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Reflections Of Med Students Upon First Patient Deaths Prove Valuable To Experienced Clinicians

Medical students caring for the terminally ill must learn to be both sensitive and resilient to cope with workplace stress and provide comfort to patients and their families, said a bioethicist to a crowd this week at the University of Chicago’s MacLean Center for Clinical Medical Ethics.

Mark Kuczewski
Mark Kuczewski

“Being present to patients and families is a complex skill of being personally engaged, available and open to particular needs,” said Mark Kuczewski, director of the Neiswanger Institute for Bioethics and Health Policy at Loyola University Chicago. “There is a struggle to be desensitized enough to do one’s work, but sensitive enough to deal with the particular patient and family.”

Kuczewski, in collaboration with other end of life care experts, asked 68 students completing clinical clerkships to reflect and write about their experiences caring for dying patients. Researchers then mined answers for common themes.

Many students noted a lack of discussion about care options for patients approaching death, Kuczewski said, because clinicians were too immersed in details of immediate treatments.

Not once did my team mention or consider that Ms. W was in the process of dying. I did not hear any talk about end of life care, so I didn’t think it was necessary to talk about this with the family. I spent a lot of time with them (the family) answering questions…She (patient’s sister) was very suspicious and felt like she was not getting the whole story. I don’t think she did get the whole story either.

Other students said they were shocked by the suddenness of death and lack of acknowledgement by nurses and attending physicians.

I didn’t even get a chance to say goodbye to the family. Before I even realized what had happened, the family was gone, the patient removed from the list and my next patient waiting for me to take care of them. The team didn’t make any comments about her death that morning, and everything seemed to continue and move on as if nothing had happened…I initially did not know what I wish had happened, but the way the situation ended lacked any closure for me.

Kuczewski identified common “pledges” from students from which veteran clinicians could benefit. The most common commitment: to remain aware of and sensitive to the needs of families, and not allow needs to go unaddressed.

All I can do is take from this experience and move forward by being there for others when the time comes.

I will never let that be OK again.

The second most common pledge was to refer families to pastoral care.

If I am not available to be present with those grieving, I will make sure that other qualified people are, so these people are not alone.

On a couple of different occasions the family asked me if I would join them in a quick word of prayer when I came to check in on the patient. Through these moments I completely forgot that I was in the medical profession, and I became connected and a part of this family and the grieving and emotional process.

The study, published in the medical journal Academic Medicine, calls for teaching institutions to standardize team protocols to help students formally recognize and process patient deaths.

“Something akin to a spiritual ‘time out’ procedure after a patient dies might be an efficient yet effective way to acknowledge death,” researchers write.

It also calls on educators to find ways to support students in their wish to remain connected to dying patients and their families.

“Most immediately, students need support in developing habits of action conducive to their stated goals,” they write. “Encouraging students to follow dying patients who have rotated off their service, allowing students to offer their pager number and physical presence to dying patients and other like behaviors should be recognized as ’best practices’ among faculty.”