Understanding death and dying in select first nations communities in northern Manitoba: issues of culture and remote service delivery in palliative care.

OBJECTIVES: The purpose of this study was to delineate and describe the local palliative care services available to residents of remote Aboriginal communities in northern Manitoba; to identify attitudes and beliefs about death, dying and palliative care in these communities; and to explore obstacles related to palliative care service delivery from the perspectives of culture and geographic isolation. STUDY DESIGN: Forty-four in-depth semi-structured interviews were conducted with a reputational sample of key informants including Aboriginal people resident in remote communities, community elders and religious leaders, doctors, nurses and allied health care providers working in First Nations Communities, as well as specialist service providers in Winnipeg. Thematic qualitative analysis was done on the data collected. Data collected from interviews with northern physicians and nurses was coded and analyzed. RESULTS: Currently, many Aboriginal people living in remote communities are transported to large urban centers to die, isolated from friends, family and their culture. However, the majority of Aboriginal people and health care providers interviewed reported that Aboriginal people living in remote communities would prefer to die at home. The issues surrounding palliative care provision in remote Aboriginal communities are cultural and geographic. Culturally sensitive care requires that patients have access to family supports and traditional services if requested. Geographic isolation requires that: 1. patient-specific care plans be created for use in the remote community; 2. effective lines of communication are established between remote health care providers and urban specialists; 3. health care providers and family care-givers be properly trained to fill their respective roles; and 4. appropriate guidelines and resources be available in the community to support this type of care. CONCLUSIONS: Providing the equipment, supports and education necessary for home-based palliative care in remote Aboriginal communities can be an effective way of addressing the medical, psycho-social, and spiritual needs of these patients.

Mortality in the Kivalliq Region of Nunavut, 1987-1996.

INTRODUCTION: The Kivalliq region of Nunavut, Canada, had a 1996 population of 7,131, of which 87% were Inuit. An attempt was made to characterize patterns of mortality in the region. STUDY DESIGN: Descriptive regional mortality study, based on 10-year retrospective review of health records data. METHODS: All deaths and stillbirths of Kivalliq residents during the study period were identified. Available health records data were reviewed for each death, including medical charts, death certificates and coroner's reports where applicable. Age-standardized mortality rates, both overall and cause-specific, were calculated and compared to both Canadian national rates and territorial rates from the same time period. RESULTS: The infant mortality rate was 32.3/1,000 live births, five times Canada's rate. Leading causes of infant deaths were prematurity and Sudden Infant Death Syndrome (SIDS). The overall mortality rate was 1.8 times that of Canada, with leading causes of death being cancers (especially lung cancer), circulatory disease, respiratory disease, unintentional injury and suicide. CONCLUSIONS: Identified areas of concern included mortality due to premature birth, SIDS, unintentional injuries, suicides, respiratory disease and lung cancer. It is hoped that this study's results will assist territorial leaders, health workers and citizens in health planning activities.

Quantification of emphysema: a composite physiologic index derived from CT estimation of disease extent.

The combination of functional indices best reflecting the extent of emphysema is not known. High-resolution computed tomography (HRCT) studies of 106 patients with emphysema [men=71; median age=61 (range=26-86 years)] were reviewed and the extent of emphysema was quantified: (a) visually (emphysema(vis)) and (b) by automated estimation (emphysema(auto)). Functional-morphologic relationships were compared for the two scoring systems, and a composite physiologic index (CPI) (providing the best fit of functional indices against emphysema extent) was derived. Emphysema(vis) and emphysema(auto) were strongly correlated (r=0.90; p<0.0005), but the extent of emphysema(vis) was consistently greater (p<0.00005). Emphysema(vis) correlated most strongly with indices of gas transfer [percent predicted single-breath carbon monoxide diffusing capacity (Dl(co)) and alveolar volume (K(co)); r=-0.70, both p<0.0005]. The combination of physiologic indices most representative of emphysema extent on CT (using visual or automated methods) consisted of K(co) and forced expiratory volume in 1 s (FEV(1)) levels. The equation explanatory power was higher for visual scoring [emphysema(vis)=96.8-(0.67 x % predicted K(co))-(0.41 x % predicted FEV(1)); equation r(2)=0.57] than automated estimation (equation r(2)=0.48). Weighted combinations of K(co) and FEV(1) levels provide a CPI best reflecting morphologic emphysema extent. CPI has the potential to refine the stratification of patients in epidemiological and therapeutic studies.