FORT DEFIANCE, Arizona — 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.