Palliative care and traditional practices of death and dying in Wa'ab (Yap Proper) and in the Outer Islands of Yap.

Background: Death remains one of the most important and significant activities in Yap, an event that involves the entire island. A death of a Yapese not only unites the family, it initiates a complex series of reaffirmed kinship ties, rituals and exchanges that refocus the entire community and create new social identities for the participants. How these ties, exchanges, and identities are changing due to new economic challenges and new social pressures were the focus of this preliminary study, which sought to document the resiliency or fragility of traditional structures, measured in the efforts around death and dying in Yap and to identify ways that the health care system can intervene to improve palliative care.

Methods: 226 persons (49 on Wa'ab--Yap Proper--and 177 on the Outer Islands) participated in 16 focus groups, of which eight were on Wa'ab and eight on four Outer Islands: Fais, Falalop, Fetherai, and Mogmog. We additionally conducted 6 semi-structured open-ended key informant interviews, added to capture more of Yap's enormous sociocultural diversity.

Results: The islands of Yap, particularly the Outer Islands, continue to support one of the world's best traditional palliative care involving the immediate family, more distant relatives and in many cases the entire community. However, participants showed considerable concern for ways that this system is weakening and offered numerous suggestions for improving and strengthening palliative care in Yap.

Discussion: Although caution must be exercised not to undermine the existing system, six recommendations on how the health system can intervene can be identified. These involve identifying a key resource person on each island; supplying small, practical "comfort care" kits; making more pain medication available; conducting regular home visits; improving patient-physician and physician-family communication; designing a suicide intervention strategy; and documenting existing variations of how the dying are cared for on the other Outer Islands of Yap.