's indigenous population to a minority.

"This hospital was founded for natives suffering from Western diseases. The ali'i felt they should have Western medicine. Now, as much as we always defer to Western medicine, the whole concept of tradition is alive again. While Queen's is here for everyone, I think the idea of the Native Hawaiian Health Program is to be true to our heritage, so we are coming full circle," Paloma said.