Family doctor Genevieve Auclair has practised 鈥渦p north鈥� in Nunavik for 16 years, which represents her whole medical career. Her commitment to providing excellent care under circumstances very different from a practice in the 鈥渟outh鈥� is evident from her passion for her work, commitment to the population she serves and ability to constantly adapt to the resources at hand. About 14,000 people inhabit Nunavik which is approximately 444,000 square kilometers and is located in both the Artic and subartic zones, north of the 55th parallel. Dr Auclair was interviewed by Devon Phillips.
Devon Phillips (DP): Tell me about Nunavik and your practice there. Few people have been this far north. What is the environment like?
Genevieve Auclair (GA): Nunavik is the northern third of what we now call the province of Quebec. We have more than 70 indigenous groups in Canada and the local population in Nunavik is over 90% Inuit. All the communities in Nunavik are remote: they are fly-in, fly-out only, and I currently work in Inukjuak, a town that is considered 鈥渂igger鈥� for the region, which means close to 2,000 people but without a hospital. The closest hospital is 200 km away by plane. We have basic healthcare, a clinic with a few doctors, nurses, midwives, interpreters, social workers, community workers and a dentist.
I have been working in this region for 16 years. Initially I was based out of the hospital in Puvirnituq 200 km away and over the years, to even smaller towns where there are no full-time doctors. So I have worked in various palliative care spaces and each is very different.
For the people in Nunavik, tertiary care takes place in the 鈥渟outh鈥�, in Montreal.
DP: The communities in Nunavik are remote. How do people get from treatment centres in the south back to their communities for end-of-life care?
GA: For people to come back home after treatment in Montreal, the shortest flight to Nunavik from Kuujjuaq or Puvirnituq is a 2 hour ride in a jet. But towns like Inukjuak, jets don鈥檛 go there so it鈥檚 a small plane, a propellor Dash-8 and that is 6 hours of flying and landing, up and down many times. The towns where it takes more time to fly, it involves aircraft changes so it would be at least 7 hours and that鈥檚 if everything is on time.
DP: What about your choice to work in Nunavik? How did that come to be?
GA: I came to do an internship in Nunavik when I was a medical student, 20 years ago. The human connection struck me as special. This is also why I enjoy doing palliative care even though in our setting, it is uncomfortable, always starting over. Palliative care is not something I do daily but when I do it, it鈥檚 very intense. I really care about keeping families united. I feel that this is an important part of life. Having worked in Nunavik has made me a better person. That is why I keep coming back.
DP: Tell me about those different communities where you have provided palliative care.
GA: There are three main villages where I have done clinical work, Puvirnituq, Inukjuak and Ivujivik, and they have three different ways of approaching palliative care. The infrastructure and the size of the local healthcare team means different challenges. In Puvirnituq where there is a hospital, if the family got exhausted, we could admit the patient to the hospital and all the family could visit.
GA: The difference with Inukjuak, a community of about the same size as Puvirnituq but with no hospital, is that if you want the commodities of a hospital with 24/7 nurses, you have to be flown away from your home town and the 20 relatives that would like to spend time with you cannot easily follow. The hospital does provide airfare and accommodation for one or two family members depending on the situation. Of course, other people can pay their way but there is a big pull for people at the end of life to stay at home. Actually, this is universal. Staying home to die is important.
DP: Is dying at home important in Inuit culture?
GA: Yes, from what I have observed. Even in the hospital settings many people show up for the last days and last few hours. I鈥檝e seen young kids roam around a person expected to pass away soon. I have been told by family members that kids need to be included in order to understand that death is a normal part of life.
DP: What are some of the main challenges delivering home care?
GA: We don鈥檛 have a dedicated palliative care team where I work now, Inukjuak, or in any community in Nunavik currently, so palliative care falls unto the home care team because they are equipped with a car and an interpreter.
The downside of the homecare team is that they work from Monday to Friday, 9 to 5. Palliative care does not stop at 5 pm and it does not take a break on weekends, so when we have someone in active palliative care, the home care nurse will usually volunteer to support them, even after hours.
We have seen beautiful care happen in the home. It means the world to family members that we provide palliative care at home, so they can share songs, prayers, feasts, just be together.
The main difference between in-hospital and home care is that in the hospital there are nurses so we can offer subcutaneous 24/7. In the home, family members are not necessarily comfortable administering subcutaneous injections. So as a doctor, I have had to think outside the box and go with different formulations, syrup, sublingual medication, patches, intrarectal, if the person is comfortable with this.
The other thing is that we are a small community clinic so we don鈥檛 have everything on the shelf. I have had to spend time with pharmacists over the phone trying to figure out how to crush which pill and what would be a good substitute. I need to know many different uses of each medication.
DP: What about palliative care in the very small villages?
GA: Ivujivik, the northernmost village, has 400 people and only 2 nurses and these nurses do everything. The nurses have to provide quality palliative care and make sure that the rest of clinic activities continue.
We try to make sure medication is long-acting to avoid multiple visits during the night. But I have never seen any resistance or opposition from our nurses. When you go to work in a small town, it鈥檚 part of the deal to be flexible.
DP: You said the two nurses in Ivujivik do absolutely everything. And as a family doctor, are you also doing everything?
GA: Exactly! When I look at what I did at the end of the day, I am like, wow, this is so varied! In any single day, I can evaluate a newborn, prescribe birth control for a teenager, treat depression. So as much as I am involved in palliative care, I am also involved in emergency care, home care, and in multiple medical spheres including pediatrics, adult care, geriatrics, psychiatry, so yes, the family doctors here do everything. There are no specialists that are full time in this territory. I consult other family physicians or a pharmacist. I feel the pharmacist understands better what I have on the shelves, and what my challenges are. We can鈥檛 just order a new medication; it may take days to get it because they are shipped up by plane and there can be blizzards, winds and fog that prevent flights from landing. We don鈥檛 have empty shelves but we are also not geared to receive someone who is receiving high doses of narcotics without a head鈥檚 up. We have two previous family physicians who used to work in our territory that are now doing full time palliative care practice and they are available by email for consultation.
DP: These days I understand you are splitting your time between Nunavik and Montreal.
GA: Yes, in my first years I was full time doctor in Nunavik, 8 months a year. Then I switched to part time, so 4 nonconsecutive months referred to as 鈥渟tretches鈥� that can be cut up into weeks so there is some flexibility for people with families for example. We have special conditions here. After 4 weeks of work, you can feel drained in a way that is indescribable. We are not on call all the time but in Inukjuak there are are few doctors, and I can be called at any time, every night if needed.
When I am in Montreal, I have two main roles. I recruit family physicians to work in Nunavik, and I work on the public health infectious diseases team, mostly on the tuberculosis team, because we have had ongoing outbreaks in Nunavik for many years.
DP: Looking to the future, what is on your wish list for Nunavik in terms of palliative care?
GA: The first priority is to have more Inuit healthcare workers. That would be best for optimizing palliative care and for cultural safety. I wish we had more nurses. It鈥檚 hard to recruit and it鈥檚 hard to retain healthcare professionals. The conditions of life are hard. There is no cellular network in most of the towns, running water depends on humans driving a truck filling up tanks in every town and in every house. Of course, this impacts on more than palliative care, but having more nurses would allow us to more comfortably offer round-the-clock care to people dying at home.
DP: Sounds like you are maximizing what鈥檚 possible with the resources you have.
GA: Doing more with less, that鈥檚 our daily life. And sometimes it鈥檚 doing more than you can imagine. I would never be able to do this work alone. It takes a team. Even though we have had different individuals over the years on the team, I have always seen everyone working toward the same objectives, providing quality care.