4/11/2016
1
Considerations in Caring for Native American Peoples at
End of LifeBridget B. Stiegler, D.O.
Palliative Medicine, Northern Arizona Healthcare
Flagstaff Medical Center, Flagstaff Arizona
Board Certified Internal Medicine, Palliative Medicine, Hospice
• No financial or professional disclosures.
4/11/2016
2
Agenda
• A Look at “Culture”• Native American Tribes in Arizona• Core Concepts of Traditional Indian Medicine• Respectful Generalizations• Geographic/Regional/Tribal Considerations• Acknowledging the Cultural Gap• Western Medicine : Interface : Traditional Medicine• Afterlife : Interface : Life
• Throughout: Images of thriving Native American neighbors
Culture
• A group’s learned, repetitive, characteristic way of behaving, feeling, thinking and being. A strong determinant in attitudes towards health, illness, dying.
• Learned: through observation/witnessing, written and verbal story telling, direct teaching… “This is our way”
• Repetitive: recognized patterns over time, subconscious development of habits
• Characteristic: defines and identifies…without which one is an outlier
• Attitudes: Malleability, room for difference/variation
4/11/2016
3
Miss Navajo Nation Contestants 2015
Navajopeople.org
Native American Tribes In Arizona
4/11/2016
4
Native American Tribes in Arizona
AI and AN Population by State
4/11/2016
5
Native American Tribes in Arizona
• ?? Indian tribes and nations are located on ??% of Arizona land, comprising nearly ?? of all American Indians in the United States.
Native American Tribes in Arizona
• 21 Indian tribes and nations are located on 26% of Arizona land, comprising nearly 1/8 of all American Indians in the United States.
4/11/2016
6
Native American Tribes in Arizona
• Ak-Chin Indian Community
• Camp Verde Yavapai-Apache Tribe
• Cocopah Tribe
• Colorado River Indian Tribes (CRIT)
• Fort McDowell Mohave-Apache Indian Community
• Fort Mojave Indian Tribe
• Fort Yuma-Quechan Tribe
• Gila River Indian Community
• Havasupai Tribe
• Hopi Tribe
• Hualapai Tribe
• Kaibab Paiute Tribe
• Navajo Nation
• Pascua Yaqui Tribe
• Salt River Pima-Maricopa Indian Community
• San Carlos Apache Tribe
• San Juan Southern Paiute
• Tohono O’odham Nation
• Tonto Apache Tribe
• White Mountain Apache Tribe
• Yavapai-Prescott Indian Tribe
Inter-Tribal Council of Arizona(ITCA)
• ITCA Non-Profit Organization• 2214 N. Central Ave, Phoenix AZ 85004• Health, Environment, Learning, Culture, Community
• Tribal Affairs• Tribal relations• Organizational relations• Government relations• Cultural relations
4/11/2016
7
Inter-Tribal Council of Arizona (ITCA)
• Elected representatives of each tribe• How should we focus our attention?
• Core Concepts of Traditional Indian Medicine
• Respectful Generalizations
• Geographic/Regional Considerations
The Hopi Tutuveni Newspaper
The Hopi Tribe Official Website
4/11/2016
8
Core Concepts of Traditional Indian Medicine
Core Concepts of Traditional Indian Medicine
• Belief in a Supreme Creator• Creator vs. “God” • Interact with Creator through Nature; animals, seasons
• Spirituality• Traditional vs. Western Influence (Christian, LDS) – groups that had
missionary presence in early America
• Mind <> Body <> Spirit• Illness affects mind and spirit, not just body
• *Family may not trust person with the disease to make decisions• Others may perceive that illness is a spiritual sickness (wrongdoing)
• Spirit exists before and after death• There is room for crossover/interaction – this is not always
desired!
4/11/2016
9
Core Concepts of Traditional Indian Medicine
• Wellness = Harmony/Balance
• Unwellness = Disharmony• Family members may hesitate to disagree or voice opinions as
disharmony can make sickness worse (Hopi)
• Taboo• Speaking of impending death, speaking name of deceased• May be more prominent in younger/modern generations (!)
