{"id":6637,"date":"2012-02-06T13:47:33","date_gmt":"2012-02-06T18:47:33","guid":{"rendered":"http:\/\/www.bumc.bu.edu\/busm-news\/?p=2043"},"modified":"2012-02-06T13:47:33","modified_gmt":"2012-02-06T18:47:33","slug":"teaching-doctors-how-to-close-lifes-last-door","status":"publish","type":"post","link":"https:\/\/www.bumc.bu.edu\/camed\/2012\/02\/06\/teaching-doctors-how-to-close-lifes-last-door\/","title":{"rendered":"Teaching Doctors How to Close Life\u2019s Last Door"},"content":{"rendered":"

At age 78, Charles Swanigan could jog three miles at a stretch. One year later, with the prostate cancer he had battled for a decade spread throughout his body, he could hardly move. Just getting out of bed, he tells his doctor and two BU School of Medicine students paying him an autumn house call, wracks him with pain. View the video here<\/a>.<\/p>\n

Swanigan\u2019s cozy Roxbury living room, with its fireplace and hardwood floor, has added a new piece of furniture: the hospital bed where Swanigan spends his days, shriveled arms protruding above the blankets. Eating has become an ordeal; the food will no longer stay down. The retired property manager, a divorced father of four, is cared for by his 20-year-old son. As Eric Hardt, a MED associate professor and a Boston Medical Center geriatrician, tells his students, the patient has endured a radical prostatectomy and \u201cevery drug known to man.\u201d Yet Swanigan constantly clutches at new treatments that might prolong his life. \u201cHe\u2019s going down fighting,\u201d Hardt says.<\/p>\n

Now, Hardt watches in the darkened living room as Lucas Thornblade (MED\u201912) checks Swanigan\u2019s vitals, including his pulse. Thornblade\u2019s examination roams far beyond questions of blood pressure and weight. \u201cI was going to ask how you\u2019re doing spiritually and emotionally,\u201d he says. \u201cI\u2019m not sitting here worrying,\u201d Swanigan answers. \u201cIt\u2019s just, it\u2019s not fun sitting here in bed.\u201d<\/p>\n

Hardt asks if any fellow parishioners from Swanigan\u2019s church ever stop by. \u201cA few,\u201d says Swanigan. \u201cI would have thought I\u2019d have more, but\u2026\u201d<\/p>\n

\u201cThis is kind of hard to talk about,\u201d Hardt says, \u201cbut what if something unexpected and terrible happens?\u201d Swanigan says he has a will. \u201cIf your heart were to stop beating,\u201d Thornblade says, \u201csome patients would prefer to have CPR and electric shocks given.\u201d<\/p>\n

\u201cIf that happened,\u201d Swanigan asks, \u201chow much of an extension is it? Just a few weeks, a month or so? I prefer not to be resuscitated and be in a lot of pain, if that\u2019s what\u2019s going to happen.\u201d<\/p>\n

\u201cThank you for sharing that with us,\u201d says Thornblade, who helps Swanigan sign a do-not-resuscitate directive after the patient is assured that it won\u2019t preclude necessary treatment.<\/p>\n

\u201cI heard you used to play clarinet. That was my father\u2019s instrument as well,\u201d says Thornblade. \u201cHad a strong, strong desire to be a classical musician,\u201d replies Swanigan, who studied at the Boston Conservatory of Music. \u201cBut it\u2019s a tough field unless you want to go into teaching.\u201d<\/p>\n

\u201cAny plans for Thanksgiving or the holidays?\u201d the doctor asks.<\/p>\n

\u201cNo,\u201d says the patient, \u201cnothing.\u201d<\/p>\n

********<\/p>\n

\"Matthew<\/a>
Matthew Russell. Photo by Kalman Zabarsky<\/figcaption><\/figure>\n

Death is a toxic subject for doctors trained to heal, not prep their patients for the morgue. \u201cNo one wants a talk about it, because it doesn\u2019t make for a good story,\u201d says Matthew Russell, a MED assistant professor. Russsell (CAS\u201994, SPH\u201903) says end-of-life needs weren\u2019t part of the curriculum during his medical training in the 1990s. A 2007 study of 51 oncologists by Duke University\u2019s Center for Palliative Care<\/a> (palliative medicine tries to relieve pain and suffering) found that even when cancer patients did open up about their sorrows, fears, or anger, the discomfitted docs doused the discussion three-quarters of the time.<\/p>\n

