FORT DEFIANCE, Arizona ¡ª In the culture of the Navajo Indian, talking about death is thought to bring it about, so it is not discussed. A dead person¡¯s name is never spoken.

So it is up to Mitzie Begay, a Navajo who is the cross-cultural coordinator for the home-based care program at the Fort Defiance Indian Hospital, to find ways to teach people about things like living wills, durable powers of attorney, do-not-resuscitate orders, feeding tubes and ventilators. In spite of the taboos, Ms. Begay and her colleagues are trying to find a comfortable way to begin a conversation with patients and their families about death and dying.

Dr. Timothy Domer, a geriatrician who was the program¡¯s director until December, said that his patients had a different perspective from many other people. When Dr. Domer started the program five years ago, he reviewed hospital records to see how many charts contained advance directives - instructions that patients have given about their care should they become incapacitated. ¡°There were none - zero,¡± he said.

¡°Our goal is not just to change the way people die,¡± he said, ¡°but to change the way dying people live, and how their families experience and will remember the death.¡±

Ms. Begay, the new director, said that at first she was not comfortable about end-of-life discussions. But she and her staff came up with a novel approach: a poem. ¡°When that time comes, when my last breath leaves me, I choose to die in peace to meet Shi¡¯ dy¡¯ in¡± - the creator. It serves to open a discussion about living wills and advance directives.

Dr. Domer says almost 90 percent of patients in the program have signed the poem and other standard directives. ¡°Our elders tell us they want to die with dignity - the way they lived,¡± he said.

¡°We¡¯ve changed how patients live their final days by opening the discussion on death and dying, and giving patients and families the opportunity to tell us what is important to them.¡±

When someone dies in the family hogan, for example, a hole is made in the north wall to let the good spirit out, and then the hogan is abandoned.

¡°I¡¯ve seen my share of dying patients, particularly elderly patients who spoke only Navajo, whose families brought them to the hospital to die,¡± Dr. Domer said. ¡°One of the reasons they came to the hospital was that if they died in the hogan, the rest of the family would have to leave .¡±

James S. Taylor, a bioethicist , has written about Navajo views of endof- life care. He said the poem gives people the opportunity to discuss endof- life planning impersonally. ¡°It¡¯s a compassionate approach, and it¡¯s in accord with the twin values that Navajos share with mainstream American culture ? individual autonomy and personal dignity.¡±

Ms. Begay and a colleague, Gina Nez, recently visited Jimmy Begay (no relation). In World War II, Mr. Begay, 87, was one of the Navajo ¡°code talkers¡± whose radio transmissions were never deciphered by the Japanese. Mr. Begay has signed the poem and the advance directives, and so has Mitzie Begay.

¡°Traditionally, it¡¯s our belief to always have a positive attitude,¡± even when someone is dying, said Ms. Begay. ¡°After a patient dies, you don¡¯t hang on, because the deceased is no longer on Mother Earth. You wash up, take your corn pollen and go on with life.¡±


By BEN DAITZ, M.D.