How Doctors Live When Patients Die  

By Amy DiCresce  

 “Doctor, am I dying?” the patient asks.
“Well,” the doctor hesitates, glancing at his notes. “Your vital signs 
are stable, your white blood cell count is up, and in a week or so, 
you may be strong enough for another round of chemotherapy.” 
“But, am I dying?” the patient persists.  

Mary Wilson, RN, and student Manvi Prakash provide in-home care for Sarah Whysall, who is suffering from pancreatic cancer.

It’s the dreaded question and the dreaded reality that doctors eventually face: how to deal with the imminent death of a patient. Traditionally, medical education has taught physicians how to prolong, outsmart or defeat death. In the past, nobody paid much attention to the medicine associated with death, and certainly not the emotional and psychological issues of how to cope with mortality. Physician training typically employs a victory-over-illness philosophy. But what happens when the physician recognizes that the victory is beyond reach?

A new clinical experience is teaching future physicians from the Wayne State University School of Medicine to understand and administer end-of-life care. The new rotation requires third-year students to spend one full day in a hospice or palliative care setting during their family medicine clerkship. With a $500,000 training grant from the Health Resources and Service Administration (HRSA), Department of Health and Human Resources, a pilot program was instituted and evaluated in 1999. After a highly favorable response from students, the program was adopted as a permanent fixture in the WSU curriculum, beginning in the fall 2000 term.

Typically, students begin their hospice experience observing an interdisciplinary team meeting, which brings together many health care professionals to consult on the patients who will receive care that day. Then, the students accompany a hospice doctor or nurse on his or her rounds. Most students see three patients, either in a hospital setting or in the patients’ homes. Student reports (from the debriefing session at the end of the clerkship) confirm that this face-to-face experience with a terminally ill patient is an eye-opening and heart-opening experience.

Third-year student John Yu said, “I couldn’t believe how happy the patients were. I was meeting people who had only two weeks to live. I expected them to be angry and depressed. Instead, they were happy and pleasant and very much at peace. It was obvious that they were at ease with their doctors and comfortable with the care they were receiving.”

John Finn, MD, who is the executive medical director of Hospice of Michigan and an assistant professor of internal medicine at the Wayne State University School of Medicine, says most doctors don’t know much about the options that are available for their terminal patients. As part of the end-of-life curriculum, he presents lectures, leads discussions, and invites students to accompany him on his patient rounds so they can better understand how to ease their patients’ suffering and improve their quality of life in its final stages. 

“Once our patients are diagnosed as being terminally ill, we need to move from a curative model to a palliative model of medical care; and it is medical care. It’s not simply hand-holding. It’s an important medical specialty,” said Dr. Finn. “The way we care for dying patients affects the survival of everyone around them.”

Wayne State University, along with other medical schools across the country, has integrated that medical specialty more fully into the curriculum. A 1998 report from the Association of American Medical Colleges revealed that 96 percent of medical schools discuss death and dying as part of an existing class, but only a handful require it in a separate course. Half of the schools, including WSU, offer a hospice elective, as well.  

Coordinators of the hospice rotation meet regularly to monitor student feedback.  Pictured from left are Juliann Binieda, Lisa Blackwell and Dr. Kendra Schwartz.

Mark Speece, PhD, leads the end-of-life curriculum committee at the School of Medicine and has helped establish a vertically integrated training program. Students are exposed to concepts of death and dying at the following points in their undergraduate medical education:

Experience with end-of-life decisions is becoming more popular at medical schools across the country, and doctors like Kendra Schwartz, MD, who is principal investigator for this grant, believe it will soon become a requirement for accreditation from the Liaison Committee on Medical Education. In fact, WSU is planning to include it as part of the Objective Structured Clinical Examination, which tests students’ clinical skills and is required for graduation from medical school.

“We want our doctors to understand how caring for dying patients fits in as part of medicine,” said Dr. Schwartz. “The public is expecting more than they’re currently getting when their loved ones approach the end of their lives. Doctors must play a role, and they must be prepared for it.”

WSU students, who were surveyed before their hospice experiences, expressed their desire for preparation in caring for terminal patients. Initially, nearly 40 percent of students feared they would be unable to manage their emotions during such interactions. They were afraid of being overwhelmed by the emotions of the patients and family members. 

Another 35 percent were fearful of saying the wrong thing or not being able to communicate effectively and compassionately.

“Medical students overcome their fears and learn best from observing physicians, nurses and caregivers doing their jobs,” said Juliann Binienda, lecturer in family medicine and coordinator of the hospice rotation. “But the learning cannot be concentrated in the classroom. In situations like this, learning must take place while interacting with patients and their families. The personal interaction is critical. Medical students aren’t just memorizing facts. They are learning about emotional response, sensitivity, reading between the lines, and the real meaning of patient care.”  

Medical students learn about end-of-life care by interacting with hospice doctors and nurses, who help them overcome their fears and uncertainties.

Sheila Sperti, RN, is a nursing administrator with the Barbara Ann Karmanos Cancer Institute. The hospice site where she works in Southfield, Mich., is one of six sites in the greater Detroit area that trains Wayne State students during their hospice rotation. She believes this effort should continue and even more should be done. “There just aren’t enough hospice physicians to go around,” Sperti said. “These patients are very ill and in a great deal of pain, and they are reaching out for assistance. They are scared of being alone and abandoned. They need advocates who can help relieve their pain, tend to their spirit, and maintain their dignity, even in the face of death. There can never be too many doctors who are trained in these principles.”

Before their hospice experience began, students were asked, “Do you believe that interacting with dying patients will be a beneficial learning experience for you?” One hundred percent of the students said yes. As one student questioned, “How can this not be part of our skill set?” Another responded, “It will surely benefit my life and my practice of medicine.”

How then, can palliative medicine be left out of the medical education experience?