Training in End-of-life Care through Interaction with Dying Patients

Objective: The majority of medical school training focuses primarily on curative principles of care. Students receive little palliative care education despite studies indicating that for most patients the bulk of their health care occurs during the last few months of their lives. Training medical students in palliative care principles will result in more meaningful end-of-life interactions for many patients. This new curriculum component, integrated into a family medicine clerkship in the third year of training, engages medical students to interact with dying patients, their families, and the allied health professionals who care for them in various hospice venues. Increasing our future physicians' knowledge of palliative care principles, increasing understanding of pain management, and developing knowledge of hospice resources in the community will improve the overall care of the dying patient. Description: This end-of-life care curriculum was instituted in February 2000 as part of the required third-year family medicine clerkship month. Several elements occur during the month. The month begins with a lecture introducing common hospice definitions and a discussion of the contrast between palliative and curative care. At that session, students complete a pre-visit questionnaire assessing their levels of comfort interacting with dying patients. Each student is then required to spend a full day in a hospice/palliative care site. These visits are to include actual interactions with dying patients and their families either in the home, in a hospice residential facility, or in a tertiary care facility. Students also attend interdisciplinary team meetings in which various members of the hospice care team provide input on the best care of each patient. Hospice professionals at the sites have been familiarized with the curricular objectives and were consulted as to the best way to meet them. Students complete a written homework assignment to further reinforce the concept of interdisciplinary care of dying patients and a post-visit questionnaire of their impressions of the experience. At the end of the month a hospice physician gives a lecture about general principles of hospice care, including the delivery of bad news, basic concepts of pain management, and the realities of practicing end-of-life care. Following the lecture are small-group debriefing sessions during which the students share their individual experiences with dying patients. Discussion: Prior to the hospice visits many of the students indicated feeling hesitant to interact with dying patients, some fearing the perceived negative feelings associated with dying; others being nervous (“not knowing what to say”). Yet despite these hesitancies, all of the students have indicated that this learning experience was beneficial. They have been especially positive about the patient interactions. The student evaluations indicate a need not only for offering the knowledge based on end-of-life care principles but also for developing the communication skill set to work with dying patients and their families.