 There was a patient transferred to our hospital who had been cared for at another hospital and the report we got was that he had end-stage cancer, prostate cancer I think, that there was no more curative treatment than that he was essentially coming back for palliative care. I wanted to make sure that I communicated information in the right way for this family. So I actually asked the eldest son to come out with me or he stepped out with me and I asked him how much his father knew and he said really my father doesn't know anything about what's going on. So they didn't talk to him about that at all. We probably need to have some kind of conversation and you can help me talk about the best way to do this for him so that he knows how to prepare for what's coming. And he said oh well he's already doing that. In fact right now he's talking about what to do with his things. He's giving his sheep to one family member and his truck to another. And I realize this is about indirect communication. It's honest communication but it's indirect communication. So he knew without it having to be said what was going on. What was important is that the important things were happening. We just needed to understand, to listen and to follow that communication. Bruce you've seen different models that people are trying to develop to meet individual culture needs. There's not one Indian culture. Lakota is going to be different than Navajo is going to be different than my tribe of Choctaw. So to be able to communicate and have cultural brokers who help you understand what those imperatives are within the culture can do it right. Because even here on Navajo it's going to be different. It's not one size fits all but there is a skill set that we all need to have and we need to have a comfort level with addressing the issues. If what we're really trying to do in our clumsy way is say to a person an elder or an elder in their family or a person with their family we really want to take good care of you. We need to know what we need to know to take good care of you. And I know I'm going to say this the wrong way. Forgive me but here's what we need to know. They can tell very quickly where you're coming from and you can say things that if a Navajo said it to them they would be entirely offended. But they understand that we also don't necessarily know the culture but they care very deeply about whether or not we care. People always talk about it when they say taboo often is their lack of education. We're finding a lot of the elderly. It's okay to talk about because it's my condition. I need to know. I need to know about this so that I know what to do next. I have found over the 25 years that I've been out here on the reservation that a lot of the truisms that you hear, well you don't do this, you don't do that, that's a taboo, you don't do this. Well to a certain extent there's some truth to that but you never know with the individual that you have in front of you that you're talking how they feel about any of these things. And the only way you can find out is to ask them. And I have never had a problem in a conversation when I've asked them to explain to me what their feelings are on this. I've never gotten the sense that they were offended and I've asked patients later, did that offend you? Now occasionally there may be some non-traditional family members who found this to be particularly true that aren't perhaps as versed in the more traditional ways that they immediately say, oh that's taboo. They really aren't educated in their own culture. Palliative care represents a model of patient-centered, person-centered care that is really what we want to be able to provide in a whole range of care. But palliative care, it all comes together. Even though it can be difficult to provide this kind of care it can be difficult to figure out how to cross the communication barriers and how to pull everyone together into the team. There's a knowledge base that folks need to have a handle on. All of those are not excuses and we can't take a buy on this. We can't say it's too hard, we can't do this. It's the standard of care and we have to be creative. We have to use the resources that we have to the best of our ability and we're possible to identify new resources and then build. And the whole center is the patient making a decision for themselves. Patients saying, I want to be cared this way. I want to be cared at home, not in a hospital. I would prefer to die at home, not in a hospital. There are so many things that we can offer patients for symptom management and as you say, making the most of each day with the emphasis on living and doing the right thing for the patient to help them feel as well as possible. And many of the cultural concepts from traditional Indian medicine with utilizing all the spiritual gifts and all the support systems that are there within the community from traditional healers to social workers to regular ministers within the community. All the strengths that are there in the community to help the patient can be brought together into the team approach. So yeah, we're doing the walk the talk now at Fort to make sure that it works, you know. And how it works is talking to one another as a team, interdisciplinary team. The most acculturated will prefer to die in the hospital. But the most traditional will say, you know, let me die at home. But you know that whole concept about decision making, giving them the right to make a decision for themselves and how they want to die, that's like taking the traditional concept, that's how it was before. You know, revisiting the old philosophy, the values, the morals that they had before, that we're reintegrating that back into this approach of care. It is actually more traditional because it doesn't separate into treating disease, treating the body instead of treating the whole person, the spiritual, the emotional, the social context. It covers all of it. The part that you begin to value is that you're helping the individual as they define the die the way they want to. You're giving them that right and you're giving them that choice and you're supporting that and total respect about their decision. We talk a lot about respect for elders and that's a fundamental aspect of respect, is sort of knowing that we're honoring their wishes. That's a key piece. And respect for culture. And that may not be the choices you would make, but it's important that it meet what the patient's goals are. That's right. The EPIC-O for the Indian Health System is an opportunity to address the unique cultural aspects of palliative care in the Indian country. And that's why the cultural curriculum was so important. I really felt that it was essential because what we're talking about is trying to improve overall care of patients at the end of life. And if you don't include the cultural components, you're not doing right by the patient or the family. The one thing I think that with the EPIC-O curriculum, it's very adaptable. And I think that as we go forward with this in the IHS, a lot of those slides are going to be, they're not going to look exactly the way they do right now. We know that for program development, it's going to be driven by the local culture and the local needs. Hopefully, the EPIC-O for Indian Health Curriculum can be adapted over time, too, to the local needs. And ideally, it would change. It would be different when it's presented on Navajo than when it's presented in Minnesota. It might look a little bit different depending on what the community is. The reason that you train people from all the areas is to have them one look at sort of a core curriculum and then to be able to say, that really would make sense for us and especially to be able to offer to patients and families the concept that it's not that there's nothing more we can do. It's that there are lots of things that we can do to help you through this experience. I was taken care of this 76-year-old gentleman who had in-stage esophageal cancer. He had a distal esophageal lesion and he had a pig tube that had been placed. He was doing pretty well at home. He was fairly independent but he was losing a lot of weight and he wound up being put in the nursing home for the winter, which often happens. I mean, a lot of people, as I said, they'd live in houses with no running water and electricity and so he went to the nursing home. So I got to know him quite well. He spoke almost no English at all and he was losing a lot of weight. I met a family member who had come up from Phoenix to visit him and I used that opportunity to sit down and ask both of them what their understanding was of his condition and where things are potentially going. He and I had talked a couple of times and he understood that this was going to be the end, that he was going to die from this, but he didn't dwell on it. He was actually quite active in the nursing home. With the granddaughter there, I said, ask Joe what are the things that he wants to get done in the time that he has left and so I was thinking more in terms of are there family members that he wants to meet or should we have a family gathering, etc. So she talked to Joe in Navajo and she said that he says he wants to go see Mickey Mouse and I almost fell off my chair. I mean, this is a very traditional man. He had heard it sheep all his life and I said, well, explain that to me. He said, no, he wants to go see Mickey Mouse. He said that he sees it on TV and the children talk about it and he says he wants to go see Mickey Mouse and I said, so you would like him to go to California to Disney World? Is that what you're saying? Yes. And so I said, well, I think that we might be able to work this out so your family get together with your extended family and you can also tell them this is something you can do for Joe and you set up the date and the time that you're going to be going and I will work to make sure that Joe is going to survive this trip and it all worked out and I have his picture next to my desk at Disneyland. With Mickey. Well, Mickey's actually not in this particular picture because there were so many family members there that Mickey didn't fit but he absolutely met Mickey, shook hands, hugged Minnie in a million years. I never would have guessed this but if I didn't ask and it never would have happened if I hadn't asked and this is not the only time that something like that has happened I mean that really taught me just ask, don't go over with any assumptions because you never know.