Module:

INDIGENOUS PERSPECTIVES ON DEATH AND DYING
Detailed Case Scenario
Mrs. Susan Nahdee is a 78-year-old traditional Ojibway woman living in a small community 30 km from a regional hospital. She has a history of non-insulin dependent diabetes and coronary artery disease. She speaks little English and is always accompanied by her daughter each time she visits you. She presented 2 days ago to your small community’s hospital clinic quite short of breath. Through her daughter she admits to a four-day history of chest pain typical of her usual angina. Your physical exam reveals she was in congestive heart failure. You admitted her and investigations revealed that she likely had an acute myocardial infarction a couple of days ago. Her past history is significant for ischemic heart disease, having had 2 myocardial infarcts in the last 10 years. Her last MI was 3 years ago. She was found to have an 80% stenosis of her LAD and underwent angioplasty. At this time an echocardiogram was done and revealed an EF of 30%. Since her last MI she has had class II angina. Mrs. Nahdee is a widow with 5 children. She speaks Ojibway as her first language. She has lived all her life in the same community with her children. Mrs. Nahdee is a survivor of residential schools. She follows traditional Ojibway teachings and sees a traditional healer in addition to you. Her medications at the time of admission are metoprolol 150 mg bid; lasix 80 mg tid and Nitropatch 0.8 mg on qAM off QHS. She is also on some traditional medications but you are not sure what she is exactly taking. Her daughter tells you that the reason for her not coming to see you sooner is that she went to see the Healer first and hoped he would be able to make her feel better… You have been her family physician for 6 months. In this time, you feel that she is reticent in discussing her health with you. You only discovered that she was seeing a Healer after much probing. You were not happy about this since you were concerned about potential serious adverse effects and drug interactions with the regimen you prescribed. You tried to discourage her from taking these traditional medicines and from seeing the Healer however you were unsuccessful. While in hospital, she continues to worsen---it is difficult to diurese her and she remains quite dyspneic on lasix 250mg IV bid and metolazone 10 mg po bid. She develops more chest pain and becomes hemodynamically unstable. It is becoming clear to you that Mrs. Nahdee will need to be transported to a larger hospital and, if she does not start to diurese soon, she will need to be placed on dialysis and possibly life support. Unfortunately, it is winter and the roads are snow covered and very icy.
You pull Mrs. Nahdee’s daughter aside and start to tell her that her mother is having
another heart attack and that you feel she needs to be moved to another hospital. She
will likely need life support and you are not sure if she will survive….
Mrs. Nahdee’s daughter listens to you. Not once does she look at you. When you ask
her want she “wants to do”, you are met with silence. Thinking that she either is in shock
or maybe did not understand you restart the explanations somewhat impatiently since
time is running out and a decision must be made SOON….
Physical Exam

Unable to lie flat, she is sitting in bed. Her respiratory rate is 36 breaths/minute on 50%
O2, HR 125 irregular and BP 90/45. She is in obvious respiratory distress and can
speak in 3 word sentences only. She is somewhat confused. She has inspiratory
crackles throughout.
Teaching Tips:
1. Begin with a recap of outstanding issues from the last session 2. Distribute the case scenario. Allow the participants a couple of minutes to read the information or have one of the participants read the scenario 3. Ask the participants to identify issues. Write these on a flip chart. 4. The participants need to identify a number of topics for discussion including: ! How do her traditional beliefs affect her care? ! How does her culture affect communication and decision-making? ! What factors are important to consider beyond a person’s culture? ! How do your own beliefs, culture, values, and previous experiences as a clinician affect the care options you discuss with your patients? ! How does the style in which you communicate affect your approach to decision- making? What assumptions do you tend to make when approaching decision-making with patients and families? ! How have your previous experiences caring for someone from a different cultural background – e.g. an indigenous background – affected how you approach communicating and decision-making around end-of-life issues with Mrs. Nahdee? ! How do your own beliefs about death and dying affect your decision-making and the care you provide for people at the end of life? ! What is the role of traditional Healers in end-of-life care? How does the involvement of a Healer affect the care you provide? What do you think of the role of alternative medicine in care at the end of life? ! How do your beliefs about traditional healers influence the care you provide? TIP: Ask participants about their experiences in caring for Indigenous people in
the past? Did their Indigenous patients follow traditional practices? What role
did traditional beliefs play in their patient’s lives? How did they respect these
beliefs?
5. Ask participants how Mrs. Nahdee’s daughter’s cultural background may be affecting her discussions with the physician ! What are your beliefs regarding family centered care vs. patient centered? How do these beliefs impact on the care you provide? ! How would you approach decision-making with Mrs. Nahdee and her daughter? ! What role would her experience in residential schools play in her relationships ! How does the language barrier affect her ability to communicate and understand information in order to provide informed consent? How does it affect the way you convey information? ! How has your hospital accommodated needs for translation? TIP: Ask participants to reflect on how their own personal values and beliefs
affect their decision-making? What role has cultural differences played in their
previous encounters with patients and families?

Case Continued
Mrs. Nahdee’s daughter tells you she has to meet with the Chief and her brothers and sister in order to reach a decision. While she leaves to discuss things with them you wait, growing more and more impatient…. Finally, you are told the family is ready to meet with you. You enter the waiting room to find 40 people present. The Chief tells you that Mrs. Nahdee would not want to be transported to the large hospital; she would rather be cared for in her community, surrounded by her family. You agree with this decision and inform them you will do your best to keep her comfortable. The family asks if they can have the Healer see her and if they can perform their traditional ceremonies to ease her dying. You agree and leave the room. When you inform her nurse, she says:” What did you tell them? Do you know what you just agreed to????”
Directions for Facilitators

1. What role does the family play in decision-making in traditional indigenous culture?
2. What are your beliefs regarding family centered care vs. patient centered? How do these beliefs impact on the care you provide? On your ability to facilitate decision-making with your patients? 3. Ask participants to discuss the traditional indigenous ceremonies around death and 4. Ask participants how they would respond to the nurse’s concerns. TIP: It may be useful to role-play the discussion they would have with
Mrs. Nahdee’s nurse.
5. Ask participants how they accommodated indigenous traditions around death and TIP: Ask them if they have encountered situations in which traditional Indigenous
beliefs and practices have lead to conflict. How did they resolve these issues?
6. How has your hospital or community accommodated indigenous patient’s spiritual 7. What hospital support services are missing that would help you do a better job in meeting the needs of indigenous patients? 8. Ask participants to develop a strategy to accommodate indigenous traditions around

Source: http://www.cme.utoronto.ca/endoflife/Cases%20and%20Teaching%20Tips/Indigenous%20Perspectives%20Case%20and%20Teaching%20Tips.pdf