From October 1998 to May 2002, with $449,513 from RWJF's Promoting Excellence in End-of-Life Care national program, staff at the Bristol Bay Area Health Corporation created Ikayurtem Unatai (Helping Hands), a palliative care program for Native Alaskans living in the 34 villages that comprise Bristol Bay.

Bristol Bay covers 47,000 square miles in southwest Alaska and is home to 7,500 people. Many Bristol Bay area villages can be reached only by small aircraft, but weather conditions are often dangerous for flying. Most villagers depend on hunting, fishing and gathering for a large part of their food supply.

Doctors in Dillingham (the only town in Bristol Bay, with a population of 2,400) or Anchorage visit villages only four or five times per year. When people became terminally ill, they had often been flown to Anchorage, more than 300 miles away. If family members could not afford to accompany them, they were likely to die alone.

The Bristol Bay Area Health Corporation, a tribal organization created by Bristol Bay tribes in 1973, is the sole provider of comprehensive health care to Native Alaskans in the region. It:

• Trains community health aides and others to provide routine primary care to village residents.
• Supervises staff working in villages through regular telephone calls, e-mails and faxes from affiliated doctors, nurses and other clinical staff.
• Maintains a 10-bed general care hospital.

Bristol Bay's Helping Hands combined palliative care with traditional Native Alaskan practices so that elders and others nearing the end of their lives could choose where and how to die. Project staff:

• Taught health and social services staff in the villages about death, dying, bereavement, palliative care philosophy and the special needs of terminally ill people.
• Recruited volunteers in villages to help terminally ill people and their families with errands, child care, respite care and other services.
• Created and disseminated culturally sensitive material, including translating information into the native language of Yup'ik and recording audiocassettes for non-English speaking elders and people with low literacy.
• Developed protocols to help village-based health aides create and oversee comprehensive care plans that responded to wishes of patients.

Project staff published the following results in the Journal of Palliative Medicine (DeCourtney, 2003):

• More elders than anticipated asked to enroll in Helping Hands because they understood it could help them remain in their communities.
• In 1998, about half of those who died in their Bristol Bay area villages had do-not-resuscitate orders in place. By 2001, about 75 percent of people had signed these orders.
• In 1999, before Helping Hands began, 33 percent of patients with cancer, chronic obstructive pulmonary disease, congestive heart failure or renal failure died at home. In 2000 and 2001, 77 percent of people with those diseases died at home.

At the end of the RWJF grant, the Bristol Bay Area Health Corporation was able to sustain a skeletal program in Bristol Bay. The Alaska Native Tribal Health Consortium was awarded a five-year $1.5-million grant from the National Cancer Institute to establish a statewide palliative care training program for health care providers of native Alaskans.