This is part of a series on how the diverse and growing city of Brampton, Ont., provides lessons for Canada's future.
In Brampton Civic Hospital, the palliative care unit – where patients go to die – can be the most lively.
There are the sobbing family members, the revolving door of friends who come to pay their respects, and, in this suburban hospital that serves one of the most diverse populations in Canada, plenty of religious rituals.
A Buddhist family can chant for hours on end as a loved one is dying. A Hindu priest sometimes applies holy ash to a patient's forehead, and places a sacred tulsi leaf into his mouth moments before his final breath. And instead of taking the dead straight to the morgue, as is standard practice, funeral home staff might bring a gurney right to the room to take a deceased Sikh for a prompt cremation.
In Brampton, two-thirds of the population are visible minorities (38 per cent are South Asian), which means dealing with issues of religious or cultural accommodation doesn't just happen on an ad-hoc basis. Brampton Civic Hospital has a staff of four people who look after diversity issues. As Canada's visible-minority population grows, fuelled in large part by the federal government's immigration targets of about 250,000 newcomers a year, diversity departments could soon be the norm at hospitals across the country.
And a good thing too: Making accommodations for patients isn't just enlightened customer service – it can translate into superior health outcomes. Data collected at Toronto's University Health Network and the University of Massachusetts suggest language barriers contribute to longer hospital stays and higher rates of readmission, two key measures of hospital performance.
While hospitals in even the most remote communities typically have access to some form of interpretation services – even if just by phone – that's where diversity services begin and end. Not so at Brampton Civic.
At the maze-like hospital, one of two under the William Osler Health System umbrella, Gurwinder Gill has learned which elevator will get her from the food services department to the palliative ward fastest; which hallways to take from her office to a workshop on language policy offered to security staff. As the hospital's first diversity director (though now her title has evolved to director of equity), she has her hands in nearly every department.
Five years ago, when she started at William Osler, Ms. Gill had to point out to her colleagues how hostile the multifaith worship room was to followers of non-Christian faiths visiting or working at the hospital.
"People were feeling, 'I don't feel comfortable going in because I don't feel my faith is reflected in there,'" Ms. Gill said. "It took a lot for this tiny space to be more inclusive."
At her suggestion, the chairs in the room were rearranged to make space for Sikhs to sit on the ground to pray. The hospital added a sink and privacy screen for Muslims to perform ablutions; the two lonesome holy books at the front altar were joined by four others to represent the world's top six religions.
Whereas immigrants typically settled in largest numbers in Toronto, Montreal and Vancouver, now they're spreading in record numbers to suburban centres such as Brampton and Western cities such as Calgary and Edmonton, says Bob Gardner, the director of policy at the Wellesley Institute, a non-profit that researches public health. He sees Brampton Civic, along with several Toronto hospitals, as leaders in the field, but calls on their counterparts to play catchup.
"If you're any size of city and you're not considering diversity as you're doing your hospital care planning and strategic planning, that's inadequate in this day and age," he said.
In Ms. Gill's line of work, small acts of accommodation, the kind that aren't taught in medical school, can make a huge difference in improving a patient's experience.
As Ms. Gill knows all too well: In 1996, she learned that her mother, who had been on dialysis for kidney problems, was hospitalized in England. When she flew over to visit, she was struck by how helpless her Punjabi-speaking, shalwar-kameeze-wearing mother felt in that environment.
"She'd be praying, and at that time diversity in hospitals wasn't quite accepted," Ms. Gill said. "She just felt awkward doing that and the nurses not understanding what she's doing or why she's doing it."
After her flight back home was delayed, Ms. Gill stopped by the hospital one last time to see her mother on what turned out to be the final visit.
"She said, 'It's a good thing you're back because I need to throw up and I don't know how to tell the nurses,'" Ms. Gill recalled, her eyes welling up at the memory. "They were really nice nurses, but it made such a difference having somebody there that could speak the language."
Eleven days later, her mother died. As a result, end-of-life care is one of Ms. Gill's main focuses on the job.
With such a large base of newcomers as patients, some who are transferred to the palliative unit spend their dying days in the company of staff, rather than surrounded by family and friends. One recent afternoon behind the nurses' station on the palliative unit, Ms. Gill and colleague Sairah Ratanshi showcased their fix for the problem: a mobile station with a netbook that allows patients to video chat with family – who might be an ocean away – from their hospital beds.
"Patients are feeling that they don't have family members or have limited supports here. How can they [family] connect when visas can't be granted or they can't afford to come?" Ms. Gill poses to the group. "How great is technology in being able to connect?"
Ms. Gill's department has published guides for front-line hospital staff on Sikhism, Hinduism and Islam – the top three non-Christian religions practised by patients at Brampton Civic, according to data collected during patient registration last year (there is also a guide on Judaism). The guides, which were reviewed by clinical staff internally and religious groups externally, outline basic tenets of each religion and answer some questions that might come up in the hospital.
If a patient has a mental-health issue and has a kirpan (a ceremonial dagger worn by some Sikhs) that might put the patient or others at risk, a nurse could offer "a symbolic/miniature kirpan," which could be a suitable replacement. In keeping with a common religious tradition, the Islamic guide instructs staff to allow family to immediately recite the call to prayer in a Muslim baby's ear as soon as he's born, as long as "there is no required immediate medical attention."
Yet in a morning meeting when Ms. Gill circulates copies of the documents to members of the hospital's diversity advisory council, which is made up of executives as well as clinical and non-clinical staff, she offers a caveat she constantly returns to throughout the day. "I don't like to produce these cheat sheets because we could get into stereotyping," Ms. Gill said. "No matter what guidelines are in place, it's always best to ask the patient."
It's a lesson that's spread through all wards of the hospital. "If I've learned one thing from Gurwinder, it's while we respect diversity, we don't make assumptions about groups," said Paula Chidwick, William Osler's ethicist. "We have to take our direction from individuals."