Training Health Care Workers to Talk about Death

Monday's Health Beat blog included a post about how the United States trains doctors and nurses and the need for change. Maggie Mahar states that doctors and nurses need to be able to talk to their patients about death.

While moderating a panel on making medical education more “patient centered,” I suggested that dying patients should share in decisions about end-of-life care. This means that students must learn how to approach a dying patient and see her as a whole person, with fears, hopes and priorities that she needs to express—and that a doctor must respect.

Students training to become doctors and nurses should spend some time studying “palliative care”--the art of caring for patients who may well die. This includes controlling their pain and helping them consider their options. Palliative care specialists know how to talk to dying patients and their families, how to outline the pros and cons of various procedures, and how to help the patient decide whether or not he or she wants to pursue a particular course of treatment. Too often, if a patient doesn’t have a palliative care team, a doctor will simply announce: “This is what we do next. This is the protocol.” The patient is given little choice.

A palliative care team made up of a doctor, nurse and psychologist are not embarrassed by the fact that the patient is dying. They understand that the patient cannot make meaningful choices unless that fact is acknowledged. Students should be assigned to sit in when members of a palliative care team talk to patients and their families (with the permission of patient and family.)

Students need to spend time with a palliative care tem because in many medical schools death is not part of the curriculum. According to the Institute of Medicine, a 1990s study of third-year medical students revealed that 41 percent reported that they had never heard a doctor talking to a dying patient; 35 percent had never discussed care for dying patients with an attending physician, and the great majority had never been present when a surgeon told a family that a patient had died. Almost half of patients could not remember any consideration of death and dying in the curriculum.

In his 2007 book, Last Rites, Steven Kiernan cites more recent studies which reveal that death continues to get short shrift in medical education.

Yet nearly every doctor will, at some point, find himself treating a dying patient. And nurses spend more time with the dying than anyone else in a hospital. It is imperative that they learn how to control pain. Today, too many nurses are wary of giving patients the painkillers they need; some are afraid that a dying patient will become “addicted” to the opiate.

Ultimately, a doctor may well want to call in a palliative care team to make sure that the patient is getting adequate pain relief, and to help the patient consider his options. But first, the doctor who has been caring for the patient needs to acknowledge that the patient is probably dying, make peace with that fact, and communicate with the patient in a way that makes it clear that the doctor does not consider the patient’s death—or the patient himself-- a “failure."