Our findings provide some evidence for the widely held assumption that a positively perceived learning environment contributes to better academic performance.

The American Indian and Alaska Native population is aging and the leading causes of death for those aged 55 and older are chronic diseases such as cancer, heart disease, and the complications of diabetes. There are limited formal palliative care services available to rural and reservation dwelling American Indians and Alaska Natives. This collaboration between a tribally operated home health care agency and a federally operated Indian Health Service hospital, with the support of a palliative care center within an academic medical center, has established a palliative care program in the Pueblo of Zuni. The program is based in the tribal home health agency. Barriers to development included the rural setting with limited professional workforce, competing demands in a small agency, the need for coordination across distinct organizations, and the need to address the dying process in a culturally proficient manner. Family-focused interviews and other techniques were used to tailor the palliative care program to the unique cultural setting. The program has sought to integrate inpatient care of terminally ill patients at the Indian Health Service (IHS) hospital with outpatient hospice care. The initial goal of obtaining certification as a Medicare Hospice provider has not been met and remains a goal. Meanwhile alternative mechanisms for funding the services have been found. The experience of this collaboration suggests that a tribally based, culturally proficient palliative care program can be developed within an American Indian/Alaska Native community and that it can drive the local health system toward improved end-of-life care.

Recommendations for fostering expansion of end-of-life and palliative care services for AI/AN persons are discussed.

Study results demonstrate that health care providers can hold EOL care discussions with NA patients and NA patients' care preferences are affected by these discussions. The result do not support our hypothesis that there would be a lower rate of post-consult DNR status in NA patients (compared with non-NA). NA and non-NA patients and families participated in family meetings and their code status was affected to a similar degree. Furthermore, NA patients and their families choose hospice services at rates similar to non-NA patients seen by the palliative care consultation service.

The students' assessment of their palliative medicine knowledge and skills in 5 categories before and after participation in Death Rounds rated their skills after Death Rounds higher with effect sizes ranging from 0.9 to 1.9. Evidence from both the Death Rounds Questionnaire and Facilitators' Logs demonstrates that multiple issues and topics were addressed and all associated with the School of Medicine's 6 core competencies. Death Rounds minimally affect on clerkship time and faculty resources.