Subsequent Care: Part 3

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After 9 months of twice a week directly observed TB treatment, Mr. Moua slowly improved, although he continued to suffer from COPD. For five years Ms. Friedman, a home health nurse, made routine visits to his home, helping him obtain medicines, oxygen, bath supports, a cane and then a wheelchair, as he became less ambulatory. She came to know him and his family well. She called him “Txiv Ntxawg” or “Father’s Youngest Brother” and he called her, “Daughter”.

She learned when he did traditional Hmong treatments, such as herbal medicines and shaman’s ceremonies, in addition to his breathing medicines. During this time, he slowly lost energy and strength; although he continued to be head of his family, he had less influence over his children and grandchildren. He became depressed at the loss of his vitality: physical, sexually, and social.

Periodically she asked him about whether he was willing to discuss an advanced directive, but he always refused, stating that his shaman helping spirits would take care of him.One day, Ms. Friedman visited him and found him to be dyspneic and tachycardic, although not more hypoxic than usual. He explained, “Two days ago my wheezing returned and my coughing and breathing became worse, so I saw the doctor. She said my X-ray was good, my blood was good, but my “azma” was worse, so she gave me three small white pills again (Prednisone), but I am not any better.”

Ms. Friedman, “Uncle, perhaps you should go back to see the doctor then. Maybe something else is wrong or you need other medicine.”

Mr. Moua, “I could in a few days, if I am not better.”

Ms. Friedman, “What do you think is wrong? Is there anything you’re particularly concerned about?”

Mr. Moua, “This could be a spiritual problem. Tonight my youngest son has arranged for a shaman to do a shaman ceremony for me. Whenever the doctor says that nothing is wrong, then I know a spirit could be bothering me.”

Ms. Friedman, “Is there anything else that makes you think this could be a spirit problem?”

Mr. Moua laughed, “You are always good at asking me questions!! Yes, ever since last month I have been more short of breath. Last month I attended a funeral for my daughter’s husband’s mother, and I stumbled and fell, even though I had my cane. So, perhaps my soul fell and did not rise again, so my soul is gone, and that is making me sick.”

Ms. Friedman, “I am sorry to hear that you fell. I can understand your concern; falling at a funeral is dangerous. May I return tomorrow to see how you’re doing?”

Mr. Moua, “Yes, Daughter, that would be fine.”

The next day, Ms. Friedman found Mr. Moua sitting up in bed, with his oxygen on, focusing on his breathing. She asked, “Uncle, how are you doing? Are you any better? What did the shaman find out?”

Mr. Moua, “It was worse than we thought. Initially the shaman threw the goats’ horns, and found out that the problem was not that my soul had fallen at the funeral, but something else was wrong. So then he shook so that his soul and his helping spirits could travel to the spirit world. They discovered that my dead father wants me to join him in the Land of the Ancestors. Back when I was in the ICU, I had died, and my soul had traveled to the Land of the Ancestors.

“I met my father’s ghost and he had given me a choice: either be reborn as an infant in a new strong healthy body or stay in this world as an old man with a failing body and be a father to my children. I chose the latter, so that is why I survived the ICU. Now my father says he needs me and wants me to join him in the Land of the Ancestors.”

Ms. Friedman, “Oh, dear, that sounds dreadful. What can be done?”

Mr. Moua, “The shaman fought with the spirits and won. He says that I will be better in 7 days, and when I am better, we can do another ceremony to pay my father’s ghost, so he won’t take me now, but will wait for me.”

Ms. Friedman, “It seems to me like you’re worse today, though. Let me examine you.” After she did, she said, “Your lungs sound worse. What do you think about going to the hospital and seeing if some other medicine could help?”

Mr. Moua, “Do you think so? Well, maybe; let me talk with my youngest son and decide.”

Ms. Friedman, “Yes, I do think so. As you have told me before, combining medicine with the spiritual treatment can be helpful. Now may be the best time to combine both of them.”

Questions for Discussion

Questions for Discussion

1. How would you evaluate Ms. Friedman’s general interactions with Mr. Moua? What has contributed to their successful relationship?2. How would you evaluate Ms. Friedman’s interactions about this worsening period of dyspnea? What elements of cultural respect and negotiation did she display?

3. What do you think about combining biomedicine and modern nursing elements with traditional healing processes, such as the shaman ceremony?

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