The Medical Student and Care at the End of Life

2013 Virtual Mentor  
Almost 20 years ago, care of the dying was described by Daniel Callahan as an "open moral wound" in the American health care system [1] . He attributed the continued festering of this lesion to the American veneration of self-mastery and self-realization that cannot submit to the inevitable reality of death. He also cited the secularization of death, with a religious/spiritual response replaced by a medicotechnical assault, as a contributor. Physicians exaggerated and prolonged this injury by
more » ... ed this injury by the avoidance behavior generated in them by encounters with death and dying. There was a reticence to initiate discussions about advance health care planning, a failure to elicit patients' values in these matters, and a propensity to ignore directives even when they were in place. The Patient Self-Determination Act, passed more than 2 decades ago to correct this situation by encouraging discussion of end-of-life (EOL) issues, saw only a modicum of success in reversing physicians' disinclination to make such discussions a priority. Even a multimillion-dollar interventional study (SUPPORT) to improve patient-physician communication with critically ill patients succeeded only in documenting the extent and frequency of this communication gap in modern medicine [2] . Physicians' reluctance to initiate and flesh-out patient preferences regarding EOL care has been defended (and excused) on the grounds that such discussions threaten the patient's ability to maintain hope. This long-adhered-to but now outmoded belief and practice resulted in "benevolent" deception being the primary communication style in EOL care of the past. Physicians' problems with a personal sense of failure in the face of death, a disproportionate belief in the mastery of science over disease, and unacknowledged anxiety over their own deaths all contributed to this physiciancentered rather than patient-centered approach to end-of-life care. The shift from curing to the caring stance required during the dying process is not an easy transition for physicians trained in the ethos of delaying death at all costs. The financial and time constraints of modern-day practice have only accentuated the omission of endof-life conversation from encounters with patients. This serious oversight persisted even in the face of the expressed desires of their patients to be engaged in EOL conversation [2] . A major reason for this was the way in which physicians were educated throughout the last century. The Flexnerian biomedical model of medical education was strongly anchored in scientific ideas with less emphasis on or inclusion of professional ideals. Generations of physicians
doi:10.1001/virtualmentor.2013.15.8.medu1-1308 pmid:23937782 fatcat:kgvpptpcqbcejdu3q7x7wnzl6e