The traditional structure of medical education begins with teaching normal anatomy and physiology followed by the various pathologies and treatments. Once students reach the clinical years, we are taught to think in the form of a SOAP note. First, perform a history and physical; then, order the necessary diagnostic tests to obtain your subjective and objective information. Next, form your assessment and plan — what is the problem, and how do you fix it?
The medical profession attracts type-A personalities who enjoy the challenge of making difficult diagnoses and finding curative treatments. But what happens when there is no curative treatment? What happens when the best treatment option will more likely result in debilitating side effects than a cure, or when the best course of action becomes to stop treating the disease and focus on other goals?
These cases can be difficult for medical students and physicians because our education hardwires us to diagnose the problem and then to fix it. How do you teach doctors with years of training in treating disease to recognize that the patient’s best interests may require them to stop doing exactly that?
This is where palliative care and hospice come into the equation. Palliative care focuses on the person rather than the disease, yet oftentimes the role and the goals of palliative care are misunderstood. For this reason, as well as various others, palliative care is one of the most underutilized but critical resources we have in the medical field.
One reason that palliative care is such an untapped source of support is the lack of necessary training for physicians. Education covering palliative care and end-of-life issues is minimal, if not completely absent from most medical school curricula. There are various explanations for this, ranging from the emphasis on treatment in contemporary medical culture to the sheer volume of information that needs to be packed into the medical curriculum. As a result, physicians are insufficiently trained and have difficulty holding end-of-life conversations with patients. Requiring physicians to do so is equivalent to asking someone to place a Foley catheter without any instruction or demonstration. As a result, instead of fumbling through uncharted territory and having a goals-of-care discussion, we tend to go on autopilot and present more treatments and potential cures just as we are hardwired to do in medical school.
The Institute of Medicine (IOM) recognizes that medical education needs to be reformed in order to include palliative care and end-of-life education. In a report released in September 2014 called “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,” a key finding and recommendation is that medical education is lacking in this area and requires improvement. While this is a step in the right direction, most present students and past graduates will be finished with their training before these changes are implemented. As a result, it becomes our responsibility to educate ourselves so that we can provide the best care for our patients in this regard.
Another key finding in the IOM report is that the public is not adequately educated about palliative care and hospice care. Many patients, just like physicians, are afraid to bring up mortality or unsure how to discuss it. They see hospice or palliative care as admitting defeat or surrendering to their disease. This is an unfortunate perspective because palliative care has so much to offer. The focus of palliative care is to tend to the whole person rather than simply the patient’s illness. Palliative care requires us as physicians to ask significant questions: what is most important to the patient? What makes a life worth living? What are the patient’s goals, and how can we achieve them together? Oftentimes these goals may include spending time with family, attending the wedding of a loved one, attending a grandchild’s college graduation, or even something so simple as enjoying an ice cream.
As Atul Gawande states in his book “Being Mortal”: “…our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer.” Palliative care makes it possible for patients to achieve these other priorities. Although patients who opt for comfort care often discontinue aggressive treatment for their diseases, several sources report that patients receiving palliative care have decreased suffering, are more likely to die at home, and may even live longer. If patients were more educated about palliative care and physicians were better equipped to have those difficult conversations, patients and their families would reap invaluable benefits.
A final point that is the distinction between palliative care and physician-assisted suicide. Palliative care is not equivalent to physician-assisted suicide and does not entail providing lethal doses of medication to patients with terminal illnesses. The focus of palliative care is to give patients the best possible quality of life, not to hasten death. Some states and countries have allowed physician-assisted suicide in specific cases that conform to certain guidelines and restrictions. The Netherlands, for example, legalized physician-assisted suicide more than a decade ago, and increasing numbers have turned to this option in recent years. However, Gawande addresses physician-assisted suicide with these thoughts: “[T]he fact that, by 2012, one in thirty-five Dutch people sought assisted suicide at their death is not a measure of success. It is a measure of failure. Our ultimate goal, after all, is not a good death but a good life to the very end.”
In educating ourselves about end-of-life issues, learning the skills necessary to have the difficult conversations, and discovering what is most important to our patients, we can drastically improve how patients and their families encounter end-of-life experiences.
Just like your multivitamin provides your body with the vitamins that may be missing from your diet, Mind Vitamins provides you with resources that may help fill in gaps in your med school curriculum. In med school we learn the scientific aspect of medicine that is necessary to treat diseases, but there are intangible and personal aspects that are necessary to treat the whole patient. This column will enrich your education so that you may be able to better understand your patients’ perspectives and treat them not just as a disease, but as a person.