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284 15 AWidowedMother’sSearch foraGoodPlacetoDie A Case Story Mrs.Chang was a sixty-two-year-old widowed animist Hmong woman with five married daughters and one married son who, after her husband died, moved between her son’s house and her daughters’ houses so she could be with all of her children and grandchildren. She was in good health, never having seen a doctor or having had periodical prevention exams,when she noticed intermittent bleeding from her vagina for several months. Finally, she talked with her daughters and agreed to see a family practice physician despite her concerns of a pelvic exam, which she had never had. During a gentle pelvic exam, the physician found a large ulcerating mass in the end of the vagina, obscuring the cervix.After the exam,the physician,with the assistance of a trained Hmong interpreter, explained to Mrs. Chang and two of her daughters that she saw a large mass that was causing the bleeding; she was not sure exactly what kind of mass it was but she knew that it could be serious and that the Pap smear she took might be helpful . She advised Mrs. Chang to see a specialist who would take a sample of the mass to look at under the microscope. The patient and her daughters listened and decided to go home to discuss the doctor’s evaluation and recommendation with other family members. When the results of the Pap smear indicated cervical cancer, the physician talked with a daughter and made an appointment for Mrs. Chang with a specialist. When Mrs. Chang missed the appointment with the specialist,her physician tried to contact her at a daughter’s house. The daughter explained their mother was afraid of another pelvic exam, since she had bled a lot after the initial exam and was concerned the exams would make her bleed and be sick again. She had taken Hmong herbal medicines for vaginal bleeding and the bleeding had stopped. The daughter said she would bring her mother back to the physician and then to a specialist if her mother ever agreed to go. Months later, the patient agreed to see a specialist, because her bleeding had returned and she was becoming weaker. At the daughters’ invitation, her primary care physician agreed to escort the patient and her daughters to an appointment with a cancer doctor, a gynecology oncologist. During the appointment, Mrs. Chang told her physician she had decided to have surgery but under no conditions would she 15. A Widowed Mother’s Search for a Good Place to Die 285 receive radiation or chemotherapy, since these therapies were poisonous and unsuccessful .The gynecology oncologist stated the mass was a cervical cancer that had spread to the middle of the vagina, so it was not amenable to surgery and responsive only to radiation therapy. Mrs. Chang begged for surgery, and the oncologist refused. The oncologist insisted on radiation therapy, and Mrs. Chang refused. At home, Mrs. Chang, her son, daughter-in-law, five daughters, and five sons-inlaw , and an elder male clan leader discussed the possible causes and possible treatments , and the pros and cons of radiation. When the clan leader said Mrs. Chang should not receive radiation therapy because all Hmong women with cervical cancer die despite receiving radiation therapy, Mrs. Chang nodded her head, and her children remained silent.The clan leader suggested traditional Hmong and Chinese medicines and shaman ceremonies. At that point, the daughters expressed their concerns that their brother was not taking proper responsibility for their sick mother: he was not taking her to live with him, was not taking her to see the doctors, and was not obtaining traditional healing methods for her. The clan leader told the son that he must be a good son and be responsible for his mother. The son quietly replied that he was a good son and would take good care of his mother. For months Mrs. Chang continued to bleed. Three times she fainted and each time her family took her to a different emergency department where the doctors diagnosed anemia from a bleeding cervical cancer, gave her blood transfusions, and referred her to gynecology oncologists who recommended radiation therapy. Each time, she pleaded for an operation, then agreed to receive radiation but never kept her appointments. Finally, her daughters took her to a medical center in another city for another opinion, but again the doctors refused to operate, because an operation would not prolong her...

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