• Personal Responsibility for Health• Blame
Core Concepts of Traditional Indian Medicine: Circle of Life
4/11/2016
10
Core Concepts of Traditional Indian Medicine: Medicine Wheel
Tohono O’Odham: Toka Women’s League
4/11/2016
11
Respectful Generalizations
Respectful Generalizations
• Value listening over speaking. Demonstrating respect for this practice is the single best way to align and gain trust.
• ASK their understanding of the situation. “What have you heard is happening with your father’s health?”
• ASK for their interpretation of WHY this is happening “What is your sense as to why this has happened?”
• ASK how they would like to receive information, “Would you like for me to speak using details or would you like for me to speak in general terms, outlines?”
• ASK for permission to discuss the scenario “Is it ok for me to tell you my understanding of what is happening now?”
4/11/2016
12
Geographic/Regional Considerations
Geographic/Regional Considerations
• Navajo Nation in northeast makes up largest proportion of Native Americans in Arizona, followed by the Tohono O’Odham Nation, in southern AZ.
• Hopi and Apache are similar in population. Supai are quite isolated in the Havasupai Canyon region, and are likely to be cared for if practicing in Northern Arizona.
• Flagstaff versus Phoenix versus Tucson
4/11/2016
13
Navajo
-300,460 tribe members 2015 – Dine’
-Utah, AZ, New Mexico
-Code Talkers, WWII
-Hogan
Navajo
-Passed through 3 different worlds before emerging on this 4th world “Glittering World”. Two classes of people, Earth People and Holy People.
-Holy People have power to aid or harm Earth People.
-Purpose; to maintain harmony on Mother Earth.
4/11/2016
14
Hopi
• “Hopitu” meaning “Peaceful people”.
• To be Hopi is to strive towards a standard of ethics that is unachievable in this lifetime due to human limitations.
• Matrilineal clans: Children from marriage join the woman’s clan.
• When a provider requests a “family meeting”, often only females will attend.
Hopi
• Skilled farmers
• Mesas – flat topped hills
• Pueblos
• Kachina art
4/11/2016
15
Tohono O’Odham
• “Desert People”
• Kitt Peak – sacred mountain, “Navel of the World”
• Opening they emerged from after the world flood
• Significant relationship with the stars/astronomy
Tohono O’Odham
• Basket weaving
• Images with “emergence”
4/11/2016
16
Acknowledging the Gap
Acknowledging the Gap
• Helpful for native people to acknowledge the differences in verbal and/or body language – sign of respect
• “I may say this in the wrong way, forgive me if I use the wrong words…”
• “I want to know what is important in taking care of your loved one…”
4/11/2016
17
Western Medicine : Interface : Traditional Medicine
Western Medicine : Interface : Traditional Medicine
• Surrogacy• May not recognize AZ State Surrogacy Law
• Navajo Nation: decision making priority falls to birth family, not spouse. Even a spouse of 20+ years will defer to patient’s birth family for end of life decisions.
• “Cousinbrothers”, “Auntmothers”, adopted children • Family Representative, Family Spokesperson
• Story Telling• Do NOT value efficiency• Very offended by being “rushed”• Time orientation through story telling
• Assert time boundaries; “We have one hour”
4/11/2016
18
Western Medicine : Interface : Traditional Medicine
• Planning• “We will have two meetings”• “We may have difficult decisions to make. We will not make
decisions today, but we will discuss them and then come back together”
• Anticipate the need for family to return to reservation for ceremony/conference with elders
• Inclusion of/Collaboration with Traditional Healers• Invite, welcome early• Problem: Family will wait until “Western” doctors have
exhausted all options, and then ask to include medicine man when concern exists for futility of care.
• Foster resentment
Afterlife : Interface : Life
4/11/2016
19
Afterlife : Interface : Life
• Manifestation Concept• Very sensitive connection to ancestors – ancestors can access
them (good and bad)• Seeing deceased relatives near time of death• “Dementia = Dimension”, straddle life and death• May NOT want to be present (Navajo)• May NOT want to die in the home (Navajo)• Disposition challenges at end of life
• Extremely limited resources – hospice, ALTCS, SNF, symptom management teams
• Thank you!
