In Need of Care   5 comments

First, I feel compelled to say this: Rapp’s book was by far the most difficult reading I’ve ever done for a class.  Chapter nine did some serious emotional tugging that made it difficult for me to continue reading.  It was wonderfully valuable and well-written stuff, but those quotes were just so raw and difficult.

Two components of the palliative care curriculum unit clearly stand out after a reading of Rapp:

  1. Identify major aspects of suffering, loss, bereavement, ritual & meaning at the end of life.
  2. Identify major areas for consideration in end-of-life care in special populations – pregnancy (death of mother/fetal survival, survival of mother/fetal demise); neonates & infants; children; the elderly; cognitively impaired; mentally ill.

I’m thinking that doctors should have training not just in how to treat terminally-ill (or selectively aborted) patients, but also in bereavement concerns for caregivers and survivors.  The tales in Rapp of poorly handled disclosures from insensitive doctors were simply appalling, and I’d like to hope that we could infuse some compassion into our curricula.  It seems to me that patient-centered care should be of utmost importance.

How can we teach compassion to med-school students?  Can an appreciation for bereavement be made a part of existing studies, or will it seem merely like Yet Another Thing to Learn?  Could the infrastructure or staff surrounding potential losses (like those who report the results of amniocentesis, those working in geriatrics, and those working in abortion clinics) be charged with providing supportive counseling as well as medical care, or would that bankrupt the system?  We seem awfully concerned as a culture about the physical and medical wellness of patients, but the emotional well-being of both patient and family is so critical and chronically ignored.

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Posted September 28, 2010 by Chris Friend in Uncategorized

5 responses to “In Need of Care

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  1. I’m sure these questions will be central to designing a palliative care curriculum. I know I’ve talked about the value of narrative, but I do wonder what other approaches might be explored for teaching such abstracts as compassion and empathy? I remember reading Philip Carey’s experience in Of Human Bondage — he had to serve his residency doing pro bono work in London’s most impoverished neighborhoods. I don’t know if it was the affect of the narrative on me the reader, or just what I perceived Philip would be going through dealing with the horrors of poverty he saw, but it almost seems that one must be exposed to some horrible things to really develop a compassionate, humble spirit. On the otherhand, however, it is possible that this could simply lead to desensitization and stoicism. Creating a curriculum that addresses these challenges will itself be challenging.

  2. Hi Chris:

    I am not sure that we need to teach doctors compassion, rather we need to teach them rhetorical strategies that allow patients to perceive the doctors as compassionate.

    Elle

  3. Chris,
    Rapp’s book helped me see beyond the idea of palliative care as something mainly for the elderly. I think you bring up some very good questions, and I think Elle has a good point as well. I agree with Kevin that it is going to be challenging. It would be wonderful if we could instill empathy, but we will probably have to be satisfied with awareness.

    NPR featured a Diane Rehm program back in August that focused on a new study that shows how palliative care not only improves quality at the end of life, but can actually lengthen survival time.

    One of the articles linked from the website is a New Yorker piece written by Atul Gawande:
    http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=all

    This article covers several different aspects of the subject, including a brief discussion on the “prescribed set of customs” that once was a way for people to accept death. It also talks about Hospice from a doctor’s point of view (he learns about it by going with a Hospice nurse on her rounds).

    One thing I got from this article was that the contemporary American approach to death is fairly toxic; our desire to have medicine cure us at all costs and the medical community’s willingness to try and save us at any cost have resulted in a system that values length of life over quality. I guess on some level I already knew that, but some of the examples Gawande gives really brings it home.

    We are not dealing with a situation that resides totally in the doctor’s hands, and I think that produces an uncertainty (and maybe even a bit of defensiveness) when physician’s are confronted with it. Maybe the best we can do is help them understand that dying is not the worst thing that can happen to a person. In reviewing some encouraging findings on physician involvement with end of life discussions, Gawande asks “Can mere discussions do this much?” It seems this might be our lead-in for some kind of narrative construction.

    Here are the other links:
    http://thedianerehmshow.org/shows/2010-08-24/new-studies-palliative-care

    http://www.nejm.org/doi/pdf/10.1056/NEJMoa1000678

    http://www.nejm.org/doi/pdf/10.1056/NEJMe1004139

    http://www.palliativedoctors.org/

  4. I remember that NPR report!

    Maybe one strategy is to remember that doctors-in-training are people with rich life experiences (like everyone else) that include loss, and then find a way to help them tap into those feelings when dealing with patients and caregivers.

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