Medical schools aren’t adequately preparing future doctors for the reality of having conversations about death, say Jenny Nguyen and Ina Ko
Medicine has come on leaps and bounds and, as a result, in the UK we have become what has been called a “death free generation.” Many people are largely unaffected by deaths from war, childbirth, or infection and can live for decades without experiencing the death of a loved one. It has almost become an expectation that we will all live well into old age. However, death is inevitable and plays some part in every clinical specialty.
Public health figures indicate that 46.9% of people in England will die in hospital, making death an important part of hospital life that both medical students and doctors will be exposed to and required to address. Junior doctors, who commonly staff inpatient wards, are likely to be involved in prognosis counselling and end of life conversations with patients, carers, and loved ones from the very beginning of their careers. However, medical schools aren’t preparing us for the reality of having these conversations.
A UK survey of medical schools found that on average, only 20 hours of the curriculum were dedicated to palliative care, with a large proportion of these occurring in the later years of training. A study by the Royal College of Physicians of Edinburgh (RCPE) admitted that it was “unrealistic” to expect any graduating medical student to be fully prepared for palliative medicine. Yet this failure to equip junior doctors with adequate knowledge of end of life care risks patients and their loved ones being left without the support they require.
These topics should be addressed early in medical education. Pre-clinical teaching may include formal teaching on the process of death, such as common signs of a patient approaching death. During the clinical years, students should have protected time specifically with the palliative care team, as it can be uncomfortable and challenging for medical students to separate themselves from participating in the medical team’s active treatment of other patients to observe the palliative care team. An annual week’s rotation in palliative care would further students’ understanding of the services available and how best to support patients with varying needs.
Palliative care teams involve multidisciplinary staff that students may not encounter elsewhere, such as bereavement nurses. With greater diversity of experience in palliative care, students may be able to better refer to services available and explain what will happen as treatment and life comes to an end.
A major challenge to education about death is its inherent emotionality. It is essential to remove the stigma and taboo around death. Medical schools do not always provide space for discussions about the sense of failure, guilt, or sadness doctors feel when nothing else can be done. This leaves future doctors vulnerable to significant emotional stress. The RCPE found that 79% of FY1 doctors felt out of their depth when treating patients who were dying—particularly where it concerns their psychological distress, spiritual distress, and social issues. An inability to address these issues led to two thirds of FY1 doctors feeling distressed themselves when caring for people who are dying.
In 2004, the first Death Café was organised in Switzerland in order to encourage open conversations about people’s opinions and perceptions of death. The groups have now been set up in 48 countries with more than 4300 members globally. Healthcare professionals who have attended these Death Cafes have described how the sessions have been significantly different from the usual medical narrative and have allowed them insight into how the public understands death.
Many organisations providing end of life care ensure their staff and volunteers have regular supervision sessions, which facilitate discussion of their experiences. This dedicates time to reflect on the process of grieving and on any challenging incidents that can be learnt from for future cases.
The Death Cafés and hospice supervisions provide models of how healthcare professionals can engage with death in both an emotionally supportive and educational manner. Along with the introduction of regular palliative care rotations, medical schools should incorporate small group sessions to facilitate reflection and learning. This gives students the opportunity to explore their own perceptions of mortality and increase their awareness of the varying psychosocial challenges of death.
With these changes, medical schools will ultimately endow students with the skills they will need in clinical practice to provide life limited patients and their families with excellent care and support.
Jenny Nguyen is a final year medical student at Imperial College London.
Ina Ko is a fifth year medical student at Imperial College London.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare no conflicting interests