That\u2019s changing. MED\u2019s old-fashioned house calls\u2014after 150 years, the oldest such program in the country, Hardt says\u2014are an important part of the palliative and end-of-life training in the school\u2019s four-week geriatrics clerkship. (Clerkships are medical students\u2019 temporary assignments in various hospital specialties.) Lectures instruct students how to be human beings as much as doctors, and that emotional connections with dying patients are as essential to good care as a stethoscope. The students also learn that while death is universal, how we die is tailored by our individual cultural and spiritual heritage.<\/p>\n

Hardt, one of 15 docs on BMC\u2019s geriatrics team, says the training grew partly from the observation that there are more people dying within the geriatric group than anywhere else in the hospital, including the intensive care units and oncology. The lesson has taken hold in medical schools nationally, where end-of-life care, including palliative medicine, is a growing trend, says David Longnecker, director of health care affairs for the Association of American Medical Colleges<\/a>. Longnecker says that BU\u2019s education in these fields is highly regarded.<\/p>\n

The move has been fueled partly by reports such as a 2009 article<\/a> in the Association of American Medical Colleges journal Academic Medicine<\/em>, in which residents who\u2019d been given bedside training with dying patients reported feeling more competent at end-of-life care.<\/p>\n

Ebony Lawson (MED\u201912), who accompanied Hardt and Thornblade on the house call to Swanigan, says the visit showed her \u201cfirsthand how to approach difficult decisions.\u201d She knows that a doctor inevitably deals with death, and she takes that discussion seriously. Still, she says, it\u2019s emotionally difficult to talk about.<\/p>\n

********<\/p>\n

\"Eric<\/a>
Eric Hardt. Photo by Vernon Doucette<\/figcaption><\/figure>\n

\u201cHow many of you have directly cared for a patient who died?\u201d<\/p>\n

Russell puts the question to the 10 students in the palliative care lecture he gives for the clerkship. A lone hand shoots up. \u201cThere is not a standardized dying patient,\u201d he tells them. \u201cPeople will have various symptoms to various degrees of intensity. We have to understand why this symptom is happening. The answer can\u2019t be morphine, morphine, morphine in every case.\u201d He warns that rote, inept treatment could accelerate the decline of a patient whose \u201cgoal could be making it the next few weeks to their granddaughter\u2019s christening.\u201d<\/p>\n

The case studies that Russell cites are thick with medical jargon, but of his three Ms of medical examination, only the first, mechanism, probes a patient\u2019s pathology and treatment. The second, meaning, explores what illness means to the patient herself\u2014for example, asking what worries her about being nauseous. \u201cIt sounds weird, people don\u2019t do it, and you don\u2019t hear it all that much,\u201d but mere yes-no questions about symptoms fumble the chance to be of real help, he says. He exhorts the students to remember who their patients are as people. \u201cIt\u2019s the spouse of 60 years who\u2019s going to lose a wife, the family who\u2019s going to lose a matriarch. Our bread and butter is a patient and family\u2019s worst day.\u201d<\/p>\n

The third M is a stunning word for a medical class\u2014magic\u2014all the more so for the humility it teaches a profession not known for being humble. The dying crave a miracle that will save them, Russell says, but healers must not oversell their powers in hopeless cases. \u201cRemember the lesson of the Wizard of Oz,\u201d he urges.<\/p>\n

\u201cThere\u2019s no place like home?\u201d ventures a student.<\/p>\n

\u201cOh, sh\u2013,\u201d says Russell with a laugh\u2014he\u2019d forgotten that famous moral of the story. \u201cThat\u2019s not it. Another lesson.\u201d He\u2019s referring to the movie\u2019s insight that the man behind the curtain is just a man. \u201cWe have to be mindful of our participation in that illusion of Oz,\u201d he says. \u201cPatients will often want us to be the wizard. You owe it to your patients to be true to what you know\u2014which is limited.\u201d<\/p>\n

Underscoring the limits of care is the need to understand how a patient perceives them. Russell offers a case study of a 95-year-old demented woman who, near death, has stopped eating. Research confirms that her feeding tube will not prolong her life. Yet how do you suggest to her daughter that she order it removed? Students take a stab at the medical facts of the situation (\u201cUnfortunately, she\u2019s not going to be able to eat on her own,\u201d tries one), but Russell reminds them that their doctor\u2019s ear must hear the voice of the daughter\u2019s heart.<\/p>\n

