Dr Katie Smith is a doctor in training and is currently on a clinical fellowship scheme at the GMC. Katie gives us her perspective on end of life care and some advice for medical students and doctors in training looking to improve their confidence in this area. The blog focuses on end of life care in a hospital setting.
When patients are dying, we, as doctors, commonly feel powerless. We often say that there is nothing more that we can do. It is an admission that, despite our wish to help patients, we cannot solve the problem this time. It is a hands held up apology, an embarrassed confession that our medical interventions have failed to achieve the desired results. But it is also wrong. There is much we can do for patients at the end-of-life, looking after them and their families with care, compassion, and simple humanity.
At my medical school interview I said that I had always thought that the person was more important than the disease – perhaps that’s why I have ended up in Public Health, looking at the factors of health and illness that go beyond pathology alone. Nowhere is this more true than in palliative care where it is crucial to recognise the individual in front of us, understand their circumstances and not just the terminal diagnosis.
The importance of getting palliative care right
In fact, if you really wanted to be a doctor to help people, then learn to do palliative care well. I can still name the renal consultant who looked after my gran as she died; still feel a fondness for her and for the nursing staff and healthcare team in the hospital that cared for her, and us, so well in her final weeks. The value of a good death is wide reaching and the devastation of a bad death spreads even further. The impact on family, friends, staff and caregivers can be severe and long-lasting, with significant implications for their own health.
It is surprising to read that in UK medical schools a median of 25 hours is spent on palliative care across the whole of the undergraduate degree (pdf). Over 15% of medical schools do not include palliative care within their assessment processes and although it is increasingly being added to the curriculum, the provision is variable(pdf).
So if we consider that new doctors are estimated to look after 40 dying people in their first year after qualification (pdf), it is not surprising that many report currently feeling underprepared both emotionally and educationally. Although there needs to be a systemic improvement in the teaching of palliative care at both the undergraduate and postgraduate level there are also some simpler steps medical students and doctors in training could take to help improve their experience and confidence in this area.
Tips for medical students and doctors in training undertaking end of life care
Get Informed – Try to familiarise yourself with the local guidance and documentation relating to end-of-life care early on in your placement. Also it helps to know where you can access either a paper or electronic version especially out-of hours. Don’t forget that national resources can be helpful too, for example the GMC has clear guidance for doctors which provides a framework for good practice when giving treatment and care to patients who are reaching the end of their lives.
Seek Opportunities– Particularly during medical school, where possible and appropriate, try to observe seniors looking after patients and families in palliative care situations. It gives you a chance to learn about the clinical aspects of caring for someone at the end of life, and also to learn about communication approaches first-hand. It is also helpful both in undergraduate and post-graduate training to have teaching on the practical aspects of palliative care, such as prescribing, using syringe drivers, and rapid discharge processes. If it is an area you feel lacking in confidence, try and discuss with those who co-ordinate your teaching whether a session could be arranged.
Palliative care is a team effort
Check the phonebook – One of the most helpful things I discovered as a foundation doctor, was that our local hospice had a 24 hour helpline, and I made use of it on more than one occasion. Find out what services are available where you work, is there a pain management team, an in-house palliative care team, or any local community providers that are available to help when you have questions? Again, this is something it is helpful to know in advance, and if you do find something useful, let your colleagues know.
Know your limitations – No matter how much teaching you have had, and how well you know the paperwork, don’t operate in isolation. Palliative care is a team effort, even in the middle of the night. It is easy to try and work by yourself, particularly on a busy shift when everyone is inundated. Involve the nurses, your seniors and other multidisciplinary colleagues, including chaplaincy and holistic services where available. You can’t and shouldn’t be doing it all alone.
Be human – Don’t forget about the patient and their family, clear and regular communication is so important, particularly during palliative care. Similarly, don’t forget about yourself. Don’t underestimate how caring for patients and their relatives during death can affect you. Remember it is ok to ask for help.
Please share your views and any tips or advice you have on end of life care.
Katie Smith is an ST2 in Public Health based in the North West of England. She is currently a Clinical Fellow at the GMC as part of a 12-month out of programme placement through the National Medical Director’s Clinical Fellow Scheme.
The National Medical Director’s Clinical Fellow Scheme provides doctors in training with the opportunity to work in national healthcare organisations for a year. The scheme, run by the Faculty of Medical Leadership and Management, aims to develop a range of skills, including leadership, management and strategy development.