Hematology/oncology was one of my first rotations during my third year of medical school. Most of the patients on our service had a new diagnosis of cancer or were receiving cancer treatment. One of the first patients I worked with, Ms. D, was a middle-aged woman with refractory acute myeloid leukemia who had undergone multiple rounds of chemotherapy. She was quick-witted and energetic and was known for giving everyone nicknames during rounds.
Despite the frequent invasive procedures, almost daily transfusions and lack of energy from treatment, she maintained a graceful demeanor and was always ready to crack a joke or two during rounds. Her optimism was infectious and lifted the mood of the whole team. However, I began to see her slowly deteriorate over the next month, and she passed on the second to last day of my rotation. I had developed a strong friendship with Ms. D during the rotation, and her passing became one of the first confrontations with grief that I encountered as a rising medical student.
Entering the third year of medical school, the adjustment is both rapid and demanding as medical students shift from classroom-based learning into the clinical realm. While students spend the first years of medical school in lectures learning and memorizing a vast amount of medical knowledge, it is difficult to prepare students for the emotional aspect of being in the wards. One of the biggest challenges I faced during my clinical experience pertained to the mortality of patients as treatment options dwindled. In these situations, I could not help but feel as if I were failing to help patients who were laying vulnerably in front of me. In addition, I found it difficult to enter end-of-life conversations and to attempt to comfort patients due to my lack of experience. I have come to realize that these challenges were not limited to myself. Studies on students’ experiences with death and dying showed that many students were “surprised” by the amount of death in the hospital and that students had more experiences with death and dying than they expected.
There are strategies to help students transition in the clinical environment and effectively deal with death and dying. For one, having an active support system and open communication within the medical team is an important initial step. Additionally, integrating formal end-of life training into the medical school curriculum can prepare trainees to cope with loss and is associated with positive attitudes about physicians’ responsibility and ability to help dying patients and their families.
The emotional impact of death on members of a health care team can be highly variable and is contingent on the environment that the team creates. Since the tone of a team often originates from the more senior level members, it is important for everyone to be cognizant of how other team members may be affected by the loss a patient. Following Ms. D’s death, the attending and residents checked in with me and each other to see whether any team members were having difficulty dealing with her death.
The support that we gave each other helped us process the tragic event and maintained morale as we picked ourselves up to try to provide the best care we can for our other patients. This can be challenging, because each individual may react differently depending on the degree of care and the relationship that they had with the patient. In these cases, open communication can reduce anxiety and improve health care providers’ attitudes around death and dying.
In addition, exposure to formal teaching on end-of-life care can help students feel more comfortable with caring for dying patients. There has historically been a lack of education and formal training on end-of-life care. Although more medical schools and hospitals have established a curriculum on end-of-life care, it is often still fragmented and highly variable depending on the institution. Creating an organized and uniform curriculum on palliative care can be beneficial to students and trainees to help them confront difficult situations as they enter into their clinical years. Integrating palliative care into the existing curriculum, such as into pre-clinical courses for pharmacology and hematology/oncology as well as clinical rotations, can provide a basis for consistent end-of-life discussions throughout medical training. In addition, it may be beneficial for students to gain experience with communicating with very ill patients and their families, discussing emotional trauma with health care team members, and practicing self-awareness before they enter clinical rotations. Practicing these skills with standardized patients or medical student peers could help build a foundation for dealing with death and dying before students are tasked with providing care to patients in the wards.
Despite the sad outcome of Ms. D’s hospital course, there were several lessons I learned from her. Having the courage to engage in difficult conversations with patients about end of life care builds a foundation for empathy and support. Even young and inexperienced medical students may provide comfort for patients. In addition, addressing the fact that Ms. D was a patient who was close to me was helpful for me to cope with her loss. As medical students move into the clinical environment communication on the wards after a patient death and a formal end-of-life curriculum can be powerful tools to helping students care for patients who are dying.