Spokane medical resident Logan Patterson, a recent WSU College of Medicine graduate, wishes he had been taught more about how to relate to and care for patients who are preparing to die. He and others from WSU wrote a paper about the subject for the periodical Academic Medicine.
This interview has been lightly edited for clarity and brevity.
Logan Patterson: I think most medical students have some sort of exposure to death within their family. For me, it was my grandmother and her decline with Alzheimer's disease and then subsequent passing. That was a big motivating factor for me deciding to apply to medical school in the first place and become a doctor, which was a big change for me because I was a tech consultant briefly between undergrad and medical school.
But I would say more foundationally, it's both an area of interest of mine because of it being such a neglected topic within medicine in general. But also I think part of it's temperamental, being around death as even for people that are trained and as part of their job as doctors. It still can affect people very heavily. And so you'll get like really wide variations in personality type and how much it affects them. I seem to be someone who's able to discuss really heavy topics with patients and not take it home with me as much.
DN: So when you went through medical school, what was the extent of your training when it came to end-of-life issues?
LP: Medical school, of course, varies quite a lot institution to institution. But for me, it was really theoretical discussions in small groups. I think I remember one simulated encounter, which was basically delivering bad news. It wasn't specifically discussing advanced life or advanced care planning or goals of care, things like that. It was more just delivering a diagnosis that could be terminal. That wasn't necessarily part of the scenario. It was very limited and mostly couched in sort of like theoretical discussions, not really anything practice based.
DN: What would you like to see happen, in terms of a med school curriculum when it comes to end-of-life issues?
LP: I think at the ideal situation, you would see it basically threaded throughout all four years of medical education. The first two years of medical education are basically classroom learning. And so I think in those early years, it should really be a combination of learning about different aspects of end of life, like advanced care planning, goals of care, that type of thing. Maybe seeing or having a couple simulated encounters with sort of actors that are pretending to be patients. Maybe having families of patients with terminal diagnosis after they pass talk about their own experiences, because a lot of what we do is basically helping to relieve the stress that is put on families having to make these decisions that they don't know the answers to because they never had the discussion.
In the later years, I think this is a very pie in the sky hope, but I think it would be great for basically every medical student to even do a brief rotation with palliative care, because that's, I think, the only way you're going to guarantee that a medical student will see these types of discussions in depth within a frequency to become ideally more competent at them.
DN: You alluded to this, the experience with your grandmother, what did you learn, going through her process of dying?
LP: I think probably my biggest takeaway, because I was involved a bit more directly in her care while I was in high school, but more distantly while I was in undergrad, was how much it affected my dad. It was his mother. I saw the stress that these types of slow declines can have on the family. Some of that is just inevitable, and it's just part of life that the end chapters can be difficult for people to navigate.
But there's so many other things that, like logistical things, goals of care, knowing what someone wants, giving over power of attorney for healthcare decision making, designating someone to help make financial decisions for you, things like that, that could really have made the journey a lot easier, because she encountered so many issues towards the end of her life. Maybe some of them could have been avoided or made easier on her as the patient and also on my dad and my family at large if this sort of planning and discussions had happened earlier while she was still more lucid.
DN: So now you’re going to be a cancer doctor yourself. How does this help you become a better cancer doctor?
LP: Cancer, of course, as everyone knows, is a disease that is often terminal.
Within radiation specifically, you'll hear different numbers from different radiation oncologists, but generally it's something like 25% to 50% of what we do is palliative radiation, which means we're not doing it with the goal of curing the disease, we're doing it with the goal of prolonging someone's life or making their symptoms better.
And so being able to have these sorts of like discussions with patients about what you can potentially help them with, and then basically being able to convey that this is not curative treatment, that what we're doing here is really trying to help you live the best life as long as possible while you're still here.
These types of discussions ideally should be had regularly with oncologists, whenever you meet a patient for the first time. It's not always the case, but I think the skills are very transferable.
DN: So you’ve written about this in a paper. What do you hope people get out of that paper?
LP: I think my biggest hope is really that it starts to lay a better foundational understanding about what types of teaching methods are used for this subject in medical school, because one of the big takeaways for us was really that there is a huge variation in how different institutions try to approach it.
We saw some programs doing what I described earlier and having a fully integrated curriculum throughout all four years of medical school, but mostly it was one-off interventions, the occasional simulated patient encounter. The occasional workshop is very scattered, not a lot of similarities in how the effectiveness of these interventions were assessed.
It basically creates a situation where it's hard to know what the best way to teach it is because we haven't really been doing much research on it. So I would hope that this would at least help establish a bit of a foundational understanding about what type of research and what type of interventions are happening.
