Piece of paper with a closeup on the words "End-of-Life decisions"

Training tomorrow’s doctors: How to help when the healing stops

July 2, 2015

Twenty or so second-year students, or M2s, sat around four pushed-together tables in a training room at the Texas A&M Health Science Center Clinical Learning Resource Center in Bryan. The air was relaxed but expectant; this was not a test but a training opportunity, and a “rough draft” at that.

The College of Medicine has been instructing students on palliative, or “end-of-life” care, the care patients receive for terminal conditions where the goal is to comfort and ease pain rather than to cure, for years. But with the help of second-year students Charis Santini and Georgina De la Garza, the college now offers students the chance to practice the doctor’s challenging role in such care: Delivering devastating news to patients and their loved ones, and telling patients what comes next when there is no curative path forward.

(You can learn how a real-life caregiving challenge sparked De La Garza’s interest in developing palliative care training, and how she and Santini tackled the challenge, in Part 1 of this series.)

The ground rules were drawn out through the students’ questions. How thorough should their examination be? (A “focused head-to-toe.”) Should they state out loud whatever they’re observing or concluding during diagnosis, so the observers monitoring them on the video feed can assess their history-taking? (Yes.) How long will they have? (Ten minutes.) Their primary concerns were logistical and fact-based.

Dr. Craig Borchardt, assistant professor in the Texas A&M College of Medicine’s Department of Humanities in Medicine and the head of Hospice Brazos Valley, cautioned them that the hardest part of this exercise, and its real-world counterpart, would be dealing with a patient’s emotions and managing their own emotional response. “What you will be dealing with is people who are transitioning from hope to grief,” he told them.

In another training room, Dr. Steve Moore, a hospice volunteer and physician, spoke to another group of M2s about how to deliver news to a terminally ill patient, or to a family member whose loved one has died in the hospital. His advice is a checklist of a dozen or more hard-won truths learned from years of grief counseling, as well as the intimate, personal experiences of loss that separate most of the old from most of the young.

If they are giving notice of a death, “no euphemisms,” Dr. Moore said firmly. “Someone has died. We also need to be culturally sensitive. Not everyone who comes into the hospital and dies is Judeo-Christian. Euphemisms like ‘passed on’ presume a certain range of beliefs and comforts. Don’t make assumptions.”

He ticked off a few more items, and warns against “trying to comfort by explaining what you don’t know”—reminding students they may have to deliver bad news even when they weren’t on scene when it happened. “We don’t always know why people die,” he said. “We may know that they had a particular illness and that they weren’t responsive to a particular medication… But don’t extrapolate beyond what we really know. Don’t make up an answer.”

He told them to locate the box of tissues in the room, and get it before sitting down. “You don’t want to get up and walk across the room after delivering the news.”

A student tentatively raised a hand. “Do we really want to walk across the room and bring the Kleenex back and set it in front of them before we tell them what happened?”

Students laughed, but Dr. Moore doesn’t crack a smile. “I wouldn’t put it in front of them, but I would get it,” he said.

And with that, students paired off and began heading to the examination rooms, where their patient interactions were observed by a team of nurses, chaplains and hospice workers and written feedback was given on their performance.

As students finished sessions in teams of two, they wandered back to the training room, where they waited with those who hadn’t yet completed the scenario. They reported to the mentors on the few bugs several groups seemed to be encountering—where a folder is placed and how it should be used, or running out of time before they’ve even completed their exam. They avoided discussing their patients in detail but shared tips, spoke in small clusters, and swapped impressions.

“She said ‘So I have six months to live?’” said one student. “I didn’t really know how to answer that. ‘Statistically, yes?’”

“I told my patient the prognosis was just a guess,” another student chimed in from a few seats away. “I also told him that you might live longer, and that hospice patients do tend to live longer.”

“That’s good,” the first said.

“My patient was almost more concerned about her husband than about herself,” said Antonio Toribio. “She was so concerned about how he’d react. So I offered to talk to her husband—we set up an appointment for next week, for him to come back with her and I could walk them both through it all, so she wouldn’t have to go home and fight with him about it.”

In the observation room, chaplain Skip Stutts watched a medical student stumble through giving a death notice to a patient’s family member. “How they handle themselves instinctually in this situation is as much about them, the doctor, as it is about the patient.”

Students have to self-reflect to gauge their own emotional and linguistic crutches and compensate for them. They also have to work out the practical mechanics, the rhythm, of delivering bad news—what words to use, in what order, and how and when to offer a comforting touch. Some students talk for so long about the details leading up to the death before even saying the patient had died, it seems as though they’re subconsciously avoiding it. Others blurt it out as they’re sitting down, and then struggle to provide needed detail after the patient has started crying or turning inward.

Although De la Garza and Santini wrote the scenarios, Laura Livingston, who manages the Clinical Learning Resource Center, scripted the emotional responses in broad strokes for the patient actors to interpret. One woman, told the students that her preschool daughter died in the hospital after she’d been told it was safe for her to leave for an hour or two, retreated to a corner of the room and crouched to the floor, sobbing. Watching this scenario several times yielded multiple student responses: some hover, or pace, or sit awkwardly nearby, while others instinctively crouch down next to her, hold her and reestablish eye contact.

“It’s really about overcoming your own boundaries to be there for the person,” one student said afterward. “I don’t personally like a lot of touch, but this isn’t about me. It makes me come a little out of my shell to be there for the person at their level.”

“Each person needs support in a different way,” agreed Sunaina Suhog. “We’re learning to read these things.”

At the end of the exercise, students and patients alike were debriefed, in separate groups. For students, the challenge remained largely technical; they learned a lot today, but the harshest instruction will come when they receive written feedback and review their recorded encounters. Patients’ debrief was largely an emotional check-in; after acting out the same trauma 10 times over in a few hours, Livingston said, “It can take an emotional toll. We have to be pretty careful.”

De la Garza and Santini seemed pleased with the experiment. De la Garza said the exercises were challenging for them, too—they had written so many cases, and there’s a big difference between imagining how you’d like to respond and doing it. They also had no idea how patients would react to the news. “Being there in that room, every reaction is so unexpected,” De la Garza says.

She had come a long way since her grandmother’s death the previous summer. She surveyed the room of students and staff and reflected on what she and Santini had accomplished with the hospice team. Abuela would have been proud. “I believe every physician, regardless of specialty, should be able to determine when they’re doing more harm than good and refer their patients to get palliative care,” De la Garza said. “Everyone deserves to have a dignified death.”

Story by Jeremiah McNichols

Read Part 1 of this two-part story.

— Madison Matous

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