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Training to help the dying

“Treatment failed after four days, and the patient expired shortly thereafter."

This was an unusual way to end a microbiology study case. Usually, these medical school lectures on hypothetical cases end with our "patient" making a full recovery.

It's reassuring when a case ends positively. So my fellow students and I were a bit unnerved to lose a patient, even a hypothetical one.

Exposure to death is rare in medical school because the curriculum emphasizes diagnosis and treatment above all else. We memorize mechanisms of disease and countless drugs so that we may help our future patients survive. As Dr. Atul Gawande points out in a recent New Yorker article, we are taught to view death as the enemy.

When death is mentioned, it is usually contained to short sentences that are afterthoughts, not teaching points.

This optimistic perspective is helpful when doctors can treat patients. But what are we to do when we are faced with untreatable prostate cancer, progressive Alzheimer's disease, chronic congestive heart failure — or any other conditions that a patient is likely to die from?

Evidence suggests that we will frequently face scenarios where treatment is futile. For example, studies show that CPR in the intensive care unit results in less than 10 percent survival, and that five-year survival rates for most lung cancer patients are in the realm of 10 to 20 percent. In these situations, many physicians understandably revert to what they were taught in medical school. They treat the disease, hoping that their patients will fall in the upper end of prognosis estimates.

But palliative care and symptom management would be more useful and effective in many of these situations than our exposure to it would suggest. A recently published randomized trial showed that terminal lung cancer patients who received palliative care in addition to standard treatment lived three months longer than patients receiving only standard treatment. Plus, those who got the palliative care had less pain.

Other studies show no differences in survival between hospice and nonhospice patients with cancer. But the hospice patients said they were more satisfied with the care they got.

Medical students assume that palliative care is a last resort. What if we were taught to think of palliative care as a treatment, like Viagra or Lipitor?

This training needs to start in medical school. If we learned how patients die — not simply what they die from — perhaps we would be more willing to accept death when we practice.

We are taught the physiology of diseases like depression and diabetes. We learn exactly how diseases affect the organs and functions of the body.

What if we learned about the physiology of death? If medical students viewed death as a set of symptoms and not a failure of treatment, maybe learning about it would be less taboo.

When a patient is dying, effective communication with his physicians can be even more important than actual treatment. Many schools integrate communication with dying patients and breaking bad news to patients and families into the curriculum. At my medical school, we have had sessions on discussing living wills and health care proxies with patients.

More could be done. Studies indicate that doctors' estimates of how long patients will survive a disease are significantly higher than what the evidence suggests. Which may sound kind, but if it propels a patient on a course of painful, expensive treatment that only makes his final months miserable, it's no service at all. More education on prognosis, better predicting the course of diseases, would be beneficial both for medical students and practicing physicians.

Restructuring how we learn about death and its treatment should be a priority in medical education because it is such a major part of health care. More than 30 percent of Medicare spending goes to care for patients in their last year of life. That number is predicted to skyrocket as baby boomers enter the Medicare pool. How much of that spending — and the uncomfortable and even harmful treatment it provides — could be reduced if end of life care got the emphasis it deserves?

Medical students must be trained not to ignore death, as I was tempted to do in my microbiology case, but rather to be honest and compassionate with their patients about its possibility. Such training will not lead to "death panels;" it will restructure how physicians view the inevitable, and will improve the health system as a whole.

Ravi Parikh, a member of the Harvard Medical School Class of 2013, graduated from Citrus County's Lecanto High School in 2005.

Training to help the dying 10/09/10 [Last modified: Saturday, October 9, 2010 5:30am]
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