End of Life Care - Community Clerkship

Well, I realize I haven't written since returning from Africa and now I'm back in good ol' Worcester. I spent the few weeks I had remaining of summer break all over new england which was amazing. It's been a quick couple months back in school, we've already finished neuroanatomy, respiratory, and renal path. I'm already enjoying second year so much more than first as we are learning so much more relevant material as well as my own adjustment to studying. Now we have 2 weeks off from class in order to participate in a a community clerkship of our choice. I chose to do the End of Life Care Clerkship.

We are 3 days into the clerkship and already, we've seen and learned a lot. We have great, dedicated faculty who have organized a great schedule for us. I chose this clerkship because I feel comfortable with the topic and I feel it's an extremely important one that often is avoided. Perhaps my own personal experience with illness gave me some experience that I needed in order to be comfortable with this topic. I feel it is an absolutely essential part of medicine and providing the care that is best for a patient and according to what they want is most important at the end of life. The way a person passes obviously impacts many people involved. I can't help but think this is an area of medicine with perhaps the greatest room for improvement at the lowest cost. In fact, an obvious secondary improvement that would be seen with addressing end of life care with patients would be a huge decrease in healthcare costs. Research shows that the vast majority of healthcare dollars are spent in the last few months of life whereas it also shows that the vast majority of people do not have the treatment they want at the end of life, such as being with family at home. The bottom line is that providing better care in accordance with what a patient and family want is better for everyone. The first day was a sort of crash course learning about medical care at the end of life and the various forms it takes, such as hospice, palliative care in the hospital, at home, and in a nursing home. We learned about insurance and payment issues as well as what research has been done to understand what patients and families want at the end of their lives. We heard from an individual about his personal experience with his mother using hospice and having a beautiful and peaceful end to her life. Something that may unfortunately be the exception to the rule but something that can provided to many more people by simply having a conversation earlier in the process.

On the second day we visited a local hospice and sat in on their rounds in the morning, going over the patient cases. We spent the rest of the day individually with a nurse and I went along for 3 home visits. I enjoyed those visits immensely and found them to be the most eye opening experience yet on the topic. The nurse I was shadowing was absolutely exceptional, one who I could only hope to have myself someday. Her personal, calm, patient, and loving care with each of her patients, all very different, was inspirational, to say the least. Seeing each patient and hearing some of their story gave me some insight into the amazingly different experiences and dynamics surrounding each person during their last days with us. The way the nurse handled the unique needs of not only each patient, but, many times, the complicated terrain of their family dynamic was impressive. She was familiar with each person at a very personal level, on that is required in order to provide the care and make the connection that can make someone's final days peaceful and personally satisfying. I found myself most impressed with not necessarily how she handled each patient directly but in a couple of the cases, how she handled the families. She provided truly unbiased care, not making any judgments of an individual. I will omit details here for privacy sake but one case was particularly complex because of the family dynamic and I found myself challenged and trying to maintain awareness of my own thoughts during the visit, watching for signs of ego in the form of judgments of another person. I was certainly disturbed by some of what I witnessed and although my inner alarms were going off, pushing me to take action, in what form, I have no idea, but I found myself, again, calmed by the nurse there with me. I can only say her handling of the situation was flawless: she managed to do the right thing even though it would have been considered inflammatory by most involved on the wrong side, but in such a way as to maintain the relationship as well as a peaceful atmosphere - something that left me in awe.

Today, the third day, we had the opportunity to spend time in the hospital setting, sitting in on palliative care rounds with both physicians in one meeting, and then nurses, pharmacists, physical therapists, social workers, and other team members in another. We heard and reviewed patient cases and discussed treatment strategies emphasizing care for the patient at all levels beyond only physical pain.