Ask a Simple Question: Four Model Programs Help American Indians Plan for End of Life

By Baldridge, Dave | Aging Today, November/December 2011 | Go to article overview

Ask a Simple Question: Four Model Programs Help American Indians Plan for End of Life


Baldridge, Dave, Aging Today


When the end is near, most of us don't cope with it very well. Both medical and social end-of-life decisions rank among life's most painful and stressful for patients and loved ones. And these important decisions often are made under the worst circumstances: in hospital corridors, in late-night conversations or during urgent phone calls with relatives.

Researchers estimate that only 20 to 30 percent of Americans have stipulated advance directives. Usually these are completed by those with terminal illness or by individuals from high socioeconomic classes. Even then, physician compliance with advance directives is poor.

Low-income minorities may have even less access to end-of-life assistance. In a 2005 study sponsored by the Mayo Clinic, nearly half of American Indian tribal health directors reported that end-of-life services were available only outside the community, or not at all. Sixty percent reported inadequate access to end-of-life care.

Fort Defiance Model Yields Dramatic Results

According to a recent report for the Centers for Disease Control and Prevention (CDC) by Health Benefits ABCs (www. agingopportunities.com/EOL%20 AI-AN%20%20CIB%201-20-2011.pdf), America's healthcare and social services professionals may need to re-examine their assumptions about American Indian and Alaska Native (AI/AN) elders' end-of-life beliefs. This groundbreaking report found that for decades, popular opinion and researchers may have incorrectly assumed that American Indian elders-especially those from traditional belief systems-would not openly discuss death and dying. Such assumptions haven't changed for years, but Native beliefs and culture are not static.

Project staff visited four end-of-life programs serving AI/ANs-in each case finding unexpected, remarkable results. The most dramatic was in the heart of Navajo Nation, at a Fort Defiance, Ariz., program serving one of the nation's most traditional elder cohorts. At the Fort Defiance Indian Hospital, the Home-Based Care Program now exceeds national rates of advance directive completion by nearly 300 percent.

"We've completed more than 800 comprehensive elder evaluations over the past five years," said Tim Domer, M.D., former director of the 11-year-old program. "When we began, 4 percent of our patients agreed to complete durable medical powers of attorney; 1 percent agreed to other advance directives. By 2009-2010, those numbers were 89 percent and 85 percent."

The program is based on several models, including PACE (Program for All-inclusive Care of the Elderly), Medicare Hospice Benefit and Care Transitions, and features post-hospitalization visits by nurses and social workers to reduce hospital re-admissions. The program's team members are invested in the community, fluent in Navajo, and express their commitment to patients through the many aspects of long-term care, not just in end-of-life situations.

"It's all about language and timing," Domer says. "Unless one asks a person what they think or want, one will never know."

Successful Models in Oklahoma, New Mexico

Visits also were made to three other successful American Indian programs.

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