All newly qualified doctors will look after patients in the last stages of life. Studies show that medical students feel underprepared and lacking in exposure to dying patients. ‘Dying and death confront every new doctor and nurse. I learned about a lot of things in medical school, but mortality wasn’t one of them.’ Atul Gawande.
I never thought I’d teach a course on death and dying to first year medical students. The eight-week course is part of a humanities module. While many of the students who sign up for the course have already had some experience of death, either among their family and friends or through work placements, most view death as a failure, as something of which to be afraid, as something that can be avoided.
I feel passionately that most medical students do not get enough exposure to death and dying. I want students to understand that their ability to ‘cope’ depends on their willingness to explore and understand their own responses to death and dying; that asking for support is not a sign of weakness, but of strength; that death is a part of life; that while it can undoubtedly be tragic and traumatic and untimely, it can also be peaceful and gentle, even beautiful; that having those difficult conversations with their patients and their families is vital.
I use books written by doctors about their own experiences with, and learning from, the dying such as Atul Gwande’s Being Mortal and Pauline Chen’s Final Exam. I bring in guests to talk to the students; in March Liz Rothschild performed a reading of her new show Outside the Box: A live show about death which will be performed at The North Wall, Oxford, on October 24, as part of the Kicking the Bucket Festival. Three student responses to Liz’s piece:
– The main thing I got is that death is very individual to each person and is dealt with in many different ways and often miscommunication is a large part in what goes wrong for the people. Also that death is not something to be afraid about and should not be left unspoken.
– When I think of death I think of sadness. However, I realise there are also lots of stories of people who have died peacefully and happily.
– I am reflecting on my own perception of death and wondering if I can look back and view it in a different way, with less sadness and sorrow.
For the final class, the students each produce and present something they have created inspired by the course: there have been funeral cakes, a final fling party, a board game (death vs the doctors), a police line-up showing images of death from the Greeks to Marvel comics; memory boxes; bio-degradable urns; poems; photographic essays; paintings; short stories; even a piece of music.
Student evaluations include a question about what they’ve gained from the course:
- talking openly about a subject which is often only discussed in a clinical sense at med school
- talking about death & seeing other peoples perceptions
- thinking about death & dying especially at home
- thinking about my feelings towards death & dying
- made me question my own attitudes towards death & dying
- made me feel comfortable to think about death in a personal way myself & I was able to address certain things I had not before
- able to explore my own personal views/thoughts/emotions around death & dying
The Clinical Teacher ran an article on the benefits of medical students talking to hospice patients. To their surprise they found that not only is this resource not fully utilised, but that concerns about patient and student welfare were not supported by research findings. The authors encourage course coordinators to use opportunities for medical students to talk to hospice patients in order to enhance their education (TCT 2012 9:9-13). I’ve found that one of the most popular sessions on the course is the one with a local hospice and hospital chaplain, a woman with a wide range of experience, from the funny to the heart-breaking, who very openly answers student questions not only about her experiences with the dying, but about how she copes with being surrounded by death and dying every day.
A US blog written by a young doctor includes the following tips for coping with death as a medical student: Allow yourself to feel; self-care; debrief; don’t compare your reaction to that of other people; say your goodbyes.
Here’s to a nation-wide curriculum on death and dying in medical schools so that our future nurses, doctors, surgeons, consultants and specialists will be able to broach the subject without fear and with compassion and honesty.