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• W2983452979 abstract "A while ago, I participated in a meeting of community representatives discussing what they felt should be included in a renewed curriculum for their local medical school. The older delegates advocated strongly for more involvement with dying patients. They suggested that senior students should be matched to a person with a terminal illness, participating in care delivery and observing end-of-life shared decision making. There was a strong sense in the room that health professionals need a greater understanding of how people may approach and prepare for death, and that learning should not solely focus on the medicalisation and delaying of the end times. At many universities, students follow a family through a pregnancy and birth, but I am not aware of formal patient–student partnerships focused on dying. Such an experience may occur for some as part of a longitudinal integrated clerkship, typically with a placement lasting 3–12 months in one location, with one supervisory team, or with similar prolonged contact, and it is important for students to receive guidance about their role in the patient's journey.1 Death is universal but human responses to death and dying, and health professional curricula on the topic, have varied over time and are diverse across cultures. A person's first encounter with death generates many different emotions, depending on the context. A health professional learner's reaction to their first death will similarly depend on the circumstances, but is likely to include one or more of the following responses: sadness; anger; horror; powerlessness; guilt; remorse; unease; bewilderment; wonder; compassion; or gratitude that the suffering is over. Some students may be uncertain about how to react: is it alright, for example, to show emotion? There may be a tension between emotional involvement and wanting to appear professionally detached.2 But what if you don't feel anything at all? This could indicate compassion fatigue – the feeling of being disconnected from patients, with subsequent emotional withdrawal – a particular risk for nurses or others with close and continuing proximity to tragic events.3 I am loath to suggest that dealing with death and dying is a competence. Rather we could consider this stage of life as an entrustable professional activity (EPA), which is a unit of professional practice that makes up daily work.4 The EPA comprises the practical, professional, ethical, legal and, indeed, the spiritual aspects of death and dying that are covered throughout training to varying degrees. The mix of communication, expression of empathy and compassion, appropriate documentation, clinical management and one's own self-care and reflection is complicated. Learners need to consider how their personal values and professional values may affect their behaviour. The situation is becoming more complex in some countries, such as those that have legalised assisted dying (and in Australia this is true for some states and not for others).5 And we should not forget that in certain jurisdictions health professionals become involved in capital punishment.6 In this issue, Gajebasia and colleagues present findings from semi-structured interviews of newly qualified doctors in England, which explored their training needs in relation to the care of dying patients in hospitals.7 I was not surprised to read that the doctors’ education at medical school varied, and that they felt underprepared and lacking in confidence in many areas, both professional (communication, prescribing, documentation, etc.) and personal (dealing with emotional responses, values, etc.). Although placements in hospices may help, they are not sufficient. Death is often unexpected and messy and confrontational, and each death is unique. Gajebasia et al. recommend support and debriefing from senior colleagues as one way to help interns learn and cope with the challenges that they face. But this supposes that senior colleagues are good role models in how to approach the end of life. Here, hidden curricular forces may also be powerful. Learners may frequently hear the gallows humour that some of their profession use to deal with loss.8 Such behaviour does not necessarily indicate a loss of empathy but rather a coping mechanism that the uninitiated view as lack of humanity. Is such humour ever justified? Kukran and Minocha, London-based medical students, reflect on interacting with dying patients in this issue.9 They stress that patients with terminal illnesses, as also indicated by the community members that I mentioned in the first paragraph, are generally supportive of having learners involved in their care. Again, the students emphasise the need for guided reflection to help make sense of feelings and to improve future interactions. It is important to remember that health and social care professionals at all stages of their working lives should not feel alone. As educators we need to emphasise where learners and colleagues may seek support. A scoping review by Anderson and colleagues has highlighted the importance of reflection within the health care team. Such a process may improve emotional well-being, although there is less evidence that it improves patient and family care.10 As with many other experiences in life, we may learn more about the human condition from literature to augment our own clinical encounters. We may also reflect on our society's diverse attitudes to and values about death from sociocultural phenomena such as the death café movement. At these cafés, which have been held in 65 countries, people come together to discuss death in order to raise awareness of the finite nature of life.11 The aim is to normalise death and to help people prepare for death whenever it may come. A preparation that is also appropriate for all health professionals." @default.
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• W2983452979 date "2019-11-17" @default.
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• W2983452979 title "Death and dying: the ultimate challenge" @default.
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• W2983452979 doi "https://doi.org/10.1111/tct.13115" @default.
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