Wednesday, March 19, 2008

DNE (Do not evacuate)

He sits in the waiting room with a portable oxygen tank in front of him, laughing with the friends he happens to have met today at the health centre, and telling stories to the children between their games of tag. He knows everyone in the health centre, he knows how they are related and where they came from, where their parents hunted and when they finally moved off of the land and into town. There is a wheel chair ramp to the health centre, but he came up the stairs, paused on each one for as long as he needed before moving along. I watched him come up the stairs, grasping the rail firmly, pursed lip breathing. Many people walked by him on the stairs. Everyone stopped to say hello, to shake hands, no one insisted to help him in his walk. I ask if he can come into the office to talk. He smiles, takes off his oxygen and walks along with me. I try to bring the portable tank and he laughs and shoo's me off, "interpreter" he says, and I hustle to find one.

In the office I ask what brings him into the health centre today.
He pauses, thinks about it, and answers in Inuktitut to the interpreter for some time. The interpreter relays the message: 'He wants you to know he is a strong man, he does not complain, but since you are asking he is feeling weaker than he should. He says he would like to go out hunting if that is possible. He says sometimes his breathing is hard, and when it is bad his wife is scared."
Do the medicines help?
'Not as much as before."
I ask him what he thinks the problem is.
Through the interpreter he tells me it is old age, his body is not young anymore, he wants to go hunting but his body does not listen. Before I can respond he asks me in english "Did white people cure old age yet?" and then laughs with both his eyes and his voice.

My own agenda for the visit is to discuss his wishes around extent of treatment and end of life care. The patient in front of me has end stage COPD and it seems an important thing to clarify. In hospitals this is framed as a DNR discussion, but here it is much more. It is a discussion about values, beliefs, and a cultural divide that at times seems as vast as the arctic itself. The current group of Inuit elders are the last Inuit people who were mainly born and grew up living on the land (that is; living a traditional nomadic lifestyle centered around hunting and survival). They are pragmatists, and when asked if they wish any particular medical intervention the usual response is 'yes, if that is what you think needs to be done'. When I first arrived in the north I had a few DNR discussions in the usual southern style, and they didn't go too well. Like they had talked about in medical school I asked the patients if their heart were to stop would they like us to try to restart it, even though the chance of success was small given their particular condition. They would look at me quizzically and through the interpreter say 'Of course he wants that, if he would die or live he wants to live. Now he wants to not talk about that anymore!'. It took me a few go-rounds to catch onto the fact that I was having the wrong conversation.

It is incorrect to think that because the Inuit people were nomadic that there was no attachment to place. Most groups travelled specific routes, returning to specific areas regularly. Place also meant (and still means) people, and small groups would meet at these specific places of intersection. Today Inuit elders are often much attached to the place they live, and often more importantly to the people there. In their own community they have a history, they are not a sick or frail elderly person, but strong hunter who is now getting old. They have a reference point other than their current physical health that is known to all those around them. It is no wonder that they might wish to remain here.

I get ready to have the conversation and frame it in the way that seems most relevant to the patient sitting in front of me. If you were to get very sick would you ever wish to go to Ottawa for treatment?
The answer is fast. 'He has already thought about this. He has been to Ottawa before and has no wish to go back.'
He understands that this means that we would not be able to do things like put in a breathing tube or do CPR because patients who survive that always have to go to Ottawa?
'He understands.'
Would he be willing to go to Iqaluit if he were sick, even if that would mean there was a chance he would die there?
This time the conversation between patient and interpreter is longer. Iqaluit is closer and more familiar but still not home.
'He would be willing to go for appointments if he could have oxygen on the plane, but he would not wish to go if there was a chance he would die there.'
That would mean he wouldn't go on the medevac plane?
'That's right, he doesn't want to be medevac'd. If he dies he wants to die here.'
Does he want treatment of his illnesses here in the community?
Again the answer is fast. 'He wants anything that will help as long as he can stay here.'

I tinker with his meds, maybe optimize them a bit, hopefully reduce some of the terrifying night-time dyspnea that is bothering him. I summarize our visit and make a DNE notation on the front of the chart. Do Not Evacuate. It is more complicated than DNR, but more meaningful too.

Through the interpreter he tells me he saw me fishing last summer and wonders if I caught anything. I tell him I didn't. He laughs, pats my shoulder and tells me to find him next summer and he will show me the right way to get a fish. He says thank you for my time and slowly walks back to his seat in the waiting room. It is still empty for him even though the room is very busy. He greets the people who have arrived while he has been in the office, puts his oxygen back on and rests for a while before walking home.

The patient presented in this account is fictional in the sense that the story is not about one single individual. It is true in the sense that it is an encounter and experience I have had dozens of times, with dozens of Inuit elders. They are pragmatic and realistic. They rarely believe themselves to be immortal, as the majority of people in North America seem to. They are reserved, but have a subtle humorous streak, and can laugh with their eyes. They are people who have been culturally transplanted, not by geography but by history and circumstance, and have keen insight into what is important to them. Usually what's important is what's close to home.


Martina said...

Fantastic post. My favourite so far.


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kiffren said...

I have been lurking here since your 2nd or 3rd post (attempted to comment one other time, but alas it was lost in cyberspace).

Just wanted to say great post!

Trudie said...

Wonderful post!

KOTN said...

Another great post in a great series of postings. Keep it up, I learn something every time I read here.

Xavier Emmanuelle said...

Great post. I was completely captivated.

Ian Furst said...

94 blogs on my RSS feeder and that is by far the most powerful post i have read in weeks. Very well explained.

Midwife with a Knife said...

Wow. What a way to practice cultural literacy.

Zippy said...

Wow, Aaron! What a powerful piece! Very're really very insightful. You give so much to your patients, but I love that you also learn so much from them.

Madame X said...

DNE! That's brilliant! Are the docs doing that everywhere in Baffin or is it something you've started? If it's your own thing, sell the other docs on it before you leave (or better yet, stay!), and make sure it gets clearly marked on the charts of the chronic elders, and isn't locked in a cupboard in the NIC office. It's a wonderful idea, all the health centres should do it. I've never seen it on a chart yet (I'm a transient nurse.)

Liana said...

I'll echo the wows, and raise you an "Amazing!".

Lovely post. I really enjoyed it.


Jennith said...

Thank you for sharing such an insightful and touching window into the world that is the north and its people.


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