\u201cWhat is feeding someone? A proxy for something.\u201d Love, suggests a student. Bingo, says Russell. \u201c\u2018So don\u2019t you ever tell me not to feed my mother, because she fed me every night.\u2019 Food is love. You\u2019re going to have to deal with that love thing. Make them know that what they\u2019re not doing is love. I need to know that what I have done for my loved one matters and has mattered, because I want to know, at the close of their life, I have done everything I could have done. What needs to happen at that moment? An emotion. She needed to hear, \u2018You did right.\u2019\u201d<\/p>\n

********<\/p>\n

\"A<\/a>
A younger, healthy Charles Swanigan, before becoming terminally ill.<\/figcaption><\/figure>\n

In 2005, with help from an Aetna grant, Hardt developed a curriculum, called Culture, Spirituality, and End of Life Care, that attunes aspiring doctors to help patients of varying races, religions, and nations.<\/p>\n

\u201cWe don\u2019t have time to talk about all of America\u2019s wondrous versions of racism,\u201d he tells his class, making it clear that a doctor must never \u201clower the standard of care just because you don\u2019t know the patient\u2019s language.\u201d Among his case studies is a Boston Globe story about a Buddhist family\u2019s battle to keep their father on life support. Although his brain activity had flatlined, and \u201cbrain death equals death\u201d in Western medicine, says Hardt, his heart continued beating, and to his family, that meant \u201cthe spirit still dwells in the body, so you can\u2019t pull the plug.\u201d Students struggle unsuccessfully with possible resolutions; in reality, Hardt says, the doctors kept life support on.<\/p>\n

Nowhere does MED\u2019s emphasis on diversity and humanity spice the curriculum more than in the final project of the clerkship. Outsiders expecting exam books or meticulously wrought case studies would be astounded at the actual projects that fourth year med students presented in November, from the aroma of jambalaya made by Toya George (MED\u201912) to a version of Jeopardy! with questions about international religions, emceed by Casper Reske-Nielsen (MED\u201912).<\/p>\n

Jambalaya, plus the spirituals she plays on her computer for the class, reflect the comforts taken by people who share her southern heritage, George tells her classmates. Reske-Nielsen\u2019s Jeopardy categories, flashed on the classroom screen, ranged from What\u2019s in Store? (about the afterlife notions of various faith traditions) to Death\u2019s a Drag. Classmates competed to answer clues like, \u201cFamadihana is the practice of this with the dead to help the spirits join their ancestors.\u201d (Answer: What is dancing? Famadihana is a tradition in Madagascar.)<\/p>\n

The final projects\u2019 nonscientific flavor, Hardt says, is a deliberate antidote to the emotionless professionalism that doctors typically adopt when confronting death and the bereaved: \u201c\u2018Get tough, I\u2019m sorry for your loss, suck it up.\u2019 And we want to combat that and say, you know, these are people. And even though you have a specialized job, you\u2019re still people too. You don\u2019t have to block that out to become a good surgeon or good internist.\u201d<\/p>\n

It\u2019s a lesson that stayed with Lucas Thornblade long after his visit to Swanigan\u2019s home. \u201cLearning about palliative care is the process of choosing which elements of medical care are appropriate for a person with a disease that may be terminal,\u201d he says. And with the geriatrics clerkship, \u201cfor the first time, we\u2019re caring for patients who may have more emotional and physical needs outside of the hospital than the patients that we\u2019re used to caring for.\u201d<\/p>\n

Charles Swanigan died at home the evening after Thanksgiving with his family at his bedside.<\/p>\n

This BU Today<\/em> story was written by Rich Barlow. He can be reached at barlowr@bu.edu<\/a>.<\/p>\n","protected":false},"excerpt":{"rendered":"

At age 78, Charles Swanigan could jog three miles at a stretch. One year later, with the prostate cancer he had battled for a decade spread throughout his body, he could hardly move. Just getting out of bed, he tells his doctor and two BU School of Medicine students paying him an autumn house call, […]<\/p>\n","protected":false},"author":903,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[1],"tags":[],"_links":{"self":[{"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/posts\/6637"}],"collection":[{"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/users\/903"}],"replies":[{"embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/comments?post=6637"}],"version-history":[{"count":0,"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/posts\/6637\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/media?parent=6637"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/categories?post=6637"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/tags?post=6637"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}