Preconceptions in Palliative Care: A Medical Student's Perspective

Introduction

Idecided to study medicine because I wanted to preserve life. The thought of spending eight weeks in an environment where doctors were no longer curing patients was an alien concept.

After a short palliative care attachment as part of our third year of training, I was left intrigued. I had many questions I wanted answering therefore I chose to spend my eight-week summer elective split between the local hospital palliative care team and a local National Health Service hospice.

Preconceptions and Expectations

Prior to my elective, I believed palliative care was synonymous with dying. I perceived it to involve the limitation of curative treatment whilst officiously striving to keep someone alive. I struggled to see a role for doctors if patients were no longer curable of their disease and, as someone who is fiercely adverse to failure, I perceived death as being just that. In a society where death is often a taboo I was at a loss as to why health care professionals would choose a career that involved the inevitable loss of life and the emotional burden that comes with it. With this in mind I associated hospices with death and pain control alone, a view I later found to be shared by several patients I met that had not experienced a hospice before.

My expectations for learning opportunities and desire to work in this area of medicine were not high; however I began with an open mind. I was tremendously anxious about my own response to death and dying and whether I would be able to control my emotions in order to stay professional. One of my biggest aims was to learn to strike a good balance between empathy and involvement in a patient's care whilst still being able to detach myself at the end of the day.

Challenging Preconceptions: Multidisciplinary Care

The process of challenging my preconceptions started almost immediately with the first patient. He was an 82-year-old gentleman with incurable lung cancer and widespread metastases that had been referred to the hospital palliative care team for advice about his potential for rehabilitation. I'm not sure what I expected, but I was greeted by a rather spritely gentleman with a good sense of humor. This in part may have been due to his high-dose steroids, but it was far from the morbid picture I had created in my mind. Already I had learned that palliative care offered so much more than pain control.

During my first two hours of palliative care I witnessed the involvement of occupational therapists, physiotherapists, social workers, nurses, doctors, and the chaplaincy in the care of one patient. I had naively associated palliative care with pain control and end-of-life care alone, and I was therefore surprised to see the important role that physiotherapists and occupational therapists played in preparing a patient for discharge.

Another assumption I held was that palliative care professionals would advocate the cessation of investigations in the event of further symptoms since they would be “pointless.” On numerous occasions I encountered patients being referred for CT scans so that their pain or change in personality could be better understood and so better managed.

Pain Control and the ‘Small Things’

I had not expected pain severity to differ so greatly between patients, nor to be so complex. I had imagined morphine to be key in pain control but had not considered the importance or effectiveness of NSAIDs and other adjuvant analgesics and the different routes of administration of drugs to suit the needs of the patient.

Many of the patients I met responded well to pain control; however, later on in my placement I met a gentleman that fit my previous stereotype of a palliative care patient: pale, cachexic, and jaundiced and in agonizing pain despite several attempts to improve it. His frank honesty about his wish to die was something I struggled to accept. To me it emphasized the stark difference between those patients that fight so hard to stay alive and those that just want to die. Just a week later, after being transferred from the hospital to the hospice, his wishes had not changed; however his pain had improved enough for him to sit outside in the garden and admire the view. He pointed out how important it was to him to have flowers and birds around him. These ‘small things’ that we take for granted are often hugely important to those in palliative care. My eyes were opened to the importance of emotional, spiritual, and cultural needs of the patient, aspects that are often overlooked in other areas of medicine.

Prognosis and Difficult Questions

Almost every patient I met had questions about their prognosis. I was deeply surprised by the frank nature in which some patients approached the subject and how openly it was discussed within families. I have learned how much honesty is valued despite this being a difficult question to answer and how environment is key to breaking ‘bad news.’ Prior to my placement I had never seen a doctor ‘crouch down’ or hold a patient's hand. On reflection I feel rather sad that I had not witnessed this in mainstream clinical practice. As an observer, these seemingly small actions made such a huge difference to the relationship between doctor and patient and made me realize that even though bad news cannot be broken gently, it can be given sensibly and sensitively, with attention to the environment.

The Bigger Picture

During my time spent with the palliative care team I also learned about the importance of caring for the family, not just the individual. Communication with the patient's family through every step of decision making was key in providing the best possible care for the patient. I began to understand just how important it was for patients and their families to choose where they would like to be for end-of-life care and how much the palliative care team strived to achieve those wishes. I had assumed that almost every patient would prefer to be at home when they die. However, I quickly learned to appreciate that families may not have the facilities or energy themselves to deal with the physical and emotional demands that come with caring for a dying relative. It also became apparent to me that the majority of patients felt an element of guilt for the burden they believed their illness had placed on the family.

Communication between Health Care Professionals

I was particularly struck by the effectiveness of communication between health care professionals. Hierarchies are still entrenched in medical practice, but there was an evident lack of this in palliative care. Much more emphasis was placed on communication between all parties involved in a patient's care from administration staff to consultants. I also attended regular multidisciplinary team meetings and witnessed how they are lead to ensure everyone's view is heard and valued, to provide better patient care.

The Patient's Preconceptions

I felt that many of the preconceptions I had were also shared by some of the patients. I clearly remember one patient with inoperable lung cancer discussing his options for continuing care. Upon the mention of a hospice he fell silent and proceeded to describe it as “the place that people go to die.” At that point I had not visited the hospice and was inclined to agree with him. However, at the end of his six-week stay, it seemed that he had undergone a similar journey to myself! We had both changed our preconceptions of what a hospice actually is. Instead of viewing it as a ‘place of death’ he now associated it with an opportunity to enhance the quality of his life through the wide range of services offered.

Take Home Messages

I feel privileged to have spent time with the palliative care team and their patients and to take with me invaluable new skills that I can apply to many areas of medicine. During my eight-week elective many of my prior assumptions about palliative care and hospices were changed more than I could ever have imagined. Although I felt some of my prior beliefs were correct, so many more were not. In addition to pain control and preparation for death there was also rehabilitation, plans for discharge home, and most importantly, enhancement of life. I feel that greater emphasis must be placed on palliative care within educational strategies so that preconceptions that many students and patients hold regarding end-of-life care are challenged. With this I feel that the next generation of doctors will be even better equipped to deal with what can be a very challenging, sensitive, and rewarding area of medicine.