The time before dying
From the doctor's viewpoint, he had exhausted all treatment options and that was the end of it. Yet the patient, who was dying of cancer, asked if he might continue to come in every week anyway, since he found the visits comforting. But the doctor felt he had nothing left to give him, and turned him away.
This true story is told and retold at the University of California-San Francisco, where I am a second-year med student. Our professor, who shared the vignette recently, did so to illustrate a sadly missed opportunity in medicine. The physician may have used all of his cancer expertise, but he failed to use all of his compassion.
This lesson was part of a new addition to our curriculum on end-of-life care. Just a decade ago, students at UCSF had one or two lectures at most on the topic. "It was a really big hole, both nationally and locally," says William Shore, a UCSF family medicine professor who helped design the course. We now have more than a dozen hours of required training in palliative care. We attend lectures and discussions on such topics as "Care of Dying Patients and Their Families" and "Breaking Bad News." Residents share their memories of the first patient death they witnessed. And we visit hospices, talk to chaplains, and shadow palliative-care specialists. The result is a much deeper appreciation, early on in medical school, of how physicians can help dying patients.
I visited a 92-year-old patient this winter as part of this curriculum. He lay comfortably in a twin-size bed and had photographs on the wall: a recent family reunion, a close-up of him sharing a laugh with his late wife. He reminisced about his life as a political activist in New York and his volunteer work for the McGovern campaign. And he loved to talk about his kids. One was a Peace Corps worker in Ukraine. Another edited a small newspaper.
Had I not been at the Coming Home Hospice, I wouldn't have even known this man was dying. He had a rare blood disease, and his doctor had given him a month to live. But this patient taught me that dying could be peaceful and dignified. There were no tubes invading his body. He suffered no pain. "The staff takes very good care of me here," he said.
The new coursework has taught us to talk openly with patients, not to skirt difficult issues. Studies show that despite doctors' fears about dashing hopes, patients indeed want to talk about illness and death when it is approaching. Explicit information enables them to plan better--not just financially but emotionally as well. However, these sensibilities don't come naturally. At UCSF, we are actively working to cultivate such openness. In small groups, we recently tackled a tough assignment: Reflect and write for 10 minutes about death. Then, discuss.
The professor in our group went first. Tears welled up in her eyes as she recalled her father's recent death and her feeling of being alone in the world, an adult but orphaned just the same. We passed the tissue box around--a sudden death of a cousin, a mourned grandparent.
It was for me one of the more daunting assignments in medical school. But it was also one of the most illuminating. Generations of physicians have earned--indeed prided themselves on-- their reputation as stoic technicians. But today's doctors, or at least aspiring doctors, don't have to wall in their emotions.
Lessons for life. Listening, we're learning, can be a potent tool in dealing with these touchy issues. What do you hope for? What worries you most? Whom can you turn to for support? It sounds simple, but, unfortunately, physicians often lack good listening skills. One study found that residents who were discussing do-not-resuscitate orders with patients talked nearly 80 percent of the time.
Close listening might reveal that some patients' greatest existential fear is not of dying but of never having lived at all. Encourage them, our professors say, to tell stories. Instead of more futile medications, prescribe writing a journal or assembling a photographic tour of the past. Maybe dying patients will be inspired to compose a memoir--or in some other way to find meaning in their legacy.
This story appears in the April 19, 2004 print edition of U.S. News & World Report.
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