Table 5.

Subthemes and Representative Quotations of Theme 1: Healthcare System Operations

Theme 4: Historical Trauma and Racism

Representative Quotations:

Psychosocial stress with dying is, I feel, in some instances exacerbated by feeling and knowing that you’re not getting the quality of care that you deserve—that the patient is seeking care from a healthcare institution that has sort of violated their rights or caused worsening historical trauma or is receiving care from people that are white people that are part of settler colonialism. People feel a lot of times like they’re receiving compromised medical care, and that can make it more difficult. (15, IHS Physician) The low trust in the health system is a major barrier to discussing end of life care planning… And so I think it’s a very difficult conversation to have in a place where the health system has genuinely failed the community for so long. (20, IHS Physician) So the barrier that I think is really significant for anyone hospitalized here is… the fact that they are plucked out of their community with nothing but the clothes on their back, and brought to this hospital, and plunked down in a culture that has historically traumatized, culturally cut off the importance of their own history and culture. (21, Chaplain) Remember, this is people that go to Walmart and white people stare at them. They go to a store, and people follow them because they think that they’re gonna steal something. (33, IHS AHP)