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Urgent Need for Better End-of-Life Training

By Christine Cowgill, MS, CRC

Few medical schools offer coursework on effective end-of-life care.

During the course of research for the book Soul Service: A Hospice Guide to the Emotional and Spiritual Care for the Dying, Robert Cowgill, MD, and I contacted 122 medical schools and 34 of U.S. News and World Report’s top 50 nursing schools to obtain information regarding coursework training in the areas of palliative, emotional, and spiritual care to the dying. Only eight of the medical schools and none of the nursing schools contacted had mandatory coursework in those areas of study. Only 16 of those schools offered elective coursework in those end-of-life care areas.

With the US demographics shifting to a larger aging and dying population, a more holistic approach to effective training in the care of dying patients is long overdue. Medical schools requiring mandatory training provide their graduates with a more comprehensive approach to caring for their dying patients.

In his book The Best Care Possible: A Physician’s Quest to Transform Care Through the End of Life, Ira Byock, MD, director of palliative medicine at Dartmouth Medical School and a faculty physician, expressed the need for medical school curriculum changes to include appropriate training in navigating end-of-life issues. Byock noted that medical schools underemphasize topics and skills related to terminal conditions.

For example, students lack training on how to deliver the news that cancer has progressed or how to tell family members that a loved one has died. Likewise overlooked or ignored are topics such as how to introduce hospice care to a patient or how to employ CPR in a way that people can understand. Interns and residents often have only one lecture, if any, on pain management or the ethics of stopping life-prolonging treatments. Yet most of these physicians will practice in areas such as family medicine, cardiology, neurology, internal medicine, oncology, and infectious diseases where a large number of the patients they see will be the dying elderly. These specialty physicians will, in fact, be providing their patients’ end-of-life care.

Most third-year medical students typically take hours of coursework in the areas of reproductive medicine, embryology, prenatal care, labor and delivery, and neonatal care. Four- to six-week rotations are required in obstetrics and pediatrics. Yet there are no required classes and clinical rotations on the topics of grief, caregiving, palliative care, and spirituality relating to the end of life.

Byock suggests that today’s medical schools offer an antiquated curriculum better suited to the 1940s and 1950s when most doctors delivered babies and routinely took care of infants. Only about 50% of the American population will have children, but 100% will die.

It is time to change how US physicians and nurses are trained in this important area of death and dying. While it is valuable to take some courses during their training, physicians also need learning opportunities such as rotations within hospices, nursing homes, and assisted-living facilities to practice their skills.

The newly emerging specialty area of palliative care also should be included as mandatory in medical personnel training. Atlanta-based palliative care specialist Melissa Schepp, MD, says, “I think if I had my magic wand, I would make it so that every caregiver knew a little bit about the basics of palliative care. Basically, that comfort is paramount regardless of whether you are going for a cure or not. We need to pay more attention not just to pain management but to good pain management.”

In 1997, Harvard Pilgrim Health Care organized the two-day National Consensus Conference on Medical Education for Care Near the End-of-Life. In the report “Rx: More Training Urged for Physicians Treating Dying Patients,” prepared by Kelsey Meneham, MSW, MA, for the Robert Wood Johnson Foundation, the 85 medical professionals attending the conference recommended the following:

• Care at the end of life should be taught as a core professional task throughout the continuum of medical education.

• In all phases of training, students should be exposed to dying patients and interdisciplinary teams of clinicians and other health care professionals who can teach and model the humanistic functions of medicine and who are skilled in palliative care.

• Although the preclinical years have an important role in teaching about end-of-life issues, undergraduate educators also should focus training in the clinical years where key attitudes and life-long practice patterns are learned.

• To succeed in improving end-of-life care, medical schools must train and hire more educators to provide and demonstrate state-of-the-art palliative care. These educators are needed to serve as teachers and role models for medical students, residents, fellows, medical school faculty, and physicians in practice.

Teaching end-of-life care to physicians should focus on four major goals: developing appropriate communication skills; acquiring essential technical knowledge for treating symptoms and relieving pain; learning to address the psychosocial, cultural, and spiritual needs of patients and their families; and developing the ability to reflect on personal attitudes about this work.

The late M. Scott Peck, in his work Denial of the Soul: Spiritual and Medical Perspectives on Euthanasia and Mortality, suggested a course of training for medical professionals that includes the following:

• Discussing the concept of mortality and what it means to be mortal.

• Studying how death is denied in general in our society and the Kübler Ross model in particular.

• Reading Joseph Sharp’s book Living Our Dying: A Way to the Sacred in Everyday Life.

• Discussing the afterlife and various belief systems about it.

• Exploring various religions, including those that believe in karma and reincarnation.

• Exploring and discussing ideas about the soul.

• Studying the ego and its involvement with the practice of medicine.

• Exploring secular and religious ideas about meaning.

• Examining various ethical theories, with emphasis on ideal observer theory.

• Exploring distinctions between natural and human evil and how a supposedly loving God can permit these painful things.

• Discussing the euthanasia debate and its ramifications.

Health care practitioners can request that your hospital offers training programs and continuing education courses that are required for all hospital physicians and nurses. Suggest that they follow the guidelines as outlined by Peck and the Harvard-backed recommendations. As alumni of medical and nursing schools, you can write to your school administrators to urge them to reexamine the need for mandatory end-of-life care training for students.

Through incorporation of mandatory coursework in palliative, emotional, and spiritual care and rotations with the terminally ill, our US medical and nursing schools can be updated to a better level of service.

Medical schools currently offering mandatory coursework in palliative, emotional, and spiritual care to the dying include Stanford University School of Medicine, Johns Hopkins University School of Medicine, the Mayo Clinic College of Medicine, the University of South Carolina School of Medicine, Texas A&M Health Science Center College of Medicine, Eastern Virginia Medical School, the University of Southern California Keck School of Medicine, and the UCLA David Geffen School of Medicine.

— Christine Cowgill, MS, CRC, is a certified rehabilitation counselor who has worked for more than 10 years in the area of workers’ compensation medical and vocational case management. She is a coauthor of Soul Service: A Hospice Guide to the Emotional and Spiritual Care for the Dying and an advocate for social change in the area of end-of-life care through raising awareness and increasing mandatory training for upcoming physicians and nurses in the areas of palliative, emotional, and spiritual care to the